Cleft Palate Case Study Hesi

HESI Pediatric

Practice questions with rationale
When taking the health history of a child, the nurse know what which finding is an early indication of hypothyroidism in children?
Cessation of growth in a child that had been normal
The nurse received a lab report stating a child w/ asthma has theophyline level of 15 mcg/dl. What action will the nurse take?
Hold the next dose of theophylline
a.i. Therapeutic levels of theophylline is 10-10 mcg/dl, so the child's level is w/in the therapeutic rage.
Surgery is being delayed for an infant with undescended testes. In collaboration w/ the health care provider and the family, which prescription should the nurse anticipapte?
trial of human chorionic gonadotrophic hormone
a.i A trial of HCG may aid in testicular descent, but does not replace surgical repair for true undescended testes. (cryptorchidism: may be found in the inguinal canal due to exaggerated creamasteric reflex
Which menu selection by a child w/ celiac disease indicates to the nurse that the child understands necessary dietary considerations?
a. Oven baked potato chips & cola
a.i. Celiac disease causes an intolerance to the protein gluten found in oats, rye, wheat, and barley. The child should avoid any produces containing these indredients to avoid symptoms such as diarrhea.
The mother of a 2-year-old boy consults the nurse about her son's increased temper tantrums. The mother states, "yesterday he threw a fit in the grocery store, and I did not know what to do. I was so embarrassed. What can I do if this occurs again?" Which recommendation is best for the nurse to provide this mother?
a. Walk away from him and ignore the behavior
a.i. The best approach for a toddler is to ignor the attention-seeking behavior. The parents should be somewhat nearby, w/in view of the child but should avoid reinforcing the behavior in any way. Tantrums can sometimes be avoided by talking to the child before the situation occurs
Which restraint should be used for a toddler after a cleft palate repair?
a. Elbow
a.i. Elbow restraints prevent children from bending their arms and brining their hands to the oral surgical site, (A) restrains the hands but the child can bend and bring their head to their ands. (B) is used during procedures (mummy). (D)-jacket, restrains the body torso and is not appropriate
The mother of a 4-year-old child asks the nurse what she can do to help her other children cope with their sibling's hospitalizations. Which is the best response that the nurse should offer?
a. Encourage the mother to have the children visit the hospitalized sibling.
a.i. Needs of a sibling will be better met with facture information and contact w/ the ill child, so siblings visitation should be encouraged (D). Parents are experts on their children and should determine when their children are old enough to visit. (A) in the hospital/ Separation fr. a family & home (B) may intensify fear & anxiety (suggest that the child visit a grandmother until the sibling returns home. Children may have difficulty expressing questions (C) ask the mother if the child asks when the sibling will be discharged, so the support of parents & other caregivers are needed to help alleviate their fears.
The nurse is giving preoperative instruction to a 14-year-old female client who is scheduled for surgery to correct a spinal curvature. Which statement by the client best demonstrates that learning has taken place?
a. I understand that I will be in a body cast and I will show you how you taught me to turn
a.i. Outcome of learning is best demonstrated when the client not only verbalizes an understand, but can also provide a return demonstration
During administration of a blood transfusion, a child complains of chills, headache, and nausea. Which action should the nurse implement?
a. Stop the infusion immediately and notify the healthcare provider
a.i. The child is exhibiting signs of a reaction to the blood transfusion. The blood transfusion should be stopped immediately and the healthcare provider notified ©. After the transfusion is discontinused, IV access should be maintained. (A) w/ fluids that do not introduce any more cellular products. (B & D) place the child @ risk for further blood reactions
The clinic nurse is taking the hx for a new 6-month-old client. The mother reports that she took a great deal of aspirin while pregnant. Which assessment should the nurse obtain?
a. Type of reaction to loud noises
a.i. Ototoxicity diminishes hear acuity and causes symptoms of tinnitus and vertigo in older children who can express subjective symptoms, so assessing the infant's reation to loud noises (A) helps to determine an infant's risk for hearing deficit r/t to a hx of the mother taking ototoxic drug, such as aspirin, while pregnancy (B,C,D are not assoc w/ the exposure to aspirin in utero
The mother of a preschool aged child asks the nurse if it is all right to administer Pepto Bismol to her son when he has a "tummy ache" After reminding the mother to check the label of all OTC drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother's question?
a. Do not give if the child has chickenpox, the flu, or any other viral illness
a.i. Pepto Bismol contains aspirin and there is the potential of Reye's syndrome (B). (a) is a common effect of peptobismol and does not warrant discontinuation. Pepto Bismol can be used by children (C). Pepto Bismol does not cause rebound hyperacidity (D) complication of antacids containing calcium
A 3 moth old infant develops oral thrush. Which pharmacologic agent should the nurse plan to administer for treatment of this disorder?
a. Nystatin (Mycostatin)
a.i. Nystatin (mycostatin) (A) is an antifungal drug that is effective in treating thrush, an oral fungal infection
The nurse is developing a plan of care for a 3 yr old who is scheduled for a cardiac catherization. To assist in decreasing anxiety for the child on the day of the procedure, which intervention is best for the nurse to implement?
a. C-give the child a ride on a gurney to visit the cardiac catheterization lab and meet a nurse who works there
a.i. Familizaring the child and mother w/ the department will help decrease anxiety of the child and mother (who may have more anxiety than the child). Three is a difficult age to undergo a procedure that requires cooperation. Restraints and possible sedation may be required
A 3 yr old boy is brought to the ER because he swallowed an entire bottle of children's vitamin pills. Which intervention should the nurse implement first?
a. B-determine the child's pulse and respirations
a.i. The most important principle in dealing w/ a poisoning is to treat the child first, not the poison. Initiate immediate life support measures w/ assessment of VS (B), in particular, respirations. Inserting an airway or initiating mechanical ventilation may be necessary. Assessment and identification of the poison should occur prior to A. (C & D after assessing the airway.)
A 4- year- old girl continues to interrupt her mother during a routine clinic visit. The mother appears irritated w/ the child and asks the nurse, "Is this normal behavior for a child this age?" The nurse's response should be based on which information?
a. A- children need to retian a sense of initiative w/o impinging on the rights and privileges others
a.i. Children aged 3-6 are in Erickson's initiative vs. guilt stage, which is characterized by vigorous, intrusive behavior, enterprise, and strong imagination. At this age, children develop a conscience and must learn to retain a sense of initiative w/o impinging on the rights of others
The nurse is planning the care of a 2 year old w/ severe eczema on the face, next, and scalp fr. scratching the affected areas. Which nursing intervention is most effective in preventing further excoriation due to the purities?
a. C- place elbow restraints on the child's arms.
a.i. Elbow restraints prevent arm flexion and scratching of involved area, but do not inhibit use of the nads for play activities. Others can be removed easily
a 6- year old admitted to the pediatric unit after falling of a bicycle. Which intervention should the nurse implement to assist the child's adjustments to hospitalization?
a.Explain hospital schedules to the child, such as mealtimes. Altered daily schedules and loss of rituals are upsetting to children and increase separation anxiety, and active sensitivity to the needs of children can minimize the negative effects of hospitalization. Explaining the hospital schedules (A) and establishing an individual schedule familiarizes the child to the hospital environment and decreases anxiety.
A female teenager is taking oral tetracycline HCL (Achromycin V) for acne vulgaris. What is the most important instruction for the nurse to include in this client's teaching plan?
a. A- Use sunscreen when lying by the pool
a.i. Photosensitivity is a common side effect of tetracycline HCL (AchromycinV) therapy. Severe sunburn can occur w/ minimal sun exposure and clients should be instructed to avoid sunlight and to use sunscreen
The nurse is caring for a 12 year-old w/ Syndrome of Inappropriate Antidiuretic Hormone (SIADH). This child should be carefully assessed for which complication?
a. B- changes in LOC
a.i. The child must be monitored for S/S of hypontremia, which creates secondary central nervous system alterations such as changes in LOC, seizure coma.
A child falls on the playground and is brought to the school nurse w/ a small lacreration on the forearm. Which action should the nurse implement first?
a. C-Wash the wound gently w/ mild soap and water
a.i. A small, superficial laceration to the skin should be washed gently w/ mild soap and water for several minutes, followed by thorough rinsing.
A 6-month-old infant w/ congestive heart failure (CHF) is receiving digoxin elixir. Which observation by the nurse warrants immediate intervention?
a. A- Apical heart rate of 60
a.i. A heart rate of 60 is much lower than normal for a 6-month old and warrants immediate intervention. The normal heart rate for a 6 month old is 80-150 when awake, and a rate of 70 while sleeping is considered w/in normal limits.
To assess the effectiveness of an analgesic administered to a 4-yr old, what intervention is best for the nurse to implement?
a. A- use a happy-face/sad face pain scale.
a.i. A 4 year old can readily identify w/ simple picures to show the nurse how he/she is feeling. Could be used to validate what the child is telling the nurse via the "faces" pain scale, but it is best to elicit the child's assessment of his/her pain level (C-assess for changes in the child's vs), may not accurately reflect the effectiveness of pain medication as they can also be affected by other variables, such as fear
The nurse is assessing an 8 month old child who has a medical diagnosis of tetrology of Fallot. Which symptom is the client most likely to exhibit?
a. D-clubbed fingers
a.i. Tetrology of fallot, a cyanotic heart defect, causes clubbing of fingers and toes due to tissue hypoxia
Which action by the nurse is most helpful in communicating w/ a preschool aged child?
a. B- use a doll to play and communicate
a.i. Communicating through play w/ a doll or other toy gives time for the child to feel comfortable w/ a stranger
Preoperative nursing care for a child w/ Wilm's tumor should include which intervention?
a. D-put a sign on the bed reading, "DO NOT PALPATE ABDOMEN"
a.i. Prevention of abdominial palpation minimizes the risk of rupturing the encapsulated tumor and subsequent metastasis.
The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about prevention of accidental poisonings. It is most important for the nurse to include which instruction?
a. B- store all toxic agents and medicines in locked cabinets.
a.i. The only reliable way to prevent poisoning in young children is to make them inaccessible
The nurse observes a 4 yr old boy in a daycare setting. Which behavior would the nurse consider normal for this child?
a. C- demonstrates aggressiveness by boasting when telling a story
a.i. C- 4yr old children are aggressive in their behavior and enjoy "tale telling"
A 2 yr old child w/ Down syndrome is brought to the clinic for his regular physical examination. The nurse knows which problem is frequently associated w/ Down syndrome?
a. A- congenital heart disease
a.i. Is the most common assoc w/ defect in children w/ Down Syndrome
In developing a teaching plan for a 5 year old child w/ diabetes, which component of diabetic management should the nurse plan for the child to manage first?
a. C-process of glucose testing
a.i. Developmentally a 5 yr old has the cognitive and psychomotor skills to use a glucometer and to read the number (it is especially helpful if the nurse presents this activity as a game
The nurse is assessing a 13 yr old girl w/ susptected hyperthyroidism. Which question is most important for the nurse to ask her during the admission interview?
a. B-are you experiencing any type of nervousness?
a.i. Assessing the client's physiological state upon admission is priority, and nervousness, apprehension, hyperexcitability, and palpitations are signs of hyperthyroidism, but assessing loss (even w/ a hearty appetite) (A) occurs in those w/ hyperthyroidism, but assessing the client's neurological state has a higher priority. Hormone replacement is not administered to a client who is already producing too much thyroid
The mother of a 6 month old asks the nurse when her baby will get the first MMR vaccine. Based on the recommended childhood immunization schedule published by the CDC, which response is accurate?
a. (b) the MMR vaccine should be given no sooner than 12 months of age, and ideally between 12 & 15 months of age. (a) 3-6 months should not receive the MMR vaccine due to the presence of maternal antibodies. MMR is not routinely administered @ 18-24, but others like dTaP and Hep B may be given at that time.
A 16 y old is brought to the ER with a crushed leg after falling off a horse. The adolescent's last tetanus toxoid booster was received 8 ys ago. What action should the nurse take?
a. C- administer the tetanus toxoid booster.
a.i. After the completion of the initial tetanus immunization schedule, the recommended booster for an adolescent or adult if every 10 years or less if a traumatic injury occurs that is contaminated by dirt, feces, soil, or saliva, such as puncture or crushing injuries, avulsions, wounds fr. missiles, burns or frostbite. The adolescent's injury is considered a contaminated wound requiring prophylactic therapy, so the tetanus toxoid booster should be administered
A 6 month old returns fr. surgery w/ elbow restraints in place. What nursing care should be included when caring for any restrained child?
a. B- remove restraitnts one at a time and provide range of motion exercises
a.i. Removing restraints one at a time (B) is safer than removing all of them at once. The child needs to exercise and should not be kept in restraints at all times
A 17 yr old male student reports to the school clinic one morning ofr a scheduled health exam. He tells the nurse that he just finished football practice and is on his way to class. The nurse assess his VS: temp 100, pulse, 80, RR 20, and BP is 122/82. What is the best action for the nurse to take?
a. A- tell the student to proceed directly to his regulary scheduled class.
a.i. The student has just completed football practice, and increased muscle activity increases body heat production. A temp of 100F is NORMAL for this student @ this time. The student should attend class
The nurse is planning care for school-aged children @ a community care center. Which activity is best fo the children?
a. B- playing follow the leader
a.i. School aged children strive for independence and productivity (ericksons industry vs. inferiority) & enjoy individual & group activites r/t real life situation, such as playing follow the leader
A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have esophageal atresia. Which symptoms are this newborn likely to exhibit?
a. A- choking, coughing, and cyanosis
a.i. Includes the "3 Cs" of esophageal atresia caused by the overflow of secretions into the trachea.
The nurse is assessing the neurovascular status of a child in Russell's traction. Which finding should the nurse report to the healthcare provider?
a. A- Pale bluish coloration of the toes
a.i. Russell's skin traction is used for fractures of the femur in young children and adolescents whose growth plates remain open and is applied to the lower leg using moleskin and elastic wrap bandages, which can compress the perineal nerve and arteries that supply the foot. Assessment of adequate circulation, movement, & sensation of the toes and skin distal to the application is make to identify compromised blood flow, so cyanosis should be reported immediately
A 5 month old is admitted to the hospital w/ vomiting and diarrhea. The pediatrician prescribes dextrose 5% and 0.25% normal saline w/ 2 mEq KCL/100 ml to be infused @ 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment finding?
a. B - Serum BUN & Creatinine levels
a.i. Reguardless of a client's age, adequate renal function must be present before adding potassium ot IV fluids, is important in determining the need for fluid replacement
When assessing a child w/ asthma, the nurse should expect intercostals retractions during
a. A-inspiration
a.i. Intercostals retractions result fr. respiratory effort to draw air into restricted airways
The nurse is having difficulty communicating w/ a hospitalized 6 yr old child. Which approach by the nurse is most helpful in establishing communication?
a. A- engage the child through drawing pictures
a.i. Drawing pictures is a valuable fr. non verbal communication. As the nurse & child look at the drawings, a verbal story can be told that projects the child's thinking
The vital signs of 4 yr old child w/ polyuria are: BP 80/40, pulse, 118, and Resp. 24. The child's pedal pulses are present w/ a volume of +1, and no edema is observed. What action should the nurse implement first?
a. B- Start an IV infusion of normal saline
a.i. The current VS readings and the decreased peripheral pulse volume indicate that the child is experiencing fluid volume deficit due to the polyuria, so the priority action is to restore fluid volume
A hospitalized 16 yr old male refuses all visits fr. his classmates because he is concerned about his distorted appearance. To increase the clients social interaction, what intervention is best for the nurse to initiate?
a. C- Arrange for an internet connection in the client's room for email communication
a.i. Body image and peer acceptance are key concerns for the adolescent © allows for social interaction w/o face to face contact, thus protecting his self image while also promoting social interaction
Which class of antiinfective drugs is contraindicated for use in children under 8 yrs of age?
a. B- tetracyclines
a.i. Tetracyclines cause enamel hypoplasia & tooth discoloration in children under 8 yrs of age
Which measures should be used to accurately calculate a pediatric medication dosage?
a. A, C, F
a.i. A- a child's height & weight, C- Body surface area of child, F- nomogram determined mathematical constant
During discharge teaching of a child w/ juvenile rheumatoid arthritis, the nurse should stree to the parents the importance of obtaining which diagnostic testing?
a. B- eye exams
a.i. Visual changes leading to blindness an occur in children w/ JRA/ Regular eye exams can help to prevent this complication
A burned child is brought to the ER. In estimating the percentage of the body burned, the nurse uses a modified "rule of nines" Which part of a child's body is calculated as a larger percentage of total body surface than an adult's?
a. A-Head & Neck
a.i. A child's head & neck are proportionately larger to their body than and adult's. The standard "Rule of nines" is inaccurate for determining burned body surface areas w/ children, and must be modified for use with children. Specially designed charts for children and are commonly used to determine body surface are involvement
The parents of a 3 week old infant report that the child eats well but vomits after each feeding. What information is most important for the nurse to obtain?
a. A- description of vomiting episodes in past 24 hrs
a.i. A description of the vomiting episodes will assist the nurse in determining the reason for the symptoms, which may be helpful in developing a plan of care for this infant/
An infant is born w/ a ventricular septa defect (VSD) and surgery is planned to correct the defect. The nurse regcognizes that surgical correction is designed to achieve which outcome?
a. prevents the return of oxygenated blood to the lungs Closure of VSDs stops oxygenated blood fr. being shunted fr. the left ventricle to the right ventricle. VSDs are acyanotic defects, which means that no unoxygenated blood enters the systemic circulation is common w/ tetrology of Fallot, which is a cyanotic defec
A premature newborn girl, born 24 hours ago, is diagnosed w/ a patent ductus arteriosus PDA and placed under an oxygen good @ 35%. The parents visit the nursery and ask to hold her. Which response should the nurse provide to the parents?
a. B- oxygen hood is holding the baby's oxygen level just at the point which is needed. You may stroke and talk to her.
a.i. The baby is @ 35% which is must more than room air (21%) and at this time the baby should not be moved fr. under the hood. The nurse should offer the parents an alternative such as to stroke and reassure the infant.
When discussing discipline with the mother of a 4 yr old child, the nurse should include which guideline?
a. A- parental control should be consistent
a.i. Discipline should be a positive and necessary component of childrearing that is started in infancy & should teach socially acceptable behavior, help children protect themselves fr. danger, and channel undesireable behavior into constructive activity. Misbehavior may result fr. inconsistent rules or messages, so parental attention should be clear, reasonable, and consistent.
To take the VS of a 4 month old child, which order provides the most accurate results?
a. A- respiratory rate, heart rate, then rectal temperature
a.i. The respiratory rate should be take first in infants, since touching them or performing unpleasant procedures usually makes the cry, elevating the heart rate and making respirations difficult to count. Rectal temp is the most invasive procedure, and is most likey to precipitate crying, so should be done last
A preschool-aged child who is hospitalized fy hypospadias repair is most strongly influenced by which behavior?
a. C- concern for his body integrity. He fears that his "insides will leak out" A child undergoing surgery to his genitalia is even more concerned about body integrity. The preschooler is quite verbal, so comprehension of the words he uses or hears may be inaccurate, while his imagination and fears may fantasize the reality
All of the following interventions can be used to evaluate the effectiveness of nursing and medical interventions used to treat diarrhea. Which intervention is least useful in the nurse's evaluation of a 20 month old child?
a. B-assessing fontanels
a.i. All of these interventions evaluate fluid status in infants (weight diapers, checking skin turgor, oserving mucous membranes for moisture checking for fluid status)
The nurse assigning care for 5 yr old child w/ otitis media is concerned about the child's inceasing temperature over the past 24 hours. Which statement is accurate and should be considered when planning care for the remainder of the shift?
a. B- tympanic and oral temps are equally accurate
a.i. A tympanic membrane sensor approximates core temps because the hypothalamus and eardrum are perfused by the same circulation. Typmpanic readings obtained using proper technique correlated moderately to strongly w/ oral temperatures in recent research studies
The nurse is teaching a 12 yr old male adolescent and his family about taking injections of growth hormone for idiopathic hypopituitarism. Which adverse symptoms, commonly associated w/ growth hormone therapy, should the nurse plan to describe to the child and his family?
a. A- polyuria/polydipsia
a.i. s/s of diabetes or hyperglycemia need to be reported. Those receiving growth hormone should be monitored to detect elevated blood sugars and glucose intolerance
at 8am the unlicensed assistive personnel (UAP) informed the charge nurse that a female adolescent client w/ acute glomerulonephritis has a BP of 210/110. The 4am BP reading was 170/88. The client reports to the UAP that she is upset because her boyfriend did not visit last night. What action should the nurse take first?
a. -Administer PRN prescription of nifedipine (Procardia) sublingually
a.i. Sublingual procardia lowers blood pressure very quickly, and this should be done first
A 12-month-old is admitted w/ a respiratory infection and possible pneumonia. He is placed in a tent w/ oxygen. Which nursing intervention has the greatest priority for this infant?
a. C- a patent airway has the highest priority. Humidification will liquefy the nasal secretions thereby increasing the amount of secretions and making having a bulb syringe the highest priority
The nurse is assigning care for a 4 yr old child w/ otitis media and is concerned about the child's increasing temperature over the past 24 hours. When planning care for this child it is important for the nurse to consider that
a. B- a tympanic measurement of temperature will provide the most accurate reading
a.i. A tympanic membrane sensor is an excellent site because botht he eardrum and hypothalamus (temperature-regulating center) are perfused by the same circulation. The sensor is unaffected by cerumen and the presence of suppurative or unsuppurative otitis media does not effect measurement. RULE OF THUMB: for managementsterile procedures should be assigned to licensed personnel. Management skill will tested on the NCLEX. An RN is not required to do: rectal temp
A three month old boy weighing 10 lbs 15 oz an axillary temp of 98.8. The nurse determines the daily caloric need for this child is approximately
a.600 calories per day. C- 10lbs 15oz = 10.9. Convert lbs by dividing 2.2; 10.9/2.2=4.59kg, rounded to 5kg. An infant requires 108 calories/kg/day (108 x 5=540 calories/day.) However this infant requires 10% more calories because he has one degree temperature elevation. 10% of 540 and 540 + 54= 594. This infant will require approx 600 calories/day.
The nurse is teaching the parents of a 5 yr old w. cystic fibrosis about respiratory treatment. Which statement indicates to the nruse that the parents understand?
a. C- administer aerosol therapy followed by a postural drainage before meals.
a.i. Postrural drainage for a child w/ cystic fibrosis is most effective when performed after nebulization and before meals or at least 1 hour after eating to prevent nausea & vomiting. Postural drainage uses gravity to promote mucous removal after nebulization (which open airways).. Pulmonary toileting or respiratory treatment should be given 3-4 times daily, not esisodically
A 4- yr old boy was admitted to the emergency room w/ fractured right ulna and a short arm cast is applied. When preparing the parents to take the child home, which discharge instruction has the highest priority?
a. A- call the healthcare provider immediately if his nailbeds appear blue.
a.i. A- Cyanosis indicates impaired circulation to fingers and should be reported immediately. Although the actions described may be indicated, they are implemented rather excessively & might tend to frighten the parents. It is not necessary to check the child's ability to move his fingers hourly for 2 days.
A 3 week old newborn is brought to the clinic for a follow up after a home birth. The mother reports that her child bottle feeds for 5 min only and falls asleep. The nurse auscultates a loud murmur characteristic of a ventricular septal defect (VSD), and finds the newborn is acyanotic w/ respiratory rate of 64 breaths per min. What instruction should the nurse provide the mother to ensure the infant is receiving adequate intake? (Select all that apply)
A- Monitor the infant's weight and # of wet diapers per day
B- Increase the infant's intake per feeding by 1-2 ounces per week
d. allow the infant to rest and reefed on demand or every 2 hrs
E. use a softer nipple or increase the size of the nipple opening
Rationale: Correct responses are A,B,D, E. neonates who have VSD may fatigue quickly during feeding and ingest inadequate amounts. They should be monitored for weight gain and at least 6 wet diapers per day. A one month old should ingest 2-4 ounces of formula per feeding and progress to about 30 ounces per day by 4 months of age. Due to fatigue, the infant should rest, but feed at least every 2 hours to ensure adequate intake. A softer (preemie) nipple or a larger slit in the nipple helps to reduce the sucking effort and energy expenditure, thus allowing the infant to ingest more w/ less effort. Antibiotoic prophylaxis is recommended for infants w/ VSDs, but should not be mixed in a bottle of formula because it is difficult to ensure tha the total dose is consumed
During routine screening at a school clinic, an otoscope examination of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. What action should the nurse take next?
a. B- Ask the child if he/she has had cold, runny nose, or any ear pain lately.
a.i. More information is needed to interpret these finding, the tympanic membrane is normally pearly gray, not bulging, and moves when the client blows against resistance or a small puff of air is blown into the ear canal. Since this child's findings are not completely normal, further assessment of hx and related s/s is indicated for accurate interpretation of the finding.
Which behavior should the nurse expect a two-year-old child to exhibit?
a. C- display possessiveness of toys
a.i. Two year old children are egocentric and unable to share w/ other children and behaviors of a preschooler.
The nurse is teaching a mother to give 4ml of a liquid antibiotic to a 10 month old infant. Which statement by the parent indicates a need for further teaching?
a. B- using a teaspoon will help me measure this correctly
a.i. The prescribed medication is 4ml dosage and is measured w/ the most accuracy using a syringe, so if the parent uses teaspoon which is equiavelnt to 5ml, further teaching is indicated
A 3 yr old client w/ sickle cell anemia is admitted to the ER w/ abdominial pain. The nurse palapates an enlarged liver, and x ray reveals an enlarged spleen, and a CBC reveals anemia. These findings indicate which type of crisis?
a. B- sequestration this support a sequestration crisis where blood pools in the spleen, and is characterized by abdominal pain anemia
A 14 yr old female client tells the nurse that she is concerned about the acne she has recently developed/ Which recommendation should the nurse provide?
a. C- wash the hair and skin frequently w/ soap and hot water
a.i. Washing the hair & skin w/ soap & hot water removes oil debris fr. the skin and helps prevent & treat acne. Oily skin especially bothersome during adolescence when hormones cause enlargement of sebaceous glands and increased glandular secretions which predispose the teenager to acne is contraindicated. Cosmetics "medicated" or not should be used sparingly to avoid further blocking sebaceous gland ducts. Might be indicated at a later time, if healthcare recommendations are not successful.
An 18 month old is admitted to the hospital w/ possible Hirschsprung's disease. When obtaining a nursing hx the nurse asks about bowel habits. What description of the disease?
a. D- Ribbon-like and brown
a.i. Hirschsprung's disease is a mechanical obstruction caused by inadequate motility in a part of the intestines. The condition results fr. failure of ganglion cells to migrate craniocaudally along the GI tract during gestation. The lack of peristalsis in the affected bowel segment causes constripation and smaller diameter, brown colored stools
When planning the care for a child who has had a cleft lip repair, the nurse knows that crying should be minimized because it
a. D- prevention of stress on the lip suture line is essential for optimum healing and the cosmetic appearance of a cleft lip repair. Although crying causes (increased salvation, leads to vomiting, stresses the suture line) these conditions do not create a problem for the child w/ a cleft lip repair
A 15 yr old girl tells the school nurse that all of her friends have started their periods and she feels abnormal because she has not. Which response is best for the nurse provide?
a. C- explain that menarche varies and occurs between the ages of 12-18 years
As part of the physical assessment of children, the nurse observes and palpates the fontanels. Which child's fontanel finding should be reported to the healthcare provider?
a. A- a 6 moth old w/ failure to thrive that has a closed anterior fontanel
a.i. @ 6 months of age the anterior fontanel should be open, and it should not be closed until approx 18 months
A 2 yr old child w/ gastro-esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parent's teaching plan?
a. D- a 2- year old child is comforted by consistency
The nurse is assessing a 2 year old. What behavior indicates that the child's language development is within normal limits?
a. D- half of a child's speech is understandable
a.i. Between approximately 15 & 24 months of age, a child's speech is only ½ understandable
What preoperative nursing intervention should be included in the plan of care for an infant w/ pyloric stenosis?
a. D- observe for projectile vomiting
a.i. Projectile vomiting, which contributes to metabolic alkalosis is the classic sign of pyloric stenosis
When evaluating the effectiveness of interventions to improve the nutritional status of an infant w/ gastro-esphageal reflux, which intervention is most important for the nurse to implement?
a. A- record weight daily
a.i. The most definitive measure of improved nutrition is an infant is obtaining the child's daily weight
Which finding in a 19 yr old female client should trigger further assessment by the nurse?
a. A- menstruation has not occurred
a.i. Menstruation is an expected secondary sex characteristic that occurs with pubescence and typically occurs by age 18, so A should prompt further investigation to determine the cause of this primary amenorrhea. Children receive tetanus as part of the DPT childhood immunization series, and a booster is not typically given until age 16.
A 6 month old boy and his mother are at healthcare provider's office for a well-baby check up and routine immunizations. The healthcare provider recommends to the mother that the child receive an influenza vaccine. What medications should the nurse plan to administer today?
a. B- all the immunizations w/ the influenza vaccine given at a separate site fr. any other injection
a.i. At 6 months of age, the routine immunizations should HEP B, DTaP, Hib, PCV (pneumococcal) , IPV (inactivated poliovirus) and influenza. The influenza vaccine should be given at a separate site fr. any other injection.
A nurse who is working in the Poison Control Center receives several telephone calls from parents whose children have ingested possible poisons. The nurse should recommend inducing vomiting for which child?
16-month old who drank 2 ounces of acetaminophen (Tylenol) elixir.

Cleft Lip and Cleft Palate- HESIPage 11.A Complication Occurs"Push, push, push!" Mario urges while holding Isabella's hand and watching as hisfirst-born child makes an entrance into the world. As the infant is delivered, the entire room becomes quiet and Isabella sees a look of concern on her husband's face. The baby boy is crying loudly, but the upper lip appears to be missing, and his face looks deformed. The infant is quickly placed under the radiant warmer and dried. His 1 minute Apgar score is 8. Isabella is frightened, and she has not seen her newborn son yet. "What is wrong with my baby? What is going on?" she cries.2.1.ID: 6975144170Which action should the labor and delivery nurse take?A.Explain that she has a healthy baby boy with a great cry.Her son may be healthy and have a great cry, but he has a facial abnormality that will require repair.B.Wait for the obstetrician to tell Isabella what is happening.The nurse should implement another action without waiting for the obstetrician to talk to Isabella.C.Answer Isabella's questions and allow her to see her son. CorrectThe nurse should answer Isabella's questions and allow her to see her son since he is crying and not in immediate danger. This will allow for bonding between the mother and her baby. The nurse should stay with the couple in case they have any questions or need emotional support.D.Take the infant to the neonatal intensive care unit immediately.Since the infant is not in any respiratory or cardiovascular distress, there is noneed to admit him into the neonatal ICU.CorrectAwarded 1.0 points out of 1.0 possible points.3.The labor and delivery nurse knows that many infants with a cleft lip also have a cleft palate.4.2.ID: 6975144172Which assessment technique will determine if the infant has a cleft palate?The palate is the roof of the mouth, and palpating this area with the finger willdetermine if the palate is open (cleft) or closed (not cleft).

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