maternity practice 2

Q1. The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by evaporation?
1. Warming the crib pad
2. Closing the doors to the room
3. Drying the infant with a warm blanket
4. Turning on the overhead radiant warmer

3. Drying the infant with a warm blanket

Q2. The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord was moist and that discharge was present. What is the most appropriate nursing instruction for this mother?
1. Bring the infant to the clinic.
2. This is a normal occurrence.
3. Increase the number of times that the cord is cleaned per day.
4. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.

1. Bring the infant to the clinic.

Q3. The nurse is assessing a newborn after circumcision and notes that the circumcised area is red with a small amount of bloody drainage. Which nursing action is most appropriate ?
1. Apply gentle pressure.
2. Reinforce the dressing.
3. Document the finding.
4. Contact the health care provider (HCP).

3. Document the finding.

Q4. The nurse adminsters erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis ?
1. Protects the newborn's eyes from possible infections acquired while hospitalized.
2. Prevents cataracts in the newborn born to a woman who is susceptible to rubella.
3. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor.
4. Prevents an infection called ophthalmia neonatorum from occuring after delivery in a newborn born to a mother with an untreated gonococcal infection.

4. Prevents an infection called ophthalmia neonatorum from occuring after delivery in a newborn born to a mother with an untreated gonococcal infection.

Q5. The nurse prepares to administer a vitamin K injection to a newborn, and the mother asks the nurse why her infant needs the injection. What best response should the nurse provides?
1. "Your newborn needs vitamin K to develop immunity."
2. "The vitamin K will protect your newborn form being jaundiced."
3. "Newborns have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel."
4. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

4. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

Q6. At each well-child visit, the neonate's anterior and posterior fontanelles are inspected and palpated. The posterior fontanelle should be closed by age:
1. 2 months
2. 6 months
3. 9 months
4. 12 months

1. 2 months

Q7. A 12-hour-old neonate has edema on the scalp that crosses the suture lines. This is:
1. Cephalohematoma
2. Caput succedaneum
3. Molding
4. Craniosynostosis

2. Caput succedaneum

Q8. The corneal blink reflex disappears:
1. Approximately 4 hours after birth
2. At age 4 to 6 months
3. After the child is walking
4. Never

4. Never

Q9. Of the following, which assessment finding is most indicative of a full-term infant?
1. Long lanugo present on the infant's back
2. Incurving of the upper pinnae only
3. Palpable breast tissue of 8mm
4. Transparent skin over the abdomen

3. Palpable breast tissue of 8mm

Q10. An otherwise healthy 3-day-old infant has small, yellowish-white, 1 mm papules scattered in a transverse, linear distribution along the nasal groove. These lesions are most likely:
1. Erythema toxicum
2. Millia
3. Cutis aplasia
4. Telangiectatic nevi

2. Millia

Q11. Of the following assessment findings in the newborn, which is considered an abnormal finding?
1. Deconjugate gaze
2. Webbed neck
3. Sebaceous cyst on gums
4. Head lag

2. Webbed neck

Q12. Most primitive reflexes in the newborn disappear by age:
1. 2 to 3 months
2. 4 to 6 months
3. 6 to 8 months
4. 8 to 10 months

4. 8 to 10 months

Q14. Which of the following is true regarding Mongolian spots?
1. These lesions are often mistaken for bruising.
2. These birthmarks occur predominantly in Caucasian children.
3. These lesions are at high risk for becoming malignant.
4. The birthmarks are bright red in color.

1. These lesions are often mistaken for bruising.

Q15. Weak or absent femoral pulses in the neonate are indicative of:
1. Coarctation of the aorta
2. Ventricular septal defect
3. Normal transition from fetal circulation
4. Atrial septal defect

1. Coarctation of the aorta

Q1. The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the admission of a 43 weeks gestation newborn with Apgar scores of 1 and 4. In planning for admission of this newborn, what is the nurse's highest priority?
1. Turn on the apnea and cardiorespiratory monitors.
2. Connect the resuscitation bag to the oxygen outlet.
3. Set up the intravenous line with 5% dextrose in water.
4. Set the radiant warmer control temperature at 36.5 °C (97.6 °F).

2. Connect the resuscitation bag to the oxygen outlet.

Q2. The nurse is in a newborn nursery is monitoring a preterm infant newborn for respiratory distress syndrome. Which assessment findings would alert the nurse to the possibility of this syndrome ?
1. Tachypnea and retraction
2. Acrocyanosis and grunting
3. Hypotension and bradycardia
4. Presence of a barrel chest and acrocyanosis

2. Acrocyanosis and grunting

Q3. The postpartum nurse is providing instructions to the mother of a newborn with hyperbilirubinemia who is being breast-fed. The nurse should provide which most appropriate instruction to the mother ?
1. Feed the newborn less frequently.
2. Continue to breast-feed every 2 to 4 hours.
3. Switch to bottle-feeding the infant for 2 weeks.
4. Stop breast-feeding and switch to bottle-feeding permanently.

2. Continue to breast-feed every 2 to 4 hours.

Q4. The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which assessment finding would the nurse expect to note during the assessment of this newborn ?
1. Lethargy
2. Sleepiness
3. Constant crying
4. Cuddles when being held

3. Constant crying

Q5. The nurse notes hypotonia, irritability, and a poor sucking reflex in a full-term newborn on admission to the nursery. The nurse suspects fetal alcohol syndrome and is aware that which additional sign would be consistent with this syndrome ?
1. Length of 19 inches (48cm)
2. Abnormal palmar creases
3. Birth weight of 6 lb, 14 oz (2890grams)
4. Head circumference appropriate for gestational age

2. Abnormal palmar creases

Q6. The nurse is preparing a plan of care for a newborn with fetal alcohol syndrome. The nurse should include which priority intervention in the plan of care ?
1. Allow the newborn to establish own sleep-rest pattern.
2. Maintain the newborn in a brightly lightened area of staff and parents.
3. Encourage frequent handling of the newborn by staff and parents.
4. Monitor the newborn's response to feedings and weight gain pattern.

4. Monitor the newborn's response to feedings and weight gain pattern.

Q7. The nurse is preparing to care for a newborn receiving phototherapy. Which interventions should be included in the plan of care ? Select all that apply.
1. Avoid stimulation.
2. Decreased fluid intake.
3. Expose all of the newborn's skin.
4. Monitoring skin temperature closely.
5. Reposition the newborn every 2 hours.
6. Cover the newborn's eyes with eye shields or patches.

4. Monitoring skin temperature closely.
5. Reposition the newborn every 2 hours.
6. Cover the newborn's eyes with eye shields or patches.

Q8. The nurse develops a plan of care for a woman with human immunodeficiency virus infection and her newborn. The nurse should include which intervention in the plan of care ?
1. Monitoring the newborn's vital signs routinely
2. Maintaining standard precautions at all times while caring for the newborn 3. Initiating referral to evaluate for blindness, deafness, learning problems, or behavioral problems
4. Instructing the breast-feeding mother regarding the treatment of the nipples with nystatin ointment

2. Maintaining standard precautions at all times while caring for the newborn

Q9. The nurse is planning care for a newborn of a mother with diabetes mellitus. What is the priority nursing consideration for this newborn ?
1. Developmental delays because of excessive size
2. Maintaining safety because of low blood glucose level
3. Choking because of impaired suck and swallow reflexes
4. Elevated body temperature because of excess fat and glycogen

2. Maintaining safety because of low blood glucose level

Q10. Which statement reflects a new mother's understanding of the reaching about the prevention of newborn abduction?
1. "I will place my baby's crib close to the door"
2. "Some health care personnel won't have name badges."
3. "It's OK to allow the unlicensed assistive personnel to carry my newborn to the nursery."
4. "I will ask the nurse to attend to my infant if I am napping and my husband is not here."

4. "I will ask the nurse to attend to my infant if I am napping and my husband is not here."

Q11. Which of following is a sign of post-maturity in the newborn? (Select all that apply)
1. Peeling, cracked skin
2. Fine hair covering the body
3. Presence of vernix caseosa covering the body
4. Long, brittle fingernails
5. Greenish coloring of the skin

1. Peeling, cracked skin
4. Long, brittle fingernails
5. Greenish coloring of the skin

Q1. The nurse is monitoring a child with burns during treatment for burn shock. The nurse understands that which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation?
1. Skin turgor
2. Neurological assessment
3. Level of edema at burn site
4. Quality of peripheral pulses

2. Neurological assessment

Q2. The mother of a 3-year-old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child's skin? 1. Fine grayish red lines
2. Purple-colored lesions
3. Thick, honey-colored crusts
4. Clusters of fluid-filled vesicles

1. Fine grayish red lines

Q3. Permethrin (Elimite) is prescribed for a child with a diagnosis of scabies. The nurse should give which instruction to the parents regarding the use of this treatment?
1. Apply the lotion to areas of the rash only.
2. Apply the lotion and leave it on for 6 hours.
3. Avoid putting clothes on the child over the lotion.
4. Apply the lotion to cool, dry skin at least 30 minutes after bathing.

4. Apply the lotion to cool, dry skin at least 30 minutes after bathing.

Q4. The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction?
1. "It is extremely contagious."
2. "It is most common in humid weather."
3. "Lesions most often are located on the arms and chest."
4. "It might show up in an area of broken skin, such as an insect bite."

3. "Lesions most often are located on the arms and chest."

Q5. The clinic nurse is reviewing the health care provider's prescription for a child who has been diagnosed with scabies. Lindane has been prescribed for the child. The nurse questions the prescription if which is noted in the child's record?
1. The child is 18 months old.
2. The child is being bottle-fed.
3. A sibling is using lindane for the treatment of scabies.
4. The child has a history of frequent respiratory infections.

1. The child is 18 months old.

Q6. A topical corticosteroid is prescribed by a health care provider for a child with atopic dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream?
1. Apply the cream over the entire body.
2. Apply a thick layer of cream to affected areas only.
3. Avoid cleansing the area before application of the cream.
4. Apply a thin layer of cream and rub it into the area thoroughly.

4. Apply a thin layer of cream and rub it into the area thoroughly.

Q7. The school nurse is conducting pediculosis capitis (head lice) assessments. Which finding indicates a child has a "positive" head check?
1. Maculopapular lesions behind the ears
2. Lesions in the scalp that extend to the hairline or neck
3. White flaky particles throughout the entire scalp region
4. White sacs (Nits) attached to the hair shafts in the occipital area

4. White sacs (Nits) attached to the hair shafts in the occipital area

Q8. The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply.
1. Scarring is less severe in a child than in an adult.
2. A delay in growth may occur after a burn injury.
3. An immature immune system presents an increased risk of infection for infants and young children.
4. The lower proportion of body fluid to mass in a child increases the risk of cardiovascular problems.
5. Fluid resuscitation is unnecessary unless the burned area is more than 25% of the total body surface area.
6. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.

2. A delay in growth may occur after a burn injury.
3. An immature immune system presents an increased risk of infection for infants and young children.
6. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.

Q1. The nurse analyzes the laboratory results of a child with hemophilia. The nurse understands that which result will most likely be abnormal in this child? 1. Platelet count
2. Hematocrit level
3. Hemoglobin level
4. Partial thromboplastin time (PTT)

4. Partial thromboplastin time (PTT)

Q2. The nurse is providing home care instructions to the parents of a 10-year-old child with hemophilia. Which sport activity should the nurse suggest for this child?
1. Soccer
2. Basketball
3. Swimming
4. Field hockey

3. Swimming

Q3. The nursing student is presenting a clinical conference and discusses the cause of ß-thalassemia. The nursing student informs the group that a child at greatest risk of developing this disorder is which one?
1. A child of Mexican descent
2. A child of Mediterranean descent
3. A child whose intake of iron is extremely poor
4. A breast-fed child of a mother with chronic anemia

2. A child of Mediterranean descent

Q4. A child with ß-thalassemia is receiving long-term blood transfusion therapy for the treatment of the disorder. Chelation therapy is prescribed as a result of too much iron from the transfusions. Which medication should the nurse anticipate to be prescribed?
1. Fragmin
2. Meropenem (Merrem)
3. Metoprolol (Toprol-XL)
4. Deferoxamine (Desferal)

4. Deferoxamine (Desferal)

Q5. The clinic nurse instructs parents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further instructions?
1. Stress
2. Trauma
3. Infection
4. Fluid overload

4. Fluid overload

Q6. A 10-year-old child with hemophilia A has slipped on the ice and bumped his knee. The nurse should prepare to administer which prescription?
1. Injection of factor X
2. Intravenous infusion of iron
3. Intravenous infusion of factor VIII
4. Intramuscular injection of iron using the Z-track method

3. Intravenous infusion of factor VIII

Q7. The nurse is instructing the parents of a child with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction should the nurse tell the parents?
1. Administer the iron at mealtimes.
2. Administer the iron through a straw.
3. Mix the iron with cereal to administer.
4. Add the iron to formula for easy administration.

2. Administer the iron through a straw.

Q8. Laboratory studies are performed for a child suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia?
1. Elevated hemoglobin level
2. Decreased reticulocyte count
3. Elevated red blood cell count
4. Red blood cells that are microcytic and hypochromic

4. Red blood cells that are microcytic and hypochromic

Q9. The nurse is reviewing a health care provider's prescription for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? Select all that apply.
1. Restrict fluid intake.
2. Position for comfort.
3. Avoid strain on painful joints.
4. Apply nasal oxygen at 2 L/minute.
5. Provide a high-calorie, high-protein diet.
6. Give meperidine (Demerol), 25 mg intravenously, every 4 hours for pain.

1. Restrict fluid intake.
6. Give meperidine (Demerol), 25 mg intravenously, every 4 hours for pain

Q10. The nurse is conducting staff in-service training on von Willebrand's disease. Which should the nurse include as characteristics of von Willebrand's disease? Select all that apply.
1. Easy bruising occurs.
2. Gum bleeding occurs.
3. It is a hereditary bleeding disorder.
4. Treatment and care are similar to that for hemophilia.
5. It is characterized by extremely high creatinine levels.
6. The disorder causes platelets to adhere to damaged endothelium.

1. Easy bruising occurs.
2. Gum bleeding occurs.
3. It is a hereditary bleeding disorder.
4. Treatment and care are similar to that for hemophilia.
6. The disorder causes platelets to adhere to damaged endothelium.

Q1. The nurse is monitoring a child for bleeding after surgery for removal of a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which intervention should the nurse perform immediately?
1. Reinforce the dressing.
2. Notify the health care provider (HCP).
3. Document the findings and continue to monitor.
4. Circle the area of drainage and continue to monitor.

2. Notify the health care provider (HCP).

Q2. A child undergoes surgical removal of a brain tumor. During the postoperative period, the nurse is monitoring the child and notes that the child is restless, the pulse rate is elevated, and the blood pressure has decreased significantly from the baseline value. The nurse suspects that the child is in shock. Which is the most appropriate nursing action?
1. Notify the HCP.
2. Place the child in a supine position.
3. Place the child in Trendelenburg's position.
4. Increase the flow rate of the intravenous fluids.

1. Notify the HCP.

Q3. The mother of a 4-year-old child tells the pediatric nurse that the child's abdomen seems to be swollen. During further assessment of subjective data, the mother tells the nurse that the child is eating well and that the activity level of the child is unchanged. The nurse, suspecting the possibility of Wilms' tumor, should avoid which during the physical assessment?
1. Palpating the abdomen for a mass
2. Assessing the urine for the presence of hematuria
3. Monitoring the temperature for the presence of fever
4. Monitoring the blood pressure for the presence of hypertension

1. Palpating the abdomen for a mass

Palpating a mass too vigorously could lead to the rupture of a large tumor into the peritoneal cavity.

Q4. The pediatric nurse specialist provides a teaching session to the nursing staff regarding osteosarcoma. Which statement by a member of the nursing staff indicates a need for information?
1. "The femur is the most common site of this sarcoma."
2. "The child does not experience pain at the primary tumor site."
3. "Limping, if a weight-bearing limb is affected, is a clinical manifestation."
4. "The symptoms of the disease in the early stage are almost always attributed to normal growing pains."

2. "The child does not experience pain at the primary tumor site."

Osteosarcoma most often occurs in the long bones that make up the arms and legs, though it can occur in any bone. It tends to occur in children and young adults.
Symptoms include localized bone pain and swelling.

Q5. The nurse analyzes the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse notes that the platelet count is 19,500 cells/mm3 . On the basis of this laboratory result, which intervention should the nurse include in the plan of care?
1. Initiate bleeding precautions.
2. Monitor closely for signs of infection.
3. Monitor the temperature every 4 hours.
4. Initiate protective isolation precautions.

1. Initiate bleeding precautions.


Normal level of platelet count: 150,000 to 450,000 platelets per microliter of blood

Q6. The nurse is monitoring a 3-year-old child for signs and symptoms of increased intracranial pressure (ICP) after a craniotomy. The nurse plans to monitor for which early sign or symptom of increased ICP?
1. Vomiting
2. Bulging anterior fontanel
3. Increasing head circumference
4. Complaints of a frontal headache

1. Vomiting

Q7. A 4-year-old child is admitted to the hospital for abdominal pain. The mother reports that the child has been pale and excessively tired and is bruising easily. On physical examination, lymphadenopathy and hepatosplenomegaly are noted. Diagnostic studies are being performed on the child because acute lymphocytic leukemia is suspected. The nurse understands that which diagnostic study should confirm this diagnosis?
1. Platelet count
2. Lumbar puncture
3. Bone marrow biopsy
4. White blood cell count

3. Bone marrow biopsy

Acute lymphocytic leukemia (ALL) is a type of cancer of the blood and bone marrow

Q8. A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and protective isolation procedures are initiated. The grandmother of the child visits and brings a fresh bouquet of flowers picked from her garden and asks the nurse for a vase for the flowers. Which response should the nurse provide to the grandmother?
1. "I have a vase in the utility room, and I will get it for you."
2. "l will get the vase and wash it well before you put the flowers in it."
3. "The flowers from your garden are beautiful, but should not be placed in the child's room at this time."
4. "When you bring the flowers into the room, place them on the bedside stand as far away from the child as possible."

3. "The flowers from your garden are beautiful, but should not be placed in the child's room at this time."

Q9. A diagnosis of Hodgkin's disease is suspected in a 12-year-old child seen in a clinic. Several diagnostic studies are performed to determine the presence of this disease. Which diagnostic test result will confirm the diagnosis of Hodgkin's disease?
1. Elevated vanillylmandelic acid urinary levels
2. The presence of blast cells in the bone marrow
3. The presence of Epstein-Barr villas in the blood
4. The presence of Reed-Sternberg cells in the lymph nodes

4. The presence of Reed-Sternberg cells in the lymph nodes

Reed-Sternberg cells are large, abnormal lymphocytes (a type of white blood cell) that may contain more than one nucleus. These cells are found in people with Hodgkin lymphoma.

Q10. Which specific nursing interventions are implemented in the care of a child with leukemia who is at risk for infection? Select all that apply.
1. Maintain the child in a semiprivate room.
2. Reduce exposure to environmental organisms.
3. use strict aseptic technique for all procedures.
4. Ensure that anyone entering the child's room wears a mask,
5. Apply firm pressure to a needle stick area for at least 10 minutes

2. Reduce exposure to environmental organisms.
3. use strict aseptic technique for all procedures.
4. Ensure that anyone entering the child's room wears a mask,

Q11. The nurse is performing an assessment on a 10-year-old child suspected to have Hodgkin's disease. The nurse understands that which assessment findings are specifically characteristic of this disease? Select all that apply.
1. Abdominal pain
2. Fever and malaise
3. Anorexia and weight loss
4. Painful, enlarged inguinal lymph nodes
5. Painless, firm, and movable adenopathy in the cervical area

1. Abdominal pain
5. Painless, firm, and movable adenopathy in the cervical area

Hodgkin's lymphoma is a type of cancer that affects the lymphatic system, which is part of the body's germ-fighting immune system.

Q1. A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The school nurse provides instructions regarding how to prevent hypoglycemia during practice. Which should the school nurse tell the child to do?
1. Eat twice the amount normally eaten at lunchtime.
2. Take half the amount of prescribed insulin on practice days.
3. Take the prescribed insulin at noontime rather than in the morning.
4. Eat a small box of raisins or drink a cup of orange juice before soccer practice.

4. Eat a small box of raisins or drink a cup of orange juice before soccer practice.

Q2. The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action?
1. Hold the next dose of insulin.
2. Come to the clinic immediately
3. Encourage the child to drink liquids.
4. Administer an additional dose of regular insulin.

3. Encourage the child to drink liquids.

Euglycemic DKA treatment is on the same principles as for DKA with correction of dehydration, electrolytes deficit and insulin replacement.

Q3. A health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription?
1. Obtains a weight
2. Takes the temperature
3. Takes the blood pressure
4. Checks the amount of urine output

4. Checks the amount of urine output

Q4. An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note?
1. Sweating and tremors
2. Hunger and hypertension
3. Cold, clammy skin and irritability
4. Fruity breath odor and decreasing level of consciousness

4. Fruity breath odor and decreasing level of consciousness

Q5. A mother brings her 3-week-old infant to a clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 1 mg/ dL. The nurse reviews this result and makes which interpretation ?
1. It is positive.
2. It is negative.
3. It is inconclusive.
4. It requires rescreening at age 6 weeks.

2. It is negative.

1.2-3.4 normal range

Q6. A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of e abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion?
1. Potassium infusion
2. NPH insulin infusion
3. 5% dextrose infusion
4. Normal saline infusion

4. Normal saline infusion (for dehydration)

Q7. The nurse has just administered ibuprofen (Motrin 1B) to a child with a temperature of 38.8 0 C (102 0 F). The nurse should also take which action?
1. Withhold oral fluids for 8 hours.
2. Sponge the child with cold water.
3. Plan to administer salicylate (aspirin) in 4 hours.
4. Remove excess clothing and blankets from the child.

4. Remove excess clothing and blankets from the child.

Q8. A child has fluid volume deficit. The nurse performs an assessment and determines that the child is improving and the deficit is resolving if which finding is noted?
1. The child has no tears.
2. Urine specific gravity is 1.030.
3. Urine output is less than 1 mL/kg/hr.
4. Capillary refill is less than 2 seconds.

4. Capillary refill is less than 2 seconds.

1.2.3 severe dehydration

Q9. The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/ dL? Select all that apply.
1. Administer regular insulin.
2. Encourage the child to ambulate.
3. Give the child a teaspoon of honey.
4. Provide electrolyte replacement therapy intravenously.
5. Wait 30 minutes and confirm the blood glucose reading.
6. Prepare to administer glucagon subcutaneously if unconsciousness occurs.

3. Give the child a teaspoon of honey.
6. Prepare to administer glucagon subcutaneously if unconsciousness occurs

Q1. A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem?
1. Diarrhea
2. Metabolic acidosis
3. Metabolic alkalosis
4. Hyperactive bowel sounds

3. Metabolic alkalosis

Q2. An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time?
1. Prone position
2. On the stomach
3. Left lateral position
4. Right lateral position

3. Left lateral position

Q3. The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record?
1. Incessant crying
2. Coughing at nighttime
3. Choking with feedings
4. Severe projectile vomiting

3. Choking with feedings

Q4. The nurse provides feeding instructions to a parent of an infant diagnosed with gastroesophageal reflux disease. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis?
1. Provide less frequent, larger feedings.
2. Burp the infant less frequently during feedings.
3. Thin the feedings by adding water to the formula.
4. Thicken the feedings by adding rice cereal to the formula.

4. Thicken the feedings by adding rice cereal to the formula.

Q5. The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the mother about the child's symptoms?
1. Watery diarrhea
2. Projectile vomiting
3. Increased urine output
4. Vomiting large amounts of bile

2. Projectile vomiting

Pyloric stenosis is a problem that affects babies between birth and 6 months of age and causes forceful vomiting that can lead to dehydration. It is the second most common problem requiring surgery in newborns. The lower portion of the stomach that connects to the small intestine is known as the pylorus.

Q6. The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet?
1. Rice
2. Oatmeal
3. Rye toast
4. Wheat bread

1. Rice

Coeliac disease is a condition where your immune system attacks your own tissues when you eat gluten.

Q7. The clinic nurse reviews the record of an infant and notes that the health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which symptom most likely led the mother to seek health care for the infant?
1. Diarrhea
2. Projectile vomiting
3. Regurgitation of feedings
4. Foul-smelling ribbon-like stools

4. Foul-smelling ribbon-like stools


What is Hirschsprung's disease? Hirschsprung's disease (also called congenital aganglionic megacolon) occurs when some of your baby's intestinal nerve cells (ganglion cells) don't develop properly, delaying the progression of stool through the intestines.

Q8. The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which symptom of this disorder documented?
1. Watery diarrhea
2. Ribbon-like stools
3. Profuse projectile vomiting
4. Bright red blood and mucus in the stools

4. Bright red blood and mucus in the stools

Intussusception (in-tuh-suh-SEP-shun) is a serious condition in which part of the intestine slides into an adjacent part of the intestine. This telescoping action often blocks food or fluid from passing through. Intussusception also cuts off the blood supply to the part of the intestine that's affected.

Q9. The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder?
1. Bile-stained fecal emesis
2. The passage of currant jelly—like stools
3. Failure to pass meconium stool in the first 24 hours after birth
4. Sausage-shaped mass palpated in the upper right abdominal quadrant

3. Failure to pass meconium stool in the first 24 hours after birth

Q10. Which interventions should the nurse include when preparing a care plan for a child with hepatitis? Select all that apply.
1. Providing a low-fat, well-balanced diet.
2. Teaching the child effective hand-washing techniques.
3. Scheduling playtime in the playroom with other children.
4. Notifying the health care provider (HCP) if jaundice is present.
5. Instructing the parents to avoid administering medications unless prescribed.
6. Arranging for indefinite home schooling because the child will not be able to return to school

1. Providing a low-fat, well-balanced diet.
2. Teaching the child effective hand-washing techniques.
5. Instructing the parents to avoid administering medications unless prescribed.

Q1. After a tonsillectomy, a child begins to vomit bright red blood. The nurse should take which initial action?
1. Maintain NPO status.
2. Turn the child to the side.
3. Administer the prescribed antiemetic.
4. Notify the health care provider (HCP)

2. Turn the child to the side.

Q2. The mother of a 6-year-old child arrives at a clinic because the child has been experiencing scratchy, red, and swollen eyes. The nurse notes a discharge from the eyes and sends a culture to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. On the basis of this diagnosis, the nurse determines that which requires further investigation?
1. Possible trauma
2. Possible sexual abuse
3. Presence of an allergy
4. Presence of a respiratory infection

2. Possible sexual abuse

Q3. The nurse prepares a teaching plan for the mother of a child diagnosed with bacterial conjunctivitis. Which, if stated by the mother, indicates a need for further teaching?
1. "I need to wash my hands frequently."
2. "I need to clean the eye as prescribed."
3. "It is okay to share towels and washcloths."
4. "I need to give the eye drops as prescribed."

3. "It is okay to share towels and washcloths."

Q4. The nurse is reviewing the laboratory results for a child scheduled for tonsillectomy. The nurse determines that which laboratoy value is most significant to review ?
1. Creatinine level
2. Prothrombin time
3. Sedimentation rate
4. Blood urea nitrogen level

2. Prothrombin time

Q5. The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position ?
1. Supine
2. Side-lying
3. High Fowler's
4. Trendelenburg's

2. Side-lying

Q6. After a tonsillectomy, the nurse reviews the health care provider's (HCP's) postoperative prescriptions. Which prescription should the nurse question ?
1. Monitor for bleeding.
2. Suction every 2 hours.
3. Give no milk or milk products.
4. Give clear, cool liquids when awake and alert

2. Suction every 2 hours.

Q7. The nurse is caring for a child after a tonsillectomy. The nurse monitors the child, knowing that which finding indicates the child is bleeding ?
1. Frequent swallowing
2. A decreased pulse rate
3. Complaints of discomfort
4. An elevation in blood pressure

1. Frequent swallowing

Q8. Antibiotics are prescribed for a child with otitis media who underwent a myringotomy with insertion of tympanostomy tubes. The nurse provides discharge instructions to the parents regarding the administration of the antibiotics. Which statement, if made by the parents, indicates understanding of the instructions provided ?
1. "Administer the antibiotics until they are gone and full course needs to be completed as prescribed."
2. "Administer the antibiotics if the child has a fever."
3. "Administer the antibiotics until the child feels better."
4. "Begin to taper the antibiotics after 3 days of a full course."

1. "Administer the antibiotics until they are gone and full course needs to be completed as prescribed."

Q9. The day care nurse is observing a 2-year-old child and suspects that the child may have strabismus*. Which observation made by the nurse indicates the presence of this condition ?
1. The child has difficulty hearing.
2. The child consistently tilts the head to see.
3. The child does not respond when spoken to.
4. The child consistently turns the head to hear.

2. The child consistently tilts the head to see.

* Strabismus is a condition in which the eyes are not aligned becaused of lack of coordination of the extraocular muscles.

Q10. A child has been diagnosed with acute otitis media (AOM) of the right ear. Which interventions should the nurse include in the plan of care ? Select all that apply.
1. Provide a soft diet.
2. Position the child on the left side.
3. Administer an antihistamine twice daily.
4. Irrigate the right ear with normal saline every 8 hours.
5. Administer ibuprofen (Motrin IB) for fever every 4 hours as prescribed and as needed.
6. Instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy.

1. Provide a soft diet.
5. Administer ibuprofen (Motrin IB) for fever every 4 hours as prescribed and as needed.
6. Instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy.

Q1. A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition?
1. Warm, dry skin
2. Decreased wheezing*
3. Pulse rate of 90 beats/minute
4. Respirations of 18 breaths/minute

2. Decreased wheezing*

* Decreased wheezing in a child with asthma may be interpreted incorrectly as an improving sign when it may actually signal an inability to move air. "A silence chest" is a worsening sign during an asthma episode. With treatment, increased wheezing actually may signal that the child's condition is improving

Q2. The mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen (Motrin IB) is not effective. Which instruction should the nurse provide to the mother?
1. Increase the dose of ibuprofen.
2. Increase the frequency of ibuprofen.
3. Encourage the child to lie on the left side.
4. Encourage the child to lie on the right side.

4. Encourage the child to lie on the right side. （on the affected side）

Q3. A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant?
1. Side or prone
2. Back or prone
3. Stomach with the face turned
4. Back rather than on the stomach

4. Back rather than on the stomach

Q4. The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent?
1. "The immunization schedule will need to be altered."
2. "The child should not receive any hepatitis vaccines. "
3. "The child will receive all the immunizations except for the polio series."
4. "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."

4. "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."

Q5. The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction?
1. The child exhibits nasal flaring and bradycardia.
2. The child is leaning forward, with the chin thrust out.
3. The child has a low-grade fever and complains of a sore throat.
4. The child is leaning backward, supporting himself or herself with the hands and arms.

2. The child is leaning forward, with the chin thrust out. (Tripod position)

Q6. A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent. Which is the most appropriate nursing action?
1. Tell the mother that the child must stay in the tent.
2. Place a toy in the tent to make the child feel more comfortable.
3. Call the health care provider and obtain a prescription for a mild sedative. 4. Let the mother hold the child and direct the cool mist over the child's face.

4. Let the mother hold the child and direct the cool mist over the child's face.

Q7. The clinic nurse reads the results of a tuberculin skin test (TST) on a 3-year-old child. The results indicate an area of induration measuring 10 mm. The nurse should interpret these results as which finding?
1. Positive
2. Negative
3. Inconclusive
4. Definitive and requiring a repeat test

1. Positive

Q8. The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the health care provider did not prescribe antibiotics. Which response should the nurse make?
1. "The child may be allergic to antibiotics."
2. "The child is too young to receive antibiotics."
3. "Antibiotics are not indicated unless a bacterial infection is present."
4. "The child still has the maternal antibodies from birth and does not need antibiotics."

3. "Antibiotics are not indicated unless a bacterial infection is present."

Q9. The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action?
1. Initiate strict enteric precautions.
2. Move the infant to a room with another child with RSV. *
3. Leave the infant in the present room because RSV is not contagious.
4. Inform the staff that they must wear a mask, gloves, and a gown when caring for the child.

2. Move the infant to a room with another child with RSV.*

*RSV is a highly communicable disorder and is not transmitted via the airborne route. The virus usually is transferred by the hands so use of contact and standard precautions during care is necessary. Using good hand washing techniques and wearing gloves and gowns are also necessary. Masks are not required. An infant with RSV is isolated in a single room or placed in a room with another child with RSV.

Q10. The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? Select all that apply.
1. Place the infant in a private room.
2. Ensure that the infant's head is in a flexed position.
3. Wear a mask at all times when in contact with the infant.
4. Place the infant in a tent that delivers warm humidified air.
5. Position the infant on the side, with the head lower than the chest.
6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children

1. Place the infant in a private room.
6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children

Q1. The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF?
1. Pallor
2. Cough
3. Tachycardia
4. Slow and shallow breathing

3. Tachycardia

1.2.4-late sign of HF

Q2. The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis?
1. Immunoglobulin
2. Red blood cell count
3. White blood cell count
4. Anti-streptolysin O titer

4. Anti-streptolysin O titer

Q3. On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease?
1. Cracked lips
2. Normal appearance
3. Conjunctival hyperemia
4. Desquamation of the skin

3. Conjunctival hyperemia

Q4. The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin (Lanoxin). Which statement made by the parent indicates the need for further instruction?
1. "I will not mix the medication with food."
2. "I will take my child's pulse before administering the medication."
3. "If more than one dose is missed, I will call the health care provider."
4. "If my child vomits after medication administration, I will repeat the dose."

4. "If my child vomits after medication administration, I will repeat the dose."

DO NOT MIX MEDICATION WITH FOOD TO KIDS

Q5. The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output?
1. Weighing the diapers
2. Inserting a Foley catheter
3. Comparing intake with output
4. Measuring the amount of water added to formula

1. Weighing the diapers

Q6. The clinic nurse reviews the record of a child just seen by a health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder?
1. Pallor
2. Hyperactivity
3. Exercise intolerance
4. Gastrointestinal disturbances

3. Exercise intolerance

Q7. The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instructions?
1. "A balance of rest and exercise is important."
2. "I can apply lotion or powder to the incision if it is itchy."
3. "Activities in which my child could fall need to be avoided for 2 to 4 weeks." 4. "Large crowds of people need to be avoided for at least 2 weeks after surgery."

2. "I can apply lotion or powder to the incision if it is itchy."