Nursing care of child

nurse in an urgent care center is reviewing laboratory results for several clients who have manifestations of influenza. Which of the following clients should the nurse report to the provider immediately?

This WBC count is high and indicates infection and possibly sepsis, which poses the greatest risk to the client. The provider must initiate blood, urine, and spinal fluid cultures and begin antimicrobial therapy

A nurse is providing immediate postoperative care for a child who had a tonsillectomy. Which of the following actions should the nurse take?

Eliminate the use of a straw when offering fluids Straws can accidentally injure the surgical site and cause bleeding. Their use should be avoided in the immediate postoperative period.

A nurse is collecting data from a 10-month-old infant at a well-infant checkup. Which of the following assessment findings should the nurse report to the provider?

A. The infant is unable to walk independently B. The infant's Moro reflex is absent C. The infant's anterior fontanel is open ✔Correct answer D D. The infant needs assistance to sit up

The infant needs assistance to sit up an infant is expected to have the ability to sit up unsupported around 8 months of age. Therefore, the nurse should report this finding to the provider.

a nurse is caring for a school-aged child who begins to have a tonic-clonic seizure when leaving the bathroom. which of the following actions should the nurse take first?

Ease the child to the floor in Sims' position the greatest risk to the child is an injury resulting from a fall; therefore, the nurse should gently ease the child onto the floor to decrease the chance of injury and turn the child on her left side to prevent aspiration.

A nurse is planning care for a 4-year-old child who has nephrotic syndrome. Which of the following actions should the nurse include?

Provide thorough skin care The nurse should provide thorough skin care for this child who has nephrotic syndrome. Skin care is especially important due to edema and the risk of infection.

A nurse is caring for a 2-day-old infant who has a myelomeningocele. Which of the following actions should the nurse take?

Monitor the infant's head circumference Infants who have myelomeningocele have an increased risk for hydrocephalus. Measuring the infant's head circumference can help determine any increase.

A nurse is assisting with the care of a child who has paralytic poliomyelitis. Which of the following actions should the nurse take?

Administer oral analgesics prior to exercises Paralytic poliomyelitis presents with pain and stiffness in the back, neck, and legs followed by signs of central nervous system paralysis. Range-of-motion exercises are necessary to prevent contractures, but they can cause discomfort.

A nurse is collecting data from an 18-month-old child who is postoperative. Which of the following pain scales should the nurse use?

FLACC The nurse should use the FLACC pain scale to monitor the infant for pain. The FLACC scale monitors facial expression, leg movement, activity, cry, and consolability in children 2 months to 7 years of age.

A nurse is collecting data from a 4-year-old preschooler about his gross motor skills. The nurse should expect the preschooler to perform which of the following activities?

Hopping on 1 foot The nurse should expect to find that a 4-year-old preschooler is able to hop on 1 foot.

A nurse is preparing to administer routine immunizations to a 6-year-old child. In addition to the diphtheria, tetanus, and pertussis (DTaP) vaccine; the measles, mumps, and rubella (MMR) vaccine; and the varicella vaccine, which of the following immunizations should the nurse plan to administer?

Inactivated poliovirus vaccine (IPV) The nurse should plan to administer the fourth dose of the inactivated poliovirus vaccine between 4 and 6 years of age. The first 3 doses are administered between 2 months and 18 months of age.

A nurse is contributing to the plan of care for a child who has aplastic anemia. Which of the following interventions should the nurse suggest?

Initiate protective environment isolation for the child The nurse should suggest protective environment isolation for this child, which consists of a private room with positive air pressure, no live flowers, and nurses donning a respirator mask, gloves, and gown prior to entering the child's room. A child who has aplastic anemia has decreased RBCs, platelets, and WBCs, causing immune suppression and increasing susceptibility to infection.

A nurse is caring for a child who has acute lymphocytic leukemia. Which of the following laboratory values should the nurse expect?

RBC 2.5 million/uL An RBC count of 2.5 million/uL is below the expected reference range. A child who has acute lymphocytic leukemia has a low RBC.

A nurse is reinforcing teaching with the guardian of a preschooler. The guardian reports the preschooler has had an imaginary playmate for about 3 months. Which of the following pieces of information should the nurse reinforce with the guardian?

"Have your child take responsibility for actions if they try to blame the imaginary friend." The nurse should inform the guardian that imaginary playmates are common during the preschool years due to the high level of imagination in this age group. Although having an imaginary friend is considered healthy, the preschooler might try to use this imaginary friend as a means of avoiding responsibility or punishment for unacceptable behavior.

A nurse is reinforcing teaching about nutritional needs with the parents of a 2-year-old toddler. Which of the following pieces of information should the nurse include?

An appropriate serving size of a solid food is 2 tablespoons A general guide to appropriate serving sizes during toddlerhood is to serve 1 tablespoon of solid food for each year the child is old. If the plate is filled with too much food, a toddler is likely to be overwhelmed and reject the food.

A nurse is collecting data from a 9-month-old infant. Which of the following findings should the nurse report to the provider as a delay in development? A. Using a pincer grasp to pick up blocks

Requiring support to sit for prolonged periods An infant should be able to sit unsupported by the age of 8 months. The nurse should report this finding to the provider because it is an indication of a delay in gross motor development.

A nurse is collecting data from a 9-month-old infant. Which of the following findings should the nurse report to the provider as a delay in development?

Requiring support to sit for prolonged periods An infant should be able to sit unsupported by the age of 8 months. The nurse should report this finding to the provider because it is an indication of a delay in gross motor development.

A nurse is caring for a 4-month-old child who has acute otitis media and a fever of 38.3°C (101°F). Which of the following medications should the nurse administer?

Amoxicillin A child who has acute otitis media should take an antibiotic to help alleviate the infection. Children younger than 6 months old should not take ibuprofen. Acetaminophen is the preferred choice for children of this age.

A nurse is collecting data about the fine motor skills of a 3-year-old preschooler. Which of the following findings should the nurse expect?

The preschooler builds a tower of 9 cubes The nurse should expect a 3-year-old preschooler to have the fine motors skills needed to build a tower of 9 to 10 blocks.

A nurse is collecting data from a newborn at birth to assign Apgar scores. At 1 min of age, the newborn is crying vigorously with limbs flexed and a heart rate of 120/min. The newborn's trunk is pink, but his hands and feet are cyanotic, and he cries when the soles of his feet are stimulated. Which of the following Apgar scores should the nurse assign this infant?

9 Apgar scoring is an evaluation of a newborn's heart rate, respiratory effort, muscle tone, reflexes, and color. A maximum score of 2 is assigned for each parameter. This infant lost 1 point for the presence of acrocyanosis.

A nurse is caring for a school-aged child who is hospitalized with acute poststreptococcal glomerular nephritis (APSGN). Which of the following interventions should the nurse perform?

Measure the blood pressure every 4 hours Children with APSGN have a significant risk of developing acute hypertension. Therefore, the nurse should monitor the child's blood pressure every 4 to 6 hours during the acute phase of the disease.

A nurse is talking with the parent of a 4-month-old infant about growth and development. Which of the following statements indicates that the parent needs further instructions?

"My baby loves to play with the pillows in her crib." Parents should never place pillows in an infant's crib since they pose a suffocation hazard.

A nurse is checking the motor development of a 9-month-old infant. Which of the following findings should the nurse report to the provider as a possible developmental delay?

Dropping a cube when passing it between the hands The ability to pass a cube from a hand to the other is a fine motor skill expected of a 7-month-old infant. Therefore, the nurse should identify the 9-month-old infant's inability to perform this task as a possible developmental delay and should report this finding to the provider.

A nurse is inspecting the eyes of a 5-day-old infant. Which of the following is the correct technique for the nurse to use?

Lift the infant's head while the infant is lying in a supine position To inspect the eyes of an infant, the nurse should lay the infant in a supine position and lift the head. This maneuver usually causes the infant to open the eyes.

A nurse is planning to collect data during a physical examination of a preschooler. Which of the following techniques should the nurse use?

Allow the child to inspect the equipment used for the exam The nurse should allow the child to inspect the equipment and provide a brief demonstration of how the equipment works. This technique will decrease fear and increase cooperation.

A nurse is reinforcing teaching with the parent of an infant who has a newly created colostomy. Which of the following instructions should the nurse reinforce about colostomy care?

"You can choose to use a diaper instead of a collection bag." Parents can choose not to use an ostomy appliance for their infant. If a parent chooses to use a diaper, stool will be discharged onto the abdomen 3 to 4 times a day, similar to the usual infant stool pattern. After the infant defecates, the parent should wash and dry the stoma and surrounding skin area well.

A nurse is preparing to assist with the physical assessment of a 2-year-old toddler. Which of the following behaviors should the nurse expect during the examination?

The child prefers to sit on the parent's lap during the examination Toddlers and infants who are able to sit typically prefer to sit in their parents' lap throughout the examination.

A nurse is caring for a toddler who is hospitalized. Which of the following interventions should the nurse take?

Instruct visitors to notify the healthcare team before leaving the child's room A nurse needs to know when caregivers are leaving the child unattended so the nurse can ensure the child is safely situated in the bed.

A nurse is contributing to the preoperative teaching plan for a school-aged child who is scheduled for cardiac surgery. Which of the following recommendations should the nurse make?

Use photographs to help explain the procedure The nurse should recognize the school-aged child's increased language ability and desire for knowledge. The nurse should use photographs and simple diagrams to explain the procedure in an interesting and concrete way that the child can understand.

A nurse is teaching the parent of a child who has ADHD and a new prescription for methylphenidate sustained-release tablets. Which of the following pieces of information should the nurse include in the teaching?

"Weigh your child twice per week while he is taking this medication." The nurse should instruct the parent to weigh the child 2 to 3 times per week to monitor for weight loss, which is an adverse effect of methylphenidate. The parent should report weight loss to the provider.

A nurse is contributing to the plan of care for a school-aged child with cystic fibrosis who is hospitalized. Which of the following should the nurse plan to include?

Assist the child with choosing high-protein, high-fat foods for meals Children with cystic fibrosis have malabsorption and need to consume a high-protein, high-calorie diet with unlimited fat to promote adequate growth.

Results of enzyme-linked immunosorbent assay (ELISA) testing for an 18-month-old infant who has Pneumocystis carinii pneumonia indicate that she is HIV-positive. When assisting with planning care, the nurse should consider which of the following factors?

The infant's mother is likely HIV-positive. Transmission of HIV from a woman to her infant can occur during pregnancy, delivery, or through breastfeeding. Although it is possible for the infant to acquire HIV from sexual abuse, mother-to-child transmission accounts for the majority of HIV/AIDS cases in infants.

A nurse is reinforcing teaching with a school-aged child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements should the nurse make?

"You can use a vial of insulin for up to 30 days." The child can use an opened vial of insulin for 28 to 30 days stored at room temperature or in the refrigerator.

A nurse on a pediatric unit is assisting with the plan of care for a preschooler who will be having a surgical procedure in the morning. The child has been crying despite his parents' presence at his bedside. The nurse should recommend engaging the child in therapeutic play for the care plan due to which of the following benefits?

Allowing the child to manipulate toy medical equipment A major function of play therapy is making potentially unmanageable situations manageable through symbolic representation, which provides children with opportunities to learn to cope. A preschooler does not have the language development to express fear of the unfamiliar medical equipment in the hospital. By encouraging the child to touch the equipment, the nurse will help decrease the child's fear and intimidation in a safe environment using age-appropriate vocabulary. The use of toys enables children to transfer anxieties, fears, fantasies, and guilt to objects rather than people.

A nurse is collecting data from a child who has type 1 diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?

Tachycardia A rapid heart rate is a manifestation of hypoglycemia. Other manifestations the nurse should expect the child to exhibit include tremors, difficulty concentrating, dizziness, hunger, and irritability.

A. Tachypnea B. Dry mouth C. Flushed skin ✔Correct answer D D. Tachycardia Correct Correct Answer:

Tachycardia A rapid heart rate is a manifestation of hypoglycemia. Other manifestations the nurse should expect the child to exhibit include tremors, difficulty concentrating, dizziness, hunger, and irritability.

A nurse is caring for an infant in an acute care setting who has a tracheostomy. Which of the following interventions should the nurse perform when suctioning?

Pause for 60 seconds between suctioning attempts The nurse should wait for 30 to 60 seconds between passages of the suction catheter to allow the infant's oxygen saturation level to return to baseline.

A nurse is caring for a 3-year-old child who has a cyanotic cardiac defect. The child cries when her parents leave the room, worsening her cyanosis and dyspnea. Into which of the following positions should the nurse place the child to reduce these manifestations?

Knee-chest The knee-chest position, which is similar to squatting, facilitates the oxygenation of the lungs. The nurse should assist the child into this position to facilitate breathing.

A nurse is reinforcing teaching with a 17-year-old client about managing manifestations of polycystic ovary syndrome (PCOS). Which of the following client statements indicates an understanding of the teaching?

"Eating more lean meats and vegetables can help me lose weight." Weight loss and diet modifications improve the body's insulin use and normalize hormone levels. A reduced-carbohydrate diet and exercise increase the cells' sensitivity to insulin and helps normalize testosterone secretions, ultimately reducing PCOS manifestations.

A nurse is reinforcing discharge teaching with the parents of a school-aged child who has nephrotic syndrome and a prescription for corticosteroid therapy. Which of the following home-care instructions should the nurse include?

Keep the child away from people who have an infection The nurse should instruct the parents to keep the child away from others who have or might have an infection. Children who have nephrotic syndrome are prescribed corticosteroids, which impair the immune system. Therefore, the child is at an increased risk of contracting an infection.

nurse at a clinic is preparing to administer highlight immunizations to a 5-year-old child. Which of the following immunizations should the nurse plan to give?

Diphtheria, tetanus, and pertussis (DTaP) Children receive booster doses of the DTaP immunization between the ages of 4 and 6. Around this age, blood titers drop due to decreasing antibodies

A nurse is contributing to the plan of care for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the priority for the nurse to recommend?

Monitor the child's oxygen saturation level When using the airway, breathing, and circulation (ABC) approach to client care, the priority intervention for the plan of care is to monitor the child's oxygen saturation level. Promoting oxygen utilization prevents further sickling of the child's red blood cells and promotes adequate oxygenation of the surrounding tissue.

A nurse is contributing to the plan of care for a 6-month-old infant who has respiratory syncytial virus (RSV). Which of the following interventions should the nurse plan to include?

A. Thicken feeding with 5 mL of rice cereal per 30 mL of formula ✔Correct answer B B. Implement droplet and contact precautions C. Administer bronchodilator therapy via blow-by technique D. Use a cool mist vaporizer Correct Correct Answer: B. Implement droplet and contact precautions Respiratory syncytial virus is a highly contagious virus that is spread through contact with respiratory secretions and via large droplets. Therefore, both forms of isolation are indicated for a client with this infection.

A nurse is reinforcing teaching with the parents of a toddler who has enterobiasis about management of the parasitic disease. Which of the following instructions should the nurse include in the teaching?

"You should keep your child's fingernails trimmed short." The nurse should instruct the parents to keep their child's fingernails trimmed short to minimize the collection of ova under the nails.

A nurse is discussing play activities with a group of parents of toddlers. Which of the following activities should the nurse recommend for this age group?

Pushing a toy lawn mower The nurse should recommend pushing a toy lawn mower as a play activity for a toddler. Toddlers are developmentally ready for push-pull toys, and they enjoy play activities that allow imitation of adults.

A nurse is reinforcing education with the parent of a toddler who has an acute vomiting illness. Which of the following interventions should the nurse include in the teaching?

Brush the child's teeth after each emesis The parent should brush the child's teeth or rinse the child's mouth to dilute the amount of hydrochloric acid that contacts the child's teeth.

A nurse is reinforcing teaching about baclofen with the guardian of a toddler who has cerebral palsy. Which of the following adverse effects should the nurse include?

Muscle weakness Muscle weakness is a common adverse effect of baclofen. Other common adverse effects include dizziness, drowsiness, and nausea.

A nurse is collecting data from the parents of a toddler. The nurse should identify that which of the following is a risk factor for lead poisoning in the toddler?

Living in a home built in 1940 Homes built before 1950 have a higher incidence of lead-based paints and lead water pipes. Children living in these homes have an increased risk of exposure to lead.

A nurse is caring for a child who has glomerulonephritis. Which of the following actions should the nurse take?

Weigh the child once each day The nurse should weigh the child at the same time each day to monitor fluid balance.

A nurse is assisting with the care of a 6-month-old infant who has respiratory insufficiency and requires continuous pulse oximetry monitoring. Which of the following actions should the nurse take?

Cover the infant's oximetry sensor with clothing The nurse should cover the infant's oximetry sensor with clothing to prevent outside light from providing a false reading. A snug-fitting sock is recommended. However, the site should be monitored frequently for color, temperature, and pulse.

A nurse is preparing a 3-month-old infant for a wellness visit with the physician. Which of the following observations should the nurse expect?

The infant looks at his hands Infants usually start to look at their hands while lying down or sitting between 12 to 20 weeks of age. Convergence on near objects is usually well established by 3 months of age.

A nurse is collecting data from a preschooler who has HIV. Which of the following manifestations should the nurse expect?

Chronic diarrhea Chronic diarrhea is an expected finding for a preschooler who has HIV.

A school nurse is caring for a school-aged child who has hemophilia and fell on the playground. The child reports a pain level of 4 on a scale of 0 to 10. Which of the following actions should the nurse take?

Apply an ice pack to the joint Immediately following an injury, a joint should be rested, elevated, and have ice applied to minimize bleeding into the joint.

A nurse in an urgent care clinic is collecting data from an infant who recently started taking digoxin for a supraventricular arrhythmia. Which of the following findings should the nurse identify as a possible indication of digoxin toxicity?

Vomiting, especially unrelated to feedings, is a manifestation of digoxin toxicity and should be reported to the provider immediately.

A nurse in a pediatric clinic is collecting data from a preschooler during a well-child visit. Which of the following findings should the nurse report to the provider?

The child's blood pressure is 122/80 mmHg The nurse should identify that this blood pressure measurement indicates significant hypertension, which requires further assessment to confirm. Therefore, the nurse should report this finding to the provider immediately.

A nurse is collecting data from a child who is postoperative and received a unit of packed RBCs during a surgical procedure. Which of the following findings indicates the child is experiencing a hemolytic transfusion reaction?

Chills and flank pain Chills and flank pain are findings that indicate an incompatibility of the transfused blood product with the client's blood. The nurse should identify that the child is having a hemolytic reaction.

A nurse is caring for an adolescent who has end-stage renal disease and is scheduled for peritoneal dialysis. Which of the following actions should the nurse take?

Obtain the adolescent's weight prior to the procedure The nurse should obtain a baseline weight prior to the initiation of the procedure and again following the procedure.

A nurse is checking the fine motor development of a 4-year-old child. The nurse should expect the child to be able to perform which of the following activities?

Copying a square The nurse should expect a 3-year-old child to have the fine motor ability to copy a circle. A 4-year-old child should have the ability to copy a square.

A nurse is assessing a 3-year-old child during a well-child examination. Which of the following findings should the nurse report to the provider?

The child cannot walk on tiptoe The nurse should identify that a child should be able to take a few steps on tiptoe by 30 months of age. Therefore, the nurse should report this finding to the provider.

A nurse on a pediatric unit is assisting with the admission of 4 children from the emergency department. After receiving a verbal report from the nurse, for which of the following children should the nurse plan to initiate droplet precautions?

A child who has pertussis The nurse should initiate droplet precautions for a child who has pertussis to decrease the risk of transmitting the infection to others on the unit. Pertussis (whooping cough) is a bacterial infection that is transmitted via exposure or direct contact with the respiratory secretions from an infected person. Manifestations of pertussis include a fever, sneezing, and a severe productive cough that generally becomes worse before getting better.

A nurse is collecting data for a developmental assessment on a 3-year-old client. Which of the following commands should the nurse expect the child to successfully complete?

"Put on your shoes." Children should be able to pull on their shoes when they are 3 years old. They typically cannot tie their shoes until they are 5 years of age.

A nurse is reinforcing teaching with the parents of an infant who has a cleft palate. The parents ask the nurse how long they should wait before the infant should have corrective surgery. The nurse explains that the parents should wait no longer than 6 to 12 months to avoid which of the following outcomes?

Difficulty with language acquisition Infants who have a cleft palate can have difficulty acquiring language because they need to use the palate for vocalizing sounds. With a cleft in the palate, these infants could develop poor speech habits.

A nurse is reviewing the medical record of a 2-month-old infant who has rotavirus. The nurse notes a hemoglobin level of 12 g/dL and a hematocrit of 51%. Which of the following statements by the nurse indicates an understanding of these laboratory values?

"The infant might be dehydrated." An increased hematocrit level indicates dehydration. Hematocrit levels rise when blood volume is decreased during dehydration.

A nurse is caring for a 1-year-old infant who has chronic otitis media. The nurse should identify that which of the following areas is at risk for a delay in development?

Speech patterns Speech patterns are developed through auditory experiences. Chronic otitis media is a common cause of hearing impairment, which can delay the development of speech.

A nurse is reinforcing teaching about home safety with the parent of a 2-month-old infant. Which of the following information should the nurse include?

Remove bibs before the infant goes to sleep The nurse should instruct the parent to remove bibs prior to the infant sleeping to decrease the risk of strangulation.

A nurse is caring for a 3-year-old toddler who has Haemophilus influenzae type b meningitis. Which of the following actions should the nurse take?

Avoid using a pillow when supine Using a pillow when in a supine position will cause flexion of the neck, which increases discomfort in most children due to nuchal rigidity.

A nurse is assessing an 18-month-old toddler during a well-child examination. Which of the following findings should the nurse report to the provider?

The toddler is unable to remove his shoes An 18-month-old toddler should be able to remove his or her own shoes, socks, and gloves. The nurse should report this finding to the provider.

A school nurse is providing care to a child who has a nosebleed. Which of the following actions should the nurse take? (Select all that apply.)

Keep the child calm Applying pressure continuously for 10 minutes to the nose with the thumb and forefinger helps control nasal bleeding. Most bleeding comes from the front portion of the nasal septum, so pressure that compresses this area is generally effective. If bleeding persists, placing ice or a cold cloth on the bridge of the nose and inserting cotton or tissue into the nostril might help. The nurse should keep the child calm because agitation can raise blood pressure, which will increase the bleeding.

A nurse is caring for a toddler who has gastroenteritis caused by salmonella. Which of the following actions is the priority for the nurse?

Initiate contact precautions Salmonella is a type of bacteria that is transmitted via contaminated feces, making contact precautions essential for preventing transmission. Due to the safety risks involved, this client is at greatest risk for transmission of salmonella to others; therefore, this is the priority action the nurse should take.

A nurse is observing the behavior of a 2-year-old child. Which of the following actions should the nurse expect to observe when the child is in an activity room with other toddlers?

Engaging in play near other children A toddler is expected to play in parallel with other children. As socialization begins, the child plays alongside other children, not with them.

A nurse is caring for a toddler. Which of the following laboratory findings should the nurse report to the provider?

Creatinine 0.9 mg/dL The expected reference range for a toddler is a creatinine level of 0.3 to 0.7 mg/dL. This level is above the expected reference range and should be reported to the provider.

A nurse is collecting data on an infant who has coarctation of the aorta. Which of the following findings should the nurse expect?

Elevated blood pressure in the arms Coarctation of the aorta is an obstructive defect in which there is constriction of the aorta near the ductus arteriosus. This narrowing causes an increased pressure in the aorta prior to the defect, which causes the blood pressure in the arms to be higher than that of the lower extremities.

A nurse is reinforcing dietary teaching with the parent of a toddler who has phenylketonuria. Which of the following foods should the nurse recommend?

Cooked carrots The nurse should instruct the parent to offer the toddler foods that are low in protein such as cooked carrots and fruits

A nurse is assisting with the care of a school-aged child who is having a tonic-clonic seizure. Which of the following actions should the nurse take first?

Position the child on his side Using evidence-based practice, the nurse should position the child on his side. Salivation increases and the swallowing reflex is lost during a tonic-clonic seizure, placing the child at risk for aspiration. Thus, it is essential to maintain the airway during a seizure.

A nurse is reinforcing teaching with the parent of a child who has ADHD and a new prescription for methylphenidate sustained-release tablets. Which of the following statements by the parent indicates an understanding of the teaching?

"I should give this medication to my child half an hour before breakfast." The parent should administer the medication to the child on an empty stomach.

A nurse is collecting data about the visual acuity of a group of school-aged children. Which of the following actions should the nurse take?

Allow each child to wear his or her glasses during the exam The nurse should allow each child to wear his or her glasses during a screening for visual acuity.

A school nurse is collecting data from an adolescent child who returned to school following a case of mononucleosis. The child has a note from his provider excusing him from gym class. Which of the following findings should the nurse identify as the reason for this excusal?

To reduce the potential of sustaining abdominal trauma An adolescent who has mononucleosis will have lymphadenopathy and often splenomegaly, which can persist for many months. For this reason, even after the adolescent is able to maintain his usual energy level and return to school, he must avoid activities that might result in trauma to the enlarged spleen.

A nurse is preparing a school-aged child for a tonsillectomy. Which of the following actions should the nurse take?

Schedule the child for a preoperative visit to the facility A preoperative visit to the facility allows the child to observe perioperative processes. This education helps the child feel at ease prior to the surgical procedure.

A nurse is reinforcing teaching with a school-aged child who has a new diagnosis of acute lymphoblastic leukemia (ALL). Which of the following statements from the child indicates an understanding of the teaching?

"I have a good chance of surviving this cancer." Most children who have ALL and receive chemotherapy are expected to survive, with up to 95% achieving remission

A nurse is reinforcing teaching with the parents of an infant who is breastfeeding. When should the nurse instruct the parents to introduce solid foods into the infant's diet?

At 4 to 6 months of age The nurse should identify that infants are developmentally ready for solid foods at 4 to 6 months of age.

A nurse is caring for a 4-year-old child who has pneumonia. The child's mother left 2 hr ago, and he is currently experiencing the despair stage of separation anxiety. Which of the following findings should the nurse expect?

Inactivity and thumb-sucking This child who is sucking his thumb and refusing to eat or drink is displaying manifestations of the second stage of separation anxiety, which is despair.

A nurse in an emergency department is assisting with the care of a 4-year-old child who ingested toilet bowl cleaner. The child has hemoptysis, is crying, and states, "It burns." Which of the following actions should the nurse take to assist with the child's care? (Select all that apply.)

Assist with the insertion of an IV for morphine administration E. Apply a pulse oximeter The nurse should ask the parent or guardian about the size of the container, how much cleaner was in the container prior to ingestion, and how much cleaner was remaining following ingestion. This information provides an estimate of the amount of cleaner the child ingested and can assist the provider in directing treatment. A child who ingests a corrosive agent is likely to have intense pain due to burns in the gastrointestinal system. The nurse should expect the provider to prescribe IV morphine or another strong analgesic to provide pain relief. Additionally, the child is at risk for airway occlusion due to edema following ingestion of a corrosive agent. Monitoring the child's oxygen saturation level assists the nurse in identifying if the child's airway is becoming obscured.

A nurse is collecting data from an infant who has diabetes insipidus (DI). Which of the following findings should the nurse expect?

Increased urine output Diabetes insipidus is characterized by a decreased secretion of ADH, which results in an increased production of urine.

A nurse is collecting data from a 1-week-old infant at a well-baby visit. The nurse should notify the provider about which of the following assessment findings?

Blue coloring of the sclera This discoloration is associated with osteogenesis imperfecta, a genetic disorder which results in bone fragility. The nurse should notify the provider of this finding.

A nurse on a pediatric unit is assisting with the care of a preschooler who is prescribed an IV medication. Which of the following techniques should the nurse use to assist with preparing the child for the procedure?

Use role-play activities with the child The nurse should use role-play activities to decrease the child's anxiety about the procedure. This approach will also provide an opportunity for the nurse to clarify any misconceptions the child might have about the procedure.

A nurse is caring for a child who has a tracheostomy. Which of the following techniques should the nurse use to suction the child's tracheostomy?

Remove the catheter while applying intermittent suction The nurse should insert the catheter without suction and then withdraw the catheter while applying intermittent suction.

A nurse is planning to reinforce teaching for a 9-year-old child who has a new diagnosis of diabetes mellitus. The nurse should identify that school-aged children are attempting to master which of the following developmental tasks?

industry vs. inferiority. During achievement of this task, children enjoy learning new skills and the sense of accomplishment that comes with mastery of a skill.

A nurse working in the emergency department is caring for a 6-month-old infant who has a new diagnosis of respiratory syncytial virus (RSV). The parent tells the nurse, "My baby won't even drink half of a bottle of formula." Which of the following actions should the nurse take?

administration of intravenous fluids for an infant who has RSV because this condition can cause dehydration as a result of the presence of a fever and the infant's inability to finish a bottle of formula. Also, fluids will help loosen congestion, which typically occurs with RSV.

A nurse is reinforcing teaching with the parents of a child who has rheumatic fever. Which of the following statements by a parent indicates an understanding of the teaching?

"My child may take aspirin for his joint pain." Children who have rheumatic fever may take salicylates (aspirin) to control the inflammatory process that occurs in the joints.

A nurse is assessing the pain level of a 3-year-old child who is postoperative following abdominal surgery. Which of the following pain scales should the nurse use?

FACES pain rating scale The FACES pain rating scale presents the client with various images of faces that represent various levels of pain. A 3-year-old child is able to identify faces that represent different pain levels

A nurse is caring for a child who has been in Buck's traction for 2 days. Which of the following actions should the nurse take to prevent complications?

Check for pulses in the affected leg every 4 hours Traction might lead to neurovascular compromise. The nurse should assess for edema, pulses, pain, color, and temperature of the extremity every 4 hours

A nurse is assisting with the plan of care for a child who has hyperthermia. Which of the following actions should the nurse take?

Position the child on a cooling blanket and cover her with a sheet

A nurse is providing teaching about foods high in fiber to the guardian of a child who has chronic constipation. Which of the following foods should the nurse recommend?

1/2 cup baked beans The nurse should recommend foods high in fiber for a child who has chronic constipation. A half cup of baked beans contains approximately 5 g of fiber.

A nurse is assisting with the admission of a child who has a urinary tract infection (UTI) and a history of myelomeningocele. After the child's admission history is complete, which of the following actions should the nurse recommend?

Attach a latex allergy alert identification band Myelomeningocele, a serious complication of spina bifida, is a neural tube defect in which the spinal cord and meninges are in a cerebrospinal fluid-filled sac at birth.

A nurse is caring for a 4-year-old child who has superficial partial-thickness burns over 50% of his body. To meet the nutritional needs of the child, which of the following actions should the nurse plan to take?

Supplement the child's feedings with enteral feedings A child who has burns over more than 25% of the total body surface area requires enteral supplementation to consume enough calories to heal.

A nurse is planning care for a 3-month-old infant who has an ileostomy. Which of the following interventions should the nurse include in the plan?

Check the bag for stool every 4 hours The nurse should check the bag for stool every 4 hours or less to prevent the bag from overfilling and leaking. Stool from an ileostomy is acidic and can cause excoriation of the skin.

A nurse is assisting with the development of a health education program for the parents of school-aged females. Which of the following pieces of information regarding sexual maturation should the nurse include?

Higher body fat content is associated with earlier onset of menarche The nurse should inform the parents that the onset of menarche is expected to occur around 10.5 to 15.5 years of age. Females who have a higher body fat content have been shown to have an earlier onset of menarche.

A nurse is collecting developmental data on a 4-year-old child. Which of the following findings should the nurse expect?

The child is able to hop on 1 foot. The nurse should expect a 4-year-old child to have the gross motor ability to hop on 1 foot.

A nurse is reinforcing teaching with the family of a child who has autism spectrum disorder. Which of the following statements indicates that the family understands the instructions?

"Structuring our daily routine will help our child." Children who have autism spectrum disorder benefit from a structured routine. This can help minimize the anxiety the child might have with sudden schedule changes and socialization requirements, as well as satisfy a preference for ritualistic behavior.

A nurse is planning care for a preschool-aged child who has autism and is being admitted to the facility. Which of the following actions should the nurse plan to take?

Encourage the parents to bring the child's stuffed animal Encouraging parents to bring a child's stuffed animal helps lessen the disruptiveness of hospitalization.

A nurse is collecting data from an infant who has acute gastroenteritis. Which of the following findings should the nurse identify as a manifestation of severe dehydration?

Skin that is cool to the touch The nurse should identify skin that is cool to the touch, acrocyanosis, and mottled skin as indications of severe dehydration. The infant might also display a delayed capillary refill of >4 seconds.