NCLEX-RN: Exam Questions (Pediatric) / NCLEX RN Registered Nurses Quiz Questions (Pediatric) (Latest 2020, Already graded A)
NCLEX-RN: Exam Questions (Pediatric) / NCLEX RN Registered Nurses Quiz Questions (Pediatric) (Latest)
A 1-day-old infant, born at 39 weeks' gestation, weighs
4 pounds, 7 ounces at birth. A pediatrician diagnoses the neonate with intrauterine growth restriction (IGR). An RN observes the newborn to be irritable, difficult to con- sole, restless, fist-sucking, and demonstrating a high- pitched, shrill cry. Based on these assessment data, the RN should:
A) Increase stimulation of the baby by handling the infant as much as possible.
B) Schedule routine feeding times every 3 to 4 hours.
C) Encourage stimulation by rubbing the infant's back
D) Tightly swaddle the infant in a flexed position.	position.
A 3-year-old child is hospitalized with multiple fractures as a result of a car accident. What is the best way for a nurse to assess this child's pain level?
A) Ask the child to rate pain using a numeric pain rating scale.
B) Rely on vital sign measurements as a way to verify pain ratings.
C) Employ the FACES pain scale with every nursing assessment.
D) Try to have the child describe the pain's intensity and quality.
A 7-year-old child is hospitalized for a tonsillectomy. What are priority nursing actions when caring for this child after surgery? Select all that apply.
A) Advancing diet as tolerated.
B) Encouraging coughing to clear the throat.
C) Monitoring PT and PTT.
D) Administering pain medication around the clock.
E) Suctioning mouth and throat frequently.
A 12-month-old child with infantile eczema is seen at the clinic for several open lesions on the arms and legs. What should a nurse caution the child's parents against?
A) Initiating a diet free of milk products.
B) The use of topical hydrocortisone cream.
C) Adding cornstarch to bath water.
D) Immunization during eczema exacerbations.
A 13-year-old client diagnosed with beta-thalassemia is hospitalized for blood transfusion. What are the priority nursing diagnoses related to this child's care? Select all that apply.
A) Risk for infection.
B) Impaired elimination.
C) Risk for injury.
D) Disturbed body image.
E) Chronic pain.
F) Activity intolerance.
A charge nurse is creating nursing assignments for a pediatric unit when one of the oncoming nurses calls to say, "Sorry, I'll be a few minutes late since I have a child home ill with the chickenpox." What type of assignment would be most acceptable for the nurse who will be late?
A) Any assignment is fine as long as the nurse wears a mask.
B) The nurse needs an assignment that does not include children with neutropenia.
C) The nurse should not be given an assignment and should be called off.
D) Any care assignment is acceptable, without restrictions.
A charge nurse is seated in front of a bank of cardiac monitors on a pediatric unit. There are four children receiving cardiac monitoring. Which finding should the charge nurse communicate at once to the child's nurse?
A) A heart rate of 50 in a 15-year-old adolescent who is sleeping.
B) A heart rate of 190 in a 1-month-old infant who is crying.
C) A heart rate of 160 in a 2-year-old child who is walk- ing in the hallway.
D) A heart rate of 75 in a 5-year-old child who is watch- ing television.
A child arrives in an emergency department with a chief complaint of asthma exacerbation. Which assessment information is most important for the nurse to obtain first?
A) Whether the child has been taking asthma medications as prescribed.
B) When the child began having symptoms.
C) Whether the child is able to speak in full sentences.
D) The child's ABG levels.
A child diagnosed with hypopituitarism is to begin receiving daily injections. At what time should a nurse instruct the child's parents to administer the injection each day?
A) Before breakfast.
B) At bedtime.
C) With lunch.
D) Any time the child prefers.
A child hospitalized with hydrocephalus is being treated with an externalized ventricular drain (EVD). A nurse begins the afternoon assessment and discovers that the drain is positioned several inches below the child's ear level. What should be the nurse's priority action?
A) Raise the drain to the child's ear level.
B) Leave the drain as is and monitor the CSF drainage hourly.
C) Quickly elevate the head of the bed.
D) Clamp the drain and complete a neurological assessment.
A child is admitted for treatment of lead poisoning. A nurse recognizes that the priority nursing diagnosis for this child is:
A) Alteration in comfort related to abdominal pain.
B) Alteration in nutrition related to pica.
C) Pain related to chelation therapy.
D) Alteration in neurologic functioning.
A child is admitted with acute exacerbation of asthma. A physician orders 100% oxygen via mask. Which physician order should be a nurse's next priority?
A) Continuous inhaled albuterol.
B) IV Solu-Medrol 2 mg/kg loading dose.
C) IV fluids at maintenance rate.
D) Chest x-ray.
A child is receiving chemotherapy for the treatment of osteosarcoma. Which morning laboratory result must a nurse report immediately to the physician?
A) Absolute neutrophil count of 1200.
B) Platelet count of 150,000.
C) Urine dipstick positive for heme.
D) WBC count of 4500.
A child is seen in an emergency department following the ingestion of lighter fluid. Which nursing action is of the highest priority at this time?
A) Induce vomiting.
B) Determine the amount of poison ingested.
C) Assess the respiratory system.
D) Administer Mucomyst as ordered.
A child recovering from abdominal surgery removes the nasogastric tube accidentally. A nurse replaces the nasogastric tube and places it to low wall suction. Two hours later, the nurse discovers that there is no drainage from the tube. What should be the nurse's first action?
A) Ask the child to change position.
B) Place an urgent call to the surgeon.
C) Flush the tube with 10 mL of sterile water.
D) Check the suction mechanism and settings.
A child with status post-Harrington rod placement for the correction of scoliosis is being cared for on the pediatric unit. The child suddenly experiences facial sweating and complains of a headache. A nurse notes also a slower heart rate on the monitor. What action should the nurse take first?
A) Call the surgeon immediately.
B) Assess patency of the urinary catheter.
C) Administer pain medication as ordered.
D) Complete a neurological assessment.
A child with type 1 diabetes is being prepared for dis- charge from a hospital. What should a nurse include as part of the teaching regarding diabetes care?
A) Expect hypoglycemic episodes to always occur after meals.
B) Insulin dosage may need to be decreased during sports activities.
C) The child should not self-administer injections until the teen years.
D) Insulin should never be administered during febrile illnesses.
A child with type 1 diabetes is receiving insulin based on carbohydrate intake. The child's insulin-to-carbohydrate ratio is 15:1. Of the items listed on the child's lunch menu shown below, the child ate 2 slices of bread, a slice of cheese, a glass of milk, a cup of soup, and half of a banana. How many units of insulin should the nurse administer based on the client's carbohydrate count? Round to the nearest whole number.
Food Item with Carbohydrate level:
Glass of low-fat milk 10g Bread slice 15g
Cheese slice Free
Cup of soup 10g
A) 2 units.
B) 3 units.
C) 4 units.
D) 5 units.
A child, hospitalized with nephrotic syndrome, has been receiving corticosteroids for a week. What should the nurse recognize as early evidence that the child is responding well to treatment?
A) Decreased general edema.
B) Increased urinary output.
C) Improved general appetite
D) Hemoglobin and hematocrit within normal limits
A client is attending a newborn discharge class and asks a nurse about the bump on the infant's head. Upon assessment, the neonate has a large, diffuse swelling on the left occiput that crosses the sagittal suture line. The nurse should explain to the mother that:
Select all that apply.
A) This is a collection of blood under the skull bone of the infant.
B) It is edematous swelling that overlies the periosteum.
C) It leads to hyperbilirubinemia in the infant.
D) It will require no treatment to resolve.
The only management is observation. No treatment is needed for caput succedaneum.
Caput succedaneum is the result of pressure on the fetal head before delivery.
A clinic nurse has a follow-up appointment with an adolescent with juvenile idiopathic arthritis (JIA). What topic should be the nurse's top priority?
A) Sleep patterns.
B) Participation in daily exercise.
C) Information regarding JIA support groups.
D) Avoidance of alcohol use.
A clinic nurse prepares to perform a physical assessment on a preschool child. What are the appropriate actions for the nurse to take when preparing for and perform- ing the examination? Prioritize the nurse's actions by placing each correct step in sequential order.
A) Allow child to keep underpants on.
B) Allow child to undress in private.
C) Ask child's preference for parental involvement.
D) Inspect ears, eyes, and mouth.
E) Proceed in head-to-toe direction.
F) Gain cooperation with bright objects as a distraction.
A hospitalized child is experiencing sickle cell vaso-occlusive crisis. The child is currently receiving an intra- venous (IV) fluid bolus, pain medication every 4 hours, and warm compresses to the extremities per physician orders. During the midday assessment, the child reports no pain. Which action should a nurse take?
A) Continue to apply warm compresses per physician order.
B) Hold the next dosage of pain medication.
C) Hold the next round of warm compresses.
D) Contact the physician for a change in orders.
A newborn arrives in a neonatal intensive care unit with a myelomeningocele. A physician writes orders to keep the infant in the prone position. A nurse should know that the most important rationale behind this order is to:
A) Prevent infection.
B) Promote circulation in the lower extremities.
C) Prevent trauma to the meningeal sac.
D) Promote comfort.
A nurse admits a teenager in sickle cell crisis to a pediatric unit. The child has an elevated heart rate but normal blood pressure, respiratory rate, and temperature. The child has an oxygen saturation of 98% on room air and rates pain in the extremities at an 8 on a 1-to-10 numeric pain rating scale. Which actions should the nurse perform at this time? Prioritize the nurse's actions by placing each correct intervention in priority order.
A) Administer oxygen.
B) Obtain the child's weight.
C) Administer IV fluids as ordered.
D) Monitor I&O.
E) Obtain an order for pain medication via PCA.
F) Apply cool, moist compresses to extremities.
A nurse and nursing student are caring for a child who sustained a head injury as a result of a fall from a play structure. The nurse knows the nursing student is pre- pared to care for the child when the student states:
A) "I will be sure to let you know if the child's pupils become fixed and dilated."
B) "I will keep the child straight in the supine position."
C) "I will look for any changes in the child's respirations, pulse, or blood pressure."
D) "I will notify the physician if the child becomes sleepy."
A nurse assesses a child who is 12 hours status post- tonsillectomy and adenoidectomy. The child reports feeling nauseated and shows the nurse a moderate amount of red-tinged vomitus in the emesis basin. Which action should the nurse take first?
A) Administer an antiemetic as ordered.
B) Offer the child ice chips as tolerated.
C) Report the findings to the physician.
D) Apply bilateral pressure to the child's neck.
A nurse assesses the respiratory status of an infant. Which finding should be of most concern to the nurse?
B) Scattered rhonchi.
C) Expiratory grunt.
D) Abdominal breathing.
A nurse attempts to give a newborn infant the first bottle feeding. While sucking, the infant becomes cyanotic and coughs, and formula is seen coming out of the infant's nose. What should be the nurse's first action?
A) Auscultate the lungs.
B) Suction the child's airway.
C) Obtain an order for an x-ray.
D) Contact the physician.
A nurse enters the room of a child following the placement of a ventriculoperitoneal shunt. The child is sitting up in bed, crying, and has vomited a small amount on the bed linens. What are the priority nursing actions? Select all that apply.
A) Complete a neurological assessment.
B) Place the child in the supine position.
C) Administer the antiemetic as ordered.
D) Complete a pain assessment.
E) Increase the child's IV rate.
A nurse is caring for a child diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which laboratory test would the nurse be least likely to obtain?
A) Urine specific gravity.
B) Blood glucose.
C) Serum sodium.
D) Urine osmolality.
A nurse is caring for a child newly diagnosed with congen- ital heart disease. The nurse should monitor the child with the understanding that the earliest sign of heart failure is:
A) Audible lung crackles.
B) Increased heart rate.
C) Weight gain.
D) Generalized edema.
A nurse is caring for a child with acute glomerulonephritis. Which nursing assessment should be the nurse's first priority when caring for this child?
A) Obtaining a daily weight.
B) Palpating extremities frequently for edema.
C) Assessing urine for hematuria.
D) Obtaining the child's blood pressure every shift.
A nurse is caring for a child with meningococcemia who is on a ventilator. This morning, the nurse finds the child's mother sitting at the bedside, crying. The mother tells the nurse, "I thought it was the flu. This is my fault because I should have come to the hospital earlier." What is the best action by the nurse in response to the mother's statements?
A) Tell the mother not to worry since many parents and even physicians frequently mistake meningitis symptoms for other infectious conditions.
B) Make a referral to social services.
C) Call the child's father and explain that the mother
needs emotional support from him.
D) Remind the mother that she did seek proper treatment as soon as she became concerned, and review the special care the child is receiving now.
A nurse is caring for a child with tetralogy of Fallot. Which assessment findings should the nurse expect? Select all that apply.
A) Ventricular septal defect (VSD).
B) Atrial septal defect (ASD).
C) Overriding aorta.
D) Pulmonic stenosis.
E) Right ventricular hypertrophy.
F) Patent ductus arteriosus (PDA).
G) Left-to-right shunting of blood.
H) Aortic stenosis
The blood flows from left to right in a child with tetralogy of Fallot through the VSD.
A nurse is caring for a newborn infant diagnosed with hypospadias. The parents ask when the surgical repair will be complete. The nurse knows that the most likely time for completion of the surgical repair will be:
A) Within the first month of life.
B) Not until the child reaches puberty.
C) Nearer the child's first birthday.
D) Before the child begins school.
A nurse is performing discharge teaching with the parents of a preschooler diagnosed with cystic fibrosis. What part of the teaching plan will best assist the parents to prevent future pulmonary infections in this child?
A) Teaching the parents proper administration of pancreatic enzymes.
B) Emphasizing the need for regular and consistent chest physiotherapy.
C) Stressing the need to seek prompt medical attention for increased work of breathing.
D) Instructing the parents to monitor the child's daily fluid intake for adequacy.
A nurse is planning to teach a child safety class to a group of new parents. When preparing a lesson regarding car seats, what should the nurse recommend?
A) Children should be seated in the rear of the car until 6 years of age.
B) Infants should face forward in an infant seat until 20 pounds.
C) Children should face the rear of the car until as close to 1 year of age as possible.
D) Make sure to use the automobile air bags as these enhance the safety of car seats.
A nurse is planning to teach a group of 10-year-old children about drug and alcohol prevention. Which characteristics of this age group are important for the nurse to consider when developing the teaching plan? Select all that apply.
A) These children are achievement-oriented.
B) They expect good behavior to be rewarded.
C) Their problem-solving approach tends to be concrete
D) The central persons in their lives tend to be friends.
E) These children are nearing puberty.
A nurse is preparing to administer an unpleasant-tasting liquid medication to a toddler. What is the best method for administering this medication?
A) Mix the medication with a cup of ice cream to mask the taste.
B) Ask the child to choose between two types of fluids as a chaser.
C) Request the parents hold the child firmly so the nurse can place the medication into the mouth.
D) Offer the child a toy out of the toy box as a reward if the child agrees to take the medication.
A nurse is working with a nursing student in caring for an infant who has just returned from the surgical recovery area following a cleft lip repair. Which action by the nursing student should cause the nurse to intervene?
A) Placement of elbow restraints on the infant.
B) Offering the parents a regular bottle with which to feed the infant.
C) Positioning the infant in the semi-Fowler's position.
D) Advising the parents of a plan to administer pain medication around the clock.
A nurse is working with a nursing student in the care of a young child status post-appendectomy. The student checks the current order of IV gentamicin and discovers the ordered dose is above the safe dose range based on the child's weight. What should be the nurse's first action?
A) Check the child's recent lab work.
B) Contact the physician.
C) Order a hearing test.
D) Obtain an order for BUN and creatinine.
A nurse performs a head-to-toe assessment on a newborn. Which finding should be of greatest concern to the nurse?
A) Capillary refill time of 2 seconds.
B) Transient mottling of the skin.
C) Irregular respirations.
D) Negative Babinski reflex.
A nurse performs a scoliosis screening at a local school. Which assessment finding by the nurse would least likely result in a scoliosis referral?
A) Unilateral rib hump noted when the child is bent forward.
B) Asymmetrical hip height noted when the child is standing erect.
C) Uneven wear noted on the bottom of the child's pant legs.
D) Rounded shoulders noted when the child is standing erect.
A nurse prepares to administer a chelating agent to a child with lead poisoning. Which laboratory tests should be obtained prior to the administration of this agent?
A) BUN and creatinine.
B) PT, PTT.
C) Urine specific gravity.
A nurse prepares to administer spironolactone (Aldactone) to an infant with congenital heart disease. The nurse understands that the main purpose of this medication is to:
A) Preserve the patent ductus arteriosus.
B) Cause vasodilation of the blood vessels.
C) Prevent the secretion of potassium.
D) Block aldosterone, which leads to diuresis.
A nurse prepares to insert a nasogastric tube in a 10-month-old child. Which actions should the nurse take to complete this procedure? Prioritize the nurse's actions by placing each correct step in sequential order.
A) Aspirate gastric contents.
B) Have the child begin a bottle feeding.
C) Place child supine with head and neck elevated.
D) Inject 10 mL of air into the tube while auscultating the stomach.
E) Tape tube securely to infant's cheek.
F) Measure from the infant's earlobe to the area of the stomach.
A nurse should suspect Hirschsprung's disease in a child who has which type of stooling pattern?
A) Pale gray stools.
B) Currant-jelly stools.
C) Loose, yellow stools.
D) Thin, ribbon-like stools.
A nurse teaches a child with spina bifida how to perform urinary self-catheterization. Which steps should the nurse include in the teaching? Place each correct step in sequential order.
A) Wash hands.
B) Open latex catheter package.
C) Lubricate tip of catheter.
D) Wash catheter with soap and water.
E) Cleanse perineum with Betadine swabs.
A nurse visits the home of a toddler. With what aspect of the home environment would the nurse be most concerned?
A) Power cords plugged into capped electrical outlets.
B) Presence of a television in the child's bedroom.
C) A swimming pool located in the backyard.
D) Cooking pot handle turned toward the front of the stove.
A nurse visits the home of a young child to administer the Denver II developmental assessment. The child is unable to perform several required items, and the parent expresses concern regarding the child's performance. What is the best way for the nurse to respond to the parent's concerns?
A) Reassure the parent that the Denver II is not a measure of the child's IQ.
B) Offer the parent some skill-building activities and explain that the child will be reassessed in 2 weeks.
C) Advise the parent that the child's primary physician will be notified and will make any necessary referrals.
D) Tell the parent that it is not unusual for children to fail the Denver II.
A nurse would be most correct in withholding digoxin (Lanoxin) prescribed to an infant if the heart rate falls below which parameter?
A) Below 100 beats per minute.
B) Below 120 beats per minute.
C) Below 140 beats per minute.
D) Below 160 beats per minute.
A nursing student prepares to administer eyedrops to a young child. What action by the nursing student should cause a registered nurse to intervene?
A) The student positions the child supine with head extended.
B) After administration, the student asks the child to close eyes and move them around.
C) The student schedules medication administration to occur just before lunchtime.
D) Prior to administration, the student pulls the lower lid down, forming a sac.
A physician prescribes digoxin (Lanoxin) for a toddler with congestive heart failure (CHF). Before administering the medication, it is most important for the nurse to:
A) First obtain an apical heart rate.
B) Determine the serum potassium.
C) Review the child's admission electrocardiogram (ECG).
D) Mix the medication with a pleasant-tasting food.
A school nurse advises the dietary staff that a special lunch tray must be created for a student who has celiac disease. What recommendation should the nurse provide to the dietary staff?
A) Make sure the student has a whole-grain bread roll each day.
B) The child may have cake if the staff is celebrating someone's birthday.
C) The child's pizza should be topped with a variety of vegetables.
D) Beans and rice are suitable side dishes for this student.
A school nurse is creating an informational brochure for parents regarding the treatment of head lice. What form of treatment should the nurse caution against?
A) Applying repeated doses of permethrin for as long as it takes until the infestation clears.
B) Washing all clothing and linens in hot water followed by drying them in a hot dryer.
C) Wearing gloves when washing the child's hair or inspecting for nits.
D) Removing nits daily from the child's hair with a fine- tooth comb.
A school nurse is preparing to teach a group of teenagers how to prevent meningitis. What aspect of meningitis prevention should the nurse be certain to include in the presentation?
A) Getting a meningitis vaccine is the only way to guarantee prevention.
B) Refraining from sharing food and drinks is a good way to prevent meningitis infection.
C) Avoiding team sports is one way to stop the spread of meningitis infection.
D) Meningitis prevention methods should be employed whenever children are in crowds.
A school-age child visits a school nurse and states that a family member has been behaving inappropriately by touching the child near the groin area. What should be the school nurse's priority action?
A) Make a report to the proper child protective authorities as mandated by law.
B) Contact the child's parents to share what the child has reported.
C) Question the child to determine all of the details of the inappropriate touching.
D) Provide the child with a safe and calm environment in which to continue the discussion.
A school-age child visits a school nurse with complaints of dizziness and shaking. The nurse confirms that the child has a history of type 1 diabetes mellitus when the child becomes diaphoretic and begins to faint. What should be the nurse's first action?
A) Administer an injection of glucagon.
B) Activate EMS.
C) Squeeze glucose gel into the cheek.
D) Test the child's blood sugar.
A toddler with Kawasaki disease is being evaluated by a primary care clinic nurse 1 week following discharge. The nurse understands that it is a priority to instruct the parents to contact the clinic immediately if the child:
A) Throws frequent temper tantrums.
B) Is exposed to someone with chickenpox.
C) Experiences night terrors.
D) Develops a low-grade fever.
A young child diagnosed with iron-deficiency anemia is prescribed a liquid iron supplement. A nurse provides the parents with instructions on administration and should be certain to advise them that:
A) The medication should be given along with the child's morning cereal breakfast.
B) The child may experience some pale-colored stools.
C) The child should be permitted to sip the medication
from a medicine cup.
D) The medication can be mixed with a small amount of fruit juice.
An infant in a newborn nursery is identified as having phenylketonuria (PKU). What is the best initial source of nutrients for an infant with this diagnosis?
A) Maternal breast milk.
An infant is admitted for probable pyloric stenosis. A physician orders IV fluids and makes the infant NPO pending a surgical consult. The infant is crying vigorously and the parents express frustration that they cannot feed their baby even though the surgery is not yet definite. Which is the best action for the nurse to take now?
A) Explain to the parents that feeding an infant with pyloric stenosis can lead to electrolyte imbalances from possible vomiting.
B) Offer the parents a pacifier for the infant.
C) Place a call to the surgeon to find out how long it will be before the consult.
D) Feed the infant a small amount of Pedialyte since the
surgical repair for this condition will most likely not occur until the following day.
An infant is admitted to a pediatric unit with labored breathing and moderate amounts of thick nasal secretions. What nursing intervention is most likely to improve the infant's oxygenation?
A) Frequent suctioning of the nares with a nasal olive.
B) Providing supplemental oxygen via nasal cannula.
C) Strict monitoring of oxygen saturation levels.
D) Placing the child in an infant seat.
An infant is brought to an emergency department with a chief complaint of nausea and vomiting. Which nursing assessment finding should indicate to a nurse that the infant's dehydration is severe?
A) The infant is lethargic with a urinary output of less than 1 mL/kg/hr.
B) The infant has weak pulses, poor skin turgor, and cool, mottled skin.
C) The infant has warm skin, increased pulse, and capillary refill of 2 seconds.
D) The infant is irritable, with dry mucous membranes and increased respirations.
An infant is hospitalized following a febrile seizure. When a nurse teaches the infant's family about the prevention of future seizures, what would be the nurse's best recommendation?
A) Place the child in a tepid bath during the next febrile illness.
B) Administer antipyretics around the clock the next time the child has a fever.
C) Contact the physician for antibiotics if the child becomes feverish again.
D) Take the child's temperature frequently during the next illness.
An infant is hospitalized for congenital adrenal hyperplasia (CAH). Which medication should a nurse anticipate to be part of the child's treatment plan?
C) Growth hormone.
D) Thyroid hormone.
An LVN/LPN from an orthopedic unit is floated to a child health unit. In creating assignments, which child should the charge nurse avoid assigning to the LVN/LPN?
A) A 10-year-old in traction for a fractured femur.
B) An 8-year-old child with Legg-Calvé-Perthes disease.
C) A 4-year-old with osteogenesis imperfecta.
D) A teenager receiving chemotherapy for osteosarcoma.
An RN and LVN/LPN are working as a team on a pediatric unit. Which task should the RN perform rather than delegating to the LVN/LPN?
A) Obtain a 12-lead ECG on a 10-year-old.
B) Change the dressing and examine the decubitus ulcer of a preschooler.
C) Administer a gavage feeding to an infant with failure to thrive.
D) Check the blood sugar of a teen in DKA.
In assessing the reflexes of a 15-month-old child, which finding would indicate that the child is experiencing normal development?
A) Positive Babinski reflex.
B) Asymmetric tonic neck reflex.
C) Positive patellar reflex.
D) Presence of doll's eye reflex.
In developing a plan of care for a hospitalized preschooler, a nurse recognizes that it is most essential to consider:
A) That the child may believe the hospitalization is a punishment.
B) Ways to provide visitation from peers.
C) How to incorporate play activities with other children.
D) Ways to promote privacy and independence.
In doing a child's admission assessment, which signs and symptoms should a nurse recognize as most likely related to rheumatic fever?
A) Vomiting and diarrhea.
B) Arthralgia and muscle weakness.
C) Conjunctivitis and red, cracked lips.
D) Bradycardia and hypotension.
The mother of a child asks a clinic nurse how to safety- proof the home. What should the nurse recognize as the most effective means to prevent accidental poisoning?
A) Keep the Poison Control Center phone number near the phone.
B) Store poisons in the garage rather than in the home.
C) Scan the home from the child's eye level and remove
D) Tell children where toxic substances are kept and
instruct them not to go there.
The parent of a young child phones an advice nurse to report that the child is ill. The child has a reddish pin- point rash most concentrated in the axilla and groin areas, a high fever, flushed cheeks, and abdominal pain. The parent also reports that the child's tongue is dark red with white spots. A nurse should recognize these symptoms as indicative of which infection?
C) Scarlet fever.
The parents of a 2-year-old child ask a nurse how to best assist the child to accomplish developmental tasks at this age. What is the best response by the nurse?
A) "Make sure that the child's siblings insist that the child share toys at playtime."
B) "Since the child understands the word 'no,' use this word frequently to establish house rules."
C) "Ask grandparents and other child care providers to follow your home schedule as much as possible."
D) "Attend to the child quickly during temper tantrums by hugging and offering reassurance."
The parents of a child recently discharged with acute spasmodic laryngitis contact a nurse to report that
the child continues to have croupy coughing spells at nighttime but is otherwise fine. What should the nurse recommend?
A) Contact the child's physician for another round of antibiotics.
B) Treat the spasms by sitting in the bathroom while a hot shower runs.
C) Bring the child back to the emergency department as soon as possible.
D) Elevate the child's head at bedtime using pillows.
The parents of a newborn infant ask a nurse how to prevent future ear infections. What is the best advice the nurse should provide these parents?
A) Avoid crowds during the winter months.
B) Allow the baby to bottle-feed in the supine position.
C) Make sure the baby receives the DTaP vaccine as
D) Continue breastfeeding as close to the baby's first birthday as possible.
What assessment findings should a nurse expect in a child with acute post-streptococcal glomerulonephritis? Select all that apply.
A) Severe hematuria.
C) Decreased urine specific gravity.
D) Weight gain.
F) Massive proteinuria.
What is the priority nursing diagnosis for an infant receiving treatment for hyperbilirubinemia?
A) Imbalanced body temperature.
B) Alteration in elimination.
C) Deficient fluid volume.
D) Interrupted family processes.
What should be the expected weight of an infant at 12 months of age whose birth weight was 3600 grams?
A) 5600 grams.
B) 7200 grams.
C) 11 kilograms.
D) 15 kilograms.
When preparing an intramuscular injection for a 1-week-old infant, which needle would be the most appropriate for the nurse to select?
A) 18 G, 7/8 inch.
When providing anticipatory guidance to the parents of a child with hemophilia, a nurse should stress that:
A) Active range-of-motion exercise should be used to treat sore joints.
B) Aspirin should be given for minor bumps and bruises.
C) Warm compresses should be applied to wounds to
D) A soft toothbrush should be used to promote oral health.
When providing client teaching to the caregivers of a young child with sickle cell disease, a nurse should stress that:
A) The child's diet should include whole grains and leafy green vegetables.
B) Immunizations should be delayed until the child enters school.
C) There is a 50% chance that the child's future offspring will have sickle cell anemia.
D) The parents should request IV Demerol if the child is hospitalized with pain crisis.
When teaching a class on home safety to new parents, on which type of exposure should a nurse focus as the primary cause of lead poisoning in children?
A) Ingesting paint dust or chips from an old home.
B) Having a parent who works near lead products.
C) Riding in a car that uses leaded gasoline.
D) Chewing on pencils with lead tips.
When visiting the home of a school-age child who is dying, what would be the best action by a hospice nurse?
A) Speak softly (whisper) when speaking in the child's presence.
B) Provide as little interaction with the child as possible.
C) Avoid correcting the child who is in denial about dying.
D) Rely on the parents for pain assessment.
Which assessment findings would cause a nurse to withhold scheduled immunizations in a child? Select all that apply.
A) Current cold symptoms (e.g., runny nose, cough).
B) History of recent blood transfusion.
C) Currently taking corticosteroids.
D) Mild diarrhea without symptoms of dehydration.
E) Family history of penicillin allergy.
F) Positive for HIV.
Which child would be the best roommate for a 9-year- old child with myelodysplasia who is hospitalized for a foot infection?
A) A 13-year-old with juvenile idiopathic arthritis.
B) A 10-year-old with a fractured femur.
C) An 8-year-old status post-appendectomy.
D) A 6-year-old with bacterial meningitis.
Which conditions in children and/or adolescents should a nurse identify as being associated with metabolic alkalosis? Select all that apply.
A) Pyloric stenosis.
C) Renal failure.
D) Bulimia nervosa.
E) Aspirin ingestion.
Which nursing intervention should a nurse perform on a young child suspected of having a diagnosis of acute epiglottitis whose oxygen saturation measures 93% on room air?
A) Allow the child to sit in a position of comfort.
B) Provide small amounts of liquid orally via a syringe.
C) Inspect the child's nares to assess degree of swelling.
D) Apply 100% oxygen via mask.
Which orders should a nurse question for a 5-month-old infant with hypoplastic left heart syndrome who is hospitalized awaiting the second stage of surgical repair? Select all that apply.
A) Call physician for oxygen saturations below 85%.
B) Daily weights.
C) Hold digoxin (Lanoxin) for heart rate less than 80 beats per minute.
D) Strict I&O.
E) Enfamil formula ad lib.
Which response to hospitalization is a nurse most likely to observe in a 4-year-old child?
A) Fearfulness of loud noises and sudden movements.
B) Frequent crying outbursts and agitation.
C) Urinary frequency and fear of mutilation.
D) Boredom or loneliness.
Which statement made by the mother of a child with cystic fibrosis should indicate to a nurse that the mother is in need of further teaching regarding the administration of pancreatic enzymes?
A) "I'll crush the capsules and mix with my child's food."
B) "The capsule can be broken and its contents sprinkled onto food."
C) "I may need to give more enzymes with larger meals."
D) "I will administer the enzymes 30 minutes after the meal."
Which symptom(s), if present in a child, should a nurse recognize as being characteristic of Kawasaki disease? Select all that apply.
A) Strawberry tongue.
B) High fever.
E) Desquamation of the extremities.
F) Elevated ESR.
Which would be an abnormal finding when doing a well-child checkup on a 1-week-old infant?
A) An audible "clunk" during the Ortolani test.
B) Symmetrical gluteal folds when the infant is held
C) Negative Barlow test.
D) Symmetrical knee height when the infant is supine.
While preparing for an admission, a nurse hears the alarm sound on the cardiac monitor of a child in the next bed. The nurse views the screen and sees what appears to be ventricular fibrillation. What is the best initial action by the nurse?
A) Call out for help.
B) Assess the child.
C) Begin chest compressions.
D) Press the "Code Blue" button.
While suctioning a child with a tracheostomy tube in place, a nurse discovers that the suction catheter will not advance inside the tracheostomy tube and the child is becoming pale and anxious, with noticeable suprasternal retractions. What should be the nurse's priority action?
A) Change the tracheostomy tube at once.
B) Instill normal saline into the tracheostomy tube and attempt suctioning again.
C) Obtain a pulse oximetry reading.
D) Auscultate lung sounds.