Growth and Development
Which characteristic best describes the fine motor skills of a 5-month-old infant?
A. Has a strong grasp relfex
B. Can build a tower of two cubes
C. Is able to grasp object voluntarily
D. Has a neat pincer grasp
C. Is able to grasp
Pincer: 11 month
Strong grasp: 1 month
Build blocks: 15 month
The nurse is obtaining vital signs on a 1-year-old child. What is the most appropriate site for assessing the pulse rate?
The nurse should assess a child who has had a tonsillectomy for
1. Frequent swallowing
A Frequent swallowing is indicative of postoperative bleeding.
B Inspiratory stridor is characteristic of croup.
C Rhonchi are lower airway sounds indicating pneumonia.
D Assessment of blood cell counts is part of a preoperative workup.
The mother of a neonate patient states her child is experiencing difficulty with feedings and is coughing. You read the EHR to find that the mother experienced polyhydramnios. What is the probable cause?
Esophageal atresia / Tracheoesophageal fistula
Which is the most critical element of pediatric emergency care?
1.
Airway management
Prevention of neurologic impairment is certainly a concern in pediatric emergency care; however, it is not considered the most critical element. Maintaining adequate circulation is accomplished after a patent airway is established. The focus of emergency care is stabilizing the child's physiologic status. Supporting the family is important, but it is not considered to be the most critical element in pediatric emergency care.)
The mother of a 3-month-old breastfed infant asks about giving her baby water because it is summer and very warm. What is the most appropriate recommendation by the nurse?
A. Water once or twice daily will make up for losses from environmental temperature
B. Water should be given if infant seems to nurse longer than usual
C. Fluids in addition to breast milk are not needed
D. Clear juices would be better than water to promote fluid intake
C. Fluids not needed
Sufficient water is provided in breast milk and in prepared formula during early infancy. Fruit juice should be avoided in infants younger than 6 months of age.
What action is appropriate when using an EMLA cream before intravenous catheter insertion?
3.
A The EMLA cream should not be rubbed into the skin.
B After the cream is applied to the skin surface, it is covered with a transparent occlusive dressing.
C The cream should be left in place for a minimum of 1 hour and no more than 2 hours.
D The nurse should use a liberal amount of EMLA cream.
A child has had cold symptoms for more than 2 weeks, a headache, nasal congestion with purulent nasal drainage, facial tenderness, and a cough that increases during sleep. The nurse recognizes that these symptoms are characteristic of which respiratory condition?
D. Sinusitis
ANS: D
A The classic symptoms of allergic rhinitis are watery rhinorrhea, itchy nose, eyes, ears, and palate, and sneezing. Symptoms occur as long as the child is exposed to the allergen.
B Bronchitis is characterized by a gradual onset of rhinitis and a cough that is initially nonproductive but may change to a loose cough.
C The manifestations of asthma may vary, with wheezing being a classic sign. The symptoms presented in the question do not suggest asthma.
D Sinusitis is characterized by signs and symptoms of a cold that do not improve after 14 days, a low-grade fever, nasal congestion and purulent nasal discharge, headache, tenderness, a feeling of fullness over the affected sinuses, halitosis, and a cough that increases when the child is lying down.
The postoperative care plan for an infant with surgical repair of a cleft lip includes
3. elbow restraints
Keeping the infant's hands away from the incision reduces potential complications at the surgical site. The infant's diet is advanced from clear liquid to soft foods within 48 hours of surgery. After surgery, the infant can resume preoperative feeding techniques. Rinsing the mouth after feeding is an inappropriate intervention.
Feeding a small amount of water after feedings will help keep the mouth clean. A cleft lip repair site should be cleansed with a wet sterile cotton swab after feedings.
3-year-old is brought to the emergency department by ambulance after her body was found submerged in the family pool. The child has altered mental status and shallow respirations. She did not require resuscitative interventions. Which condition should the nurse monitor first in this child?
4
Hypoxia
(Although a neurologic assessment will be required, it is not the area of primary assessment. The airway is always assessed first. Hypothermia offers protection to the brain. It is a concern, but not the area of primary concern. Although the child may have electrolyte imbalances, this is not the primary assessment area. Hypoxia is responsible for the injury to organ systems during submersion injuries. Hypoxia can progress to cardiopulmonary arrest. Monitoring the airway is always the number one concern.)
Which child is most likely to be frightened by hospitalization?
2.
All children can be frightened by hospitalization. However, toddlers are most likely to be frightened by hospitalization because their thought processes are egocentric, magical, and illogical. They feel very threatened by unfamiliar people and strange environments.
Young infants are not as likely to be as frightened as toddlers by hospitalization because they are not as aware of the environment. The 9-year-old child's cognitive ability is sufficient for the child to understand the reason for hospitalization. The 15-year-old adolescent has the cognitive ability to interpret the reason for hospitalization.
A child is receiving intravenous fluids. How frequently should the nurse assess and document the condition of the child's intravenous site?
1.
A The nurse assesses and documents an IV site at least every hour for signs and symptoms of infiltration and phlebitis.
B The nurse should assess a child's IV site more frequently than every 2 hours.
C The nurse should assess a child's IV site more frequently than every 4 hours.
Serious complications could occur during this time interval.
D The nurse should assess a child's IV site more frequently than every shift.
Which statement made by a parent indicates an understanding about treatment of streptococcal pharyngitis?
3.
A Surgical removal of the tonsils is a controversial issue. It may be warranted in cases of recurrent tonsillitis. It is not indicated for the treatment of acute tonsillitis.
B Comfort measures such as rest and analgesics are indicated, but these will not treat the bacterial infection.
C Streptococcal pharyngitis is best treated with oral penicillin two to three times daily for 10 days.
D Corticosteroids are not used in the treatment of streptococcal pharyngitis.
The nurse is caring for a neonate with a suspected tracheoesophageal fistula (TEF).
Nursing care should include which of the following?
1. Elevating the head, NPO
When a newborn is suspected of having TEF, the most desirable position is supine with the head elevated on an incline plane of at least 30 degrees. It is imperative that any source of aspiration be removed at once; oral feedings are withheld. Feedings should not be given to infants suspected of having TEF. The oral pharynx should be kept clear of secretion by oral suctioning.
This is to avoid cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the larynx.
How should the nurse instruct the mother who calls the emergency department because her 9-year-old child has just fallen on his face and one of his front teeth fell out?
B Place the tooth in milk or water and go directly to the emergency department.
mity, the threatening ationship.)
(The parent may replace the tooth incorrectly, so it is best not to advise the parent to do this. The parent should be told to keep the tooth moist by placing it in a saline solution, water, milk, or a commercial tooth-preserving solution and get the child evaluated as soon as possible. The tooth should be kept moist, not dry. The child should be evaluated as soon as possible. Cleaning or scrubbing the tooth could damage it. It is essential for the child to have an immediate dental evaluation.)
The parents of a preschool-aged child are in the clinic and report the child is seen playing with the genitals frequently. What response by the nurse is best?
1. Preschool children are in the Phallic or Oedipal/Electra Stage of Freud's theory during which the genitals become the focus of curiosity and interest. The nurse should explain that this behavior is normal at this stage. Teaching about disciplinary techniques and referrals to psychotherapy are inappropriate. The nurse may well want the provider to speak to the parents, but the nurse is responsible for patient/parent teaching and should provide education him- or herself.
What is the best action for the nurse to take when giving medications to a 3-year-old child?
3.
A Direct confrontation typically results in a "no" response.
B Threatening a child with a shot is inappropriate.
C Realistic choices allow the child to feel some control.
D Comparisons are not helpful in getting a child to cooperate.
A 5-year-old child is brought to the emergency department with copious drooling and a croaking sound on inspiration. Her mother states that the child is very agitated and only wants to sit upright. What should be the nurse's first action in this situation?
1.
A This child has symptoms of epiglottitis, is acutely ill, and requires emergency measures.
B If epiglottitis is suspected, the nurse should not examine the child's throat.
Inspection of the epiglottis is only done by a physician, because it could trigger airway obstruction.
C A throat cUlture could precipitate a complete respiratory obstruction.
D Vital signs can be assessed after emergency equipment is readied.
Infant patient presents with vomiting, coughing, wheezing, apnea, and abdominal pain upon palpation. You recognize these symptoms as signs of:
Hiatal Herniai
What is the nurse's immediate action when a child comes to the emergency department with sweating, chills, and fang bite marks on the thigh?
A.Secure antivenin therapy.
(Antivenin therapy is essential to the child's survival because the child is showing signs of envenomation. The use of a tourniquet is no longer recommended. When a bite or envenomation is located on an extremity, the extremity should be immobilized. Envenomation is a potentially life-threatening condition. False reassurance is not helpful for building a trusting relationship.)
A student nurse is preparing to administer an Hib vaccination to an infant.
What action by the student requires the registered nurse to intervene?
2. The anterolateral thigh is the preferred site for intramuscular administration of vaccines for infants. When the student prepares the wrong site, the registered nurse should intervene. Federal law requires parents be given vaccine information statements and sign informed consent prior to the nurse's administering vaccinations. The nurse should also assess the family's beliefs and values related to vaccination, which can help dispel myths and guide teaching.
Which assessment should the nurse perform last when examining a 5-year-old child?
D
Examination of the mouth and throat is considered to be more invasive than other parts of a physical examination. For preschool children, invasive procedures should be left to the end of the examination.
Examination of the heart, lungs, and abdomen are seen as less threatening.
Which intervention is appropriate for the infant hospitalized with bronchiolitis?
D
A The infant should be positioned with the head and chest elevated at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm.
B The etiology of bronchiolitis is viral. Antibiotics are only given if there is a secondary bacterial infection.
C Tachypnea increases insensible fluid loss. If the infant is tachypneic, fluids are given parenterally to prevent dehvdration.
D Cool, humidified oxygen is given to relieve dyspnea, hypoxemia, and insensible fluid loss from tachypnea.
What clinical manifestation should a nurse be alert for when suspecting a diagnosis of esophageal atresia?
3. Atresia is suspected when a nasogastric tube fails to pass 10 to 11 cm beyond the gum line. Abdominal radiographs will confirm the diagnosis. Prenatal radiographs do not provide a definitive diagnosis. The defect is not externally visible. Bronchoscopy and endoscopy can be used to identify this defect. Infants with esophageal atresia may have been born prematurely and with a low birth weight, but neither is suggestive of the presence of an esophageal atresia.
What should be the emergency department nurse's next action when a 6-year-old child has a systolic blood pressure of 58 mm Hq?
A. Alert the physician about the systolic blood pressure.
(Hypotension is a late sign of shock in children. The lower limit for systolic blood pressure for a child more than I year old is 70 mm Hg plus two times the child's age in years. A systolic blood pressure of 58 mm Hg calls for immediate action. The nurse should be direct in relaying the child's condition to the physician. This action does not address the problem of shock, which requires immediate intervention. Assessing the child's responsiveness is included in a neurologic assessment. It does not address the systolic blood pressure of 58 mm Hg. Although this child most likely requires intravenous fluids, the physician must be apprised of the systolic blood pressure so that appropriate intervention can be initiated.)