What occurrence results from obstruction within the ventricles of the brain or inadequate reabsorption of cerebrospinal fluid?
A. Meningitis
B.Meningocele
C. Spina bifida occulta
D. Hydrocephalus
The nurse caring for an infant with hydrocephalus. What nursing action is most important for this
nurse to implement?
A. Align the limbs
B. Support the head
C. Keep the head lower than the hip
D. Check intake and output
The nurse observes that the infant anterior fontanelle is bulging after placement of a ventriculoperitoneal shunt. How should the nurse position this infant?
A. Prone, with the head of the bed elevated
B. Supine, with the head flat
C. Side lying on the operative side
D. In a semi Fowler’s
position
What nursing action will the nurse implement after feeding an infant with hydrocephalus
A. Position the infant sitting upright in an infant seat
B. Place the infant over the shoulder to burp
C. Leave the infant in a side lying position
D. Stimulate the infant by rubbing its feet.
A newborn was just admitted to the neonatal intensive care unit with a meningomyelocele.
What is the priority preoperative nursing care of this newborn?
A. Keep the sac dry
B. Diaper snugly
C. Position prone in an incubator
D. Move from side to side every hour
The nurse is caring for a child who has had a ventriculoperitoneal shunt for hydrocephalus and observes an increasing abdominal girth. What is the most appropriate response?
A. Elevate the child’s head
B. Check bowel sounds
C. Record retention of
feeding
D. Notify the charge nurse of possible malabsorption
The nurse is providing education to parents of a child with cleft palate. What will the nurse instruct the parents to report immediately?
A. Facial paralysis
B. Ear infections
C. Increasing intracranial pressure
D. Drooling
Postoperative nursing care of the infant following surgical repair of a cleft lip would
include
A. Feeding the infant with a spoon to avoid sucking
B. Positioning the infant on the abdomen to facilitate drainage
C. Applying elbow restraints to protect the surgical area
D. Providing minimal stimulation to prevent injury to the incision
Which statement indicates that parents understand how to feed their infant who had a surgical repair for a cleft lip?
A. We are feeding the baby with a dropper for 2 weeks
B.
We resumed bottle feeding after discharge
C. We started the baby on solid food yesterday
D.The baby is drinking well from a straw
An 18 month old child had a surgical repair of a cleft palate and is now allowed to eat a regular diet. What nursing action is the most appropriate?
A. Feed solid foods with the spoon at the side of the mouth
B. Purée foods and offer them through a straw
C. Place small bites of food in the mouth
with a tongue blade
D. Offer small, frequent meals of finger foods.
When bathing an infant, what sign does the nurse recognize as a sign of development hip dysplasia?
A. Hypotonicity of the leg muscles
B. One leg is shorter than the other
C. Broadening and flattening of the buttocks
D. Two skin folds on the back of each thigh
A 3 month old infant is diagnosed with
developmental hip dysplasia. The nurse knows that what is the usual treatment for an infant with this diagnosis?
A. A pavlik harness
B. A body spica cast
C. Traction
D. Triple diapering
After delivery, a mother ask the nurse about newborn screening test. The nurse explains that what is the optimal time for testing for phenylketonuria?
A. In the first 24 hours of life
B. After 2 to 3 days
C. At 4 to 6 weeks of age
D. At 2 months of age
The nurse is advising parents about feeding their infant with phenylketonuria. What formula and or diet should the nurse suggest?
A. Lifelong high protein diet
B. A formula that is low in the amino acid leucine
C. A soy based formula
D. Substitute Lofenalac for some protein foods
Parents of a 2 month old infant with Down syndrome are attending a
well visit at the pediatric clinic. What should they be instructed to provide special attention to in regard to the generalized hypotonicity of the child?
A. Preventing hyperthermia
B. Respiratory care
C. Prevention of diarrhea
D. Incontinence care
What would the nurse include when instructing parents about positioning their toddler who has just had a body spica cast applied?
A. Prop the child upright with pillows for
meals.
B. Use the bar between the legs to turn the child
C. Put the child on her abdomen to sleep
D. Change the child’s position frequently
The nurse is caring for an Rh negative mother on the postpartum unit. What scenario indicates the need to administer RhoGAM to this patient?
A. She has had on Rh negative child and is pregnant with an Rh negative child
B. She has had an Rh positive infant and is pregnant with an
Rh positive fetus
C. She has had an O negative child and is pregnant with a B negative child
D. She is a primipara with an O negative child
Patents ask the nursery staff what the light does for their jaundiced infant. What is the nurses best response?
A. The light increases the infants metabolism
B. The light stimulates liver function
C. The light dilates blood vessels
D. The light breaks down bilirubin
Parents of a newborn with a unilateral cleft lip are concerned about having th defect repaired. The nurse explains that a child with a cleft lip usually undergoes surgical repair at which time?
A. Immediately after birth
B. By 3 months of age
C. After 12 months of age
D. Varies in every case
Phototherapy is instituted for an infant. What is the most appropriate nursing action for the
infant having phototherapy?
A. Cover the infants head with a hat
B. Dress the infant lightly in a T shirt
C. Keep the infants eyes covered
D. Reposition the infant at least every 4 to 8 hours
The nurse is caring for a macrosomic newborn whose mother has diabetes. What should the nurse assess for with this neonate?
A. Hypoglycemia
B. Erythroblastosis fetalis
C. Intracranial hemorrhage
D. Pancreatic failure
What assessment made by the nurse would lead the nurse to suspect hip dysplasia?
A. Asymmetrical gluteal folds
B. Limited addiction of the affected side
C. Foot turned inward
D. Deep inguinal creases
The nurse is providing care to a child with Down syndrome. What body system has the highest risk of congenital anomaly in a child with Down syndrome?
A. Reproductive system
B. Genitourinary system
C. Cardiovascular system
D. Gastrointestinal system
The parents of a child diagnosed with cystic fibrosis as the nurse what caused this disorder. What is the most appropriate response?
A. Cystic fibrosis is a chromosomal defect
B. Cystic fibrosis is a metabolic defect
C. Cystic fibrosis is a malformation present at birth
D. Cystic fibrosis is a blood disorder
What characteristics are typical in a child diagnosed with Down syndrome? (Select all that apply?
A. Close set eyes
B. Simian creases
C. Wide spaced front teeth.
D. Protruding tongue
E. Curved, small fingers
What will the nurse include in the plan of care when caring for an infant with an intracranial hemorrhage?(Select all that apply)
A. Keep positioned with head elevated
B.
Feed slowly to reduce possibility of vomiting
C. Stimulate often to maintain level of consciousness
D. Hold and coddle frequently to stimulate
E. Observe for increased intracranial pressure.
What would be included in the plan of care for a child just returned to the floor from surgery in which a club foot was repaired? (Select all that apply)
A. Keep cast uncovered to allow drying.
B. Check toes for capillary refill.
C. Circle with a pen any area of bleeding on the cast.
D. Keep casted leg lowered
E. Observe for skin irritation
The nurse in the newborn nursery is watchful for neonatal abstinence syndrome in the newborn of crack addicted mother. What would be the manifestations of this syndrome?(Select all that apply)
A. Body tremors
B. Excessive sneezing
C. Hyperirritability
D. Drowsiness
E. Excessive appetite
What manifestations of increasing ICP in the hydrocephalic child should the nurse be aware of? (Select all that apply)
A. High pitched cry
B. Inequality of pupils
C. Bulging fontanelles
D. Diarrhea
E. Hiccups
The nurse is obtaining intake information on new patient being seen for preconception care and notes a family history of neural tube defects. What interventions can the nurse
suggest to this woman to help prevent neural tube anomalies in a developing fetus? (Select all that apply)
A. Avoid drug use
B. Follow a low calorie, low protein diet
C. Take a folic acid supplement every day
D. Exercise daily
E. Maintain bed rest during the first trimester
The nurse is caring for a macrosomic newborn of a woman diagnosed with gestational diabetes immediately after birth. What assessment finding can the
nurse anticipate?(Select all that apply)
High blood glucose levels
B. Wight of 9 pounds or more
C. Decreased subcutaneous fat
D. Hypocalcemia
E. Hyperbilirubinemia
The home health nurse is educating parents on home phototherapy. What will the nurse include when providing information to these parents?
(Select all that apply)
A. Cover the infants eyes when under the light
B. Use a three prong plug
C. Keep a
diaper in place
D. Place the light source on an absorbent surface
E. Expose as much skin as possible
When the CSF is obstructed in the subarachnoid space rather than in the ventricles, the resulting hydrocephalus is diagnosed as _______ hydrocephalus
The nurse clarifies to the parents of a child with spina bifida that their child has a portion of the spinal cord in the sac in addition to the meninges. This type of spina bifida is known as a __________
The nurse demonstrates how to flush the ventriculoperitoneal shunt by t he use of the _______ that is in place behind the infant ear
The initial treatment for cleft lip is a surgical repair known as ______
Which child would have the most difficulty in coping
with separation from parents because of hospitalization?
A. 3 month old child
B. 16 month old child
C. 4 year old child
D. 7 year old child
A 2 year old child has been crying constantly for his mother since he was hospitalized 3 days ago. What does this behavior suggest?
A. The toddler feels abandoned by his mother
B. The child still has not adjusted to his hospitalization
C. The child is not separated from his
mother often
D. There is a poor mother child bond
Which statement best corresponds to a preschoolers understanding of hospitalization?
A. A germ made me get sick
B. I got sick because i was mad at my brother
C. My tonsils are sick and they have to come out
D. I have a cast because i broke leg
The parents of a hospitalized toddler are upset because she seems more
interested in her toys when they come to visit her. In which stage of spa ration anxiety is the toddler?
A. Protest
B. Despair
C. Denial
D. Attachment
The nurse must make a room assignment for a 16 year old with cystic fibrosis . Which roommate would be most appropriate for this patient?
A. 4 year old child who had an appendectomy
B. A 10 year old child with sickle cell disease in vaso occlusive crisis
C. A 15
year old with type 1 diabetes melitus
D. To assign the adolescent to a private room
The parents of a hospitalized 9 month old infant ask if their preschool child may visit his younger sibling. What understanding would assist the nurse most in formulating a response?
A. Preschool children can be disruptive in the hospital environment.
B. Seeing his younger sibling would probably frighten the preschooler and thus should be avoided
C. The sibling could view the infant from the doorway but not enter the room not prevent the spread of microorganisms
D. The preschooler needs to visit his infant sister to reassure himself that she is all right
A hospitalized toddler was drinking from a cup at home but now refuses to drink from anything except his favorite bottle. What is the most likely reason for this behavior?
A. He is dealing with the anxiety of
hospitalization by regressing
B. He is demonstrating attention seeking behaviors because of an over abundance of attention in the hospital
C. His is attempting to refocus the attention of the adult around him to avoid further painful procedure
D. He is exhibiting normal behavior for his age, as children often stop new behaviors after they believe they have mastered them
A nurse encourages a school age child to draw a picture after
a painful procedure. What is the best rationale for this nursing intervention?
A. Attempting to re establish rapport
B. Providing a way for the child to express his feelings
C. Encouraging quiet play
D. Distracting the child from thinking about the pain
What is the best suggestions by the nurse when parents ask when is the best time to begin to prepare a 5 year old for surgery and hospitalization?
A. As soon as the surgery
is scheduled
B. About 2 weeks before surgery
C. About 4 days before surgery
D. On the night before admission on the hospital
The mother of a 3 year old tells the nurse that she will be in to visit tomorrow around 12pm. The next morning , the child ask the nurse when is my mommy coming what is the nurse best response?
A. Your mommy will be here around noon
B. Your mommy will be here when you have lunch
C. Mommy will be
here very soon
D. Your mommy is coming in 4 hours
A 13 year old girl has been hospitalized for the past week. When discussing the girls feelings about her illness, what would the nurse expect the girl to express as her biggest concern?
A. Invasive produces
B. Loss of control
C. Appearance.
D. Separation from her boyfriend
The nurse notices that the mother of a child
with cerebral palsy corrects and redoes many of the things the nurse does for her child. What is the nurse most appropriate response to this mother?
A. Would you like to do all of your child’s care?
B. I’m doing the very best job that i can with you child
C. Why don’t you go have a cup of coffee? You are going to be exhausted if you don’t take a break
D. I’d love for you to share with me some of the special things you do for your child
The mother of a hospitalized toddler states, he cries when i visit. Maybe i should just stay away. What is the nurses best response?
A. Perhaps you are right. He only gets upset when you have to leave
B. It is important that you are here, this is a common reaction in children when they are separated from their parents
C. It might be easier for your child if you would stay with him, but this decision is up to you
D. We take good care of him and he seems fine when
you are not here
What should the nurse, preparing to collect an admission history from parents who have recently emigrated from Russia keep in mind?
A. Eye to eye contact is considered disrespectful
B. Touching the child’s head means the nurse is superior
C. Smiling is inappropriate in a serious situation
D. Staring is a sign of the nurses rudeness
Which nursing action
would facilitate rapport with a child and the child’s parents during the admission process?
A. Direct the parents to undress the child
B. Answer questions in a calm and matter of fact way
C. Perform assessments and ask questions as quickly as possible
D. Express concern about the seriousness of the child’s condition
When a 2 year old returns to her hospital room following diagnostic procedure, her parents are not
available, and the child is crying loudly. Which technique is most appropriate to alleviate the child’s distress?
A. Rock the child gently to sleep
B. Play with the child using pop up toys
C. Role play with the child to act out her feelings
D. Ask the child to draw a picture about her feelings
A 4 year old begins to cry when his mother tells him it is time for his operation. The nurse understands this is an expected reaction.
On which particular fear of the preschooler does the nurse base this understanding?
A. Loss of control
B. Restricted mobility
C. Unfamiliar routines
D. Invasive procedures
What statement by the parent of hospitalized toddler leads the nurse to determine the parent understands a hospitalized toddler need for transitional objects?
A. This stuffed animal makes him feel secure
B. He insisted on bringing this dirty old
blanket with him
C. I’m going to buy him a big stuffed animal from the gift shop
D. I’d like to get him some toys from the playroom
A 8 year old child will be hospitalized for several weeks in skeletal traction to treat a fracture femur. What does the nurse realize immobilization in this age group can generate feeling of in planning care of this child?
A. Loss of control
B. Altered body image
C. Shame and guilt
D. Fear
of bodily harm
The nurse explains to the parents of a hospitalized child that their child will receive fentanyl for an upcoming procedure. What advantage of fentanyl will the nurse explain?
A. It is specifically designed for children
B. It has a rapid onset
C. It is no addicting
D. It has a long duration
The nurse shares the information and timelines recorded on the
interdisciplinary outline of care for a child . What is this document?
A. Clinical pathway
B. Comprehensive nursing care plan
C. Holistic care approach
D. Incorporated cost analysis
The anxious parent ask if there is a danger of her 2 year old child becoming addicted to the opioid pain reliever. What is the nurse most helpful response?
A. Although this drug is addictive, the doctor monitors the dose very carefully
B.
Don’t worry, addicted children are very easy to wean off the drug
C. Addiction is rare in children when opiates are given for pain
D. Addictive behaviors are easy to assess. The drug will be stopped if that happens
The nurse is preparing to start an IV on an infant admitted to the pediatric unit. What intervention is appropriate for the nurse to implement?
A. Involve the parents
B. Provide a simple explanation to the child
C. Let the child examine the equipment
D. Suggest coping techniques.
The pediatric nurse caring for a child that wights 15 kilograms and call the physician for an order for acetaminophen for pain control. What is the maximum amount of medication per dose the nurse anticipates ordering?
A. 100mg
B. 150mg
C.225mg
D.250mg
What will the nurse include when
documenting the discharge of a pediatric patient? (Select all that apply)
A. Time of discharge
B. Adults accompanying the child and the relationship to the child
C. Condition of the child
D. Method of transportation
E. Instructions that were given to physician
The nurse suggest to parents that they use the outpatient surgical center for their child’s upcoming surger. What advantages does this type of facility have to
offer?(Select all that apply)
A. Lower cost
B. Less incidence of health care associated infections
C. Reduction of parent child separation
D. Ample time for recuperation at the facility
E. Deceased emotional impact of illness
What are the basic fears of a young child being hospitalized?(Select all that apply)
A. Separation
B. Permanent scarring
C. Pain
D. Cost
E. Body intrusion
What information will the nurse include when taking a developmental history? (Select all that apply)
A. Previous experience with hospitalization
B. Cultural needs
C. History of illness
D. Allergies
E. Child nickname
The nurse is preparing to obtain a throat culture on a toddler patient. What interventions are appropriate for the nurse to implement? (Select all that apply)
A.
Model desired behavior
B. Instruct patient not to yell
C. Use distractions
D. Explain the procedure in detail
E. Encourage the child to as questions
Parents are preparing their child for admission to the pediatric unit for minor surgery. What should they expect to see when visiting the pediatric unit?
(Select all that apply)
A. Nurses wearing all white
B. Formal atmosphere
C. Availability of a playroom
D.
Dim lighting
E. Colored bedding
When the preschooler who is hospitalized for surgery to correct a poorly healed fracture says, my doctor is going to unscrew my bent arm and screw on my new one, the nurse should ______ this misconception
A _____ ______ is a person under the age of 18 who can legally sign for consent for medical treatment for themselves or their children
_______ provides trained workers who come into the home for brief periods to relieve of the responsibility of caring for the child