Pediatric Nursing. Final Assessment.

A toddler is diagnosed with spastic cerebral palsy believed to be caused by traumatic brain injury. What should the nurse explain to the
parents regarding the type of care the child will need?

A 6-hour-old infant passes an unformed, black, tarlike stool. What conclusion should the nurse draw from this finding?

A low phenylalanine diet is prescribed for a 4-year-old with phenylketonuria. The nurse evaluates that the mother understands her child’s dietary restrictions if she eliminates which food from the child’s diet?

A mother brings her 6-year-old child, who has just stepped on a rusty nail, to the pediatrician’s office. Upon inspection, the nurse notes that the nail went through the shoe and pierced the bottom of the child’s foot. Which action should the nurse implement first?

A high-school girl asks the school nurse what to do about her fingernails that look “so awful” since she had her artificial nails removed 6 weeks ago. On inspection, the nurse finds the girl’s nails are thickened, cracked, and yellowing. What instruction should the nurse provide?

A 3-month-old infant arrives at the health center for a scheduled well-child visit. The parents ask the nurse why the infant extends the arms and legs in response to a loud sound. Which response by the nurse is best?

Which pediatric pain patient should be assigned to a newly graduated RN?

While the nurse is administering medications to a client, the client states “I do not want to take that medicine today.” Which of the following responses by the nurse would be best?

While caring for a client, the nurse notes a pulsating mass in the client’s periumbilical area. Which of the following assessments is appropriate for the nurse to perform?

The nurse caring for a 3-year-old child plans to assess the child’s pain using the Wong-Baker FACES® Pain Rating Scale. Which accompanying assessment question would be the most useful?

The nurse is caring for several children with cancer who are receiving chemotherapy. The nurse is reviewing the morning laboratory results for each of the patients. Which patient condition combined with the indicated laboratory result would cause the nurse the greatest concern?

Which of the following would the nurse expect in a child with a spinal cord lesion at C7?

A 7-month-old infant arrives at the health center for a scheduled well-child visit. When the nurse approaches the infant to obtain vital signs, the infant cries vigorously and clings fearfully to the mother. Which of the following phenomena provides the best explanation for the infant’s behavior?

A 6-year-old child who received chemotherapy and had anorexia is now cheerfully eating peanut butter, yogurt, and applesauce. When the mother arrives, the child refuses to eat and throws the dish on the floor. What is the nurse’s best response to this behavior?

Which of the following structural defects the nurse documented as elements of Tetralogy of Fallot?

An 18-month-old child has oral mucositis secondary to chemotherapy. Which task should the nurse delegate to the unlicensed assistive personnel (UAP)?

The pediatric unit charge nurse is making patient assignments for the evening shift. Which patient is most appropriate to assign to an experienced LPN/LVN?

Which of the following should the nurse anticipate in the infant who was exposed to cocaine during pregnancy?

A nurse is teaching the parents of a 6-month-old infant about normal growth and development. Which statements regarding infant development are true? Select all that apply.

A healthy 2-month-old infant is being seen in the local clinic for a well-child checkup and initial immunizations. When analyzing the pediatric record, which immunizations would the nurse anticipate administering at this appointment? Select all that apply.

A parent is planning to enroll a 9-month-old infant in a daycare facility. The parent asks a nurse what to look for as indicators that the facility is adhering to good infection control measures. Does the nurse identify which is an indication of meeting proper infection control standards? Select all that apply.

A nurse is assessing a 10-month-old infant during a checkup. Which developmental milestones would the nurse expect the infant to display? Select all that apply.

A nurse is conducting an infant nutrition class for parents. Which foods would the nurse tell parents that they may introduce during the first year of life? Select all that apply.

Which of the following statements how the nurse best describes the clinical manifestations of the preterm infant?

The pediatric unit charge nurse is working with a new RN. Which action by the new RN requires the most immediate action on the part of the pediatric unit charge nurse?

A 4-month-old infant boy is brought to the emergency department by his parents. He has been vomiting and fussy for the past 24 hours. On exam, there are circular bruises on his back. What priority assessment does the nurse anticipate?

While working in the pediatric clinic, the nurse receives a telephone call from the parent of a 13-year-old child who is receiving chemotherapy for leukemia. The patient’s sibling has chickenpox (varicella). Which action will the nurse anticipate taking next?

An unimmunized 7-year-old child who attends a local elementary school contracts rubeola (measles). The child has two siblings, ages 9 and 11 years, who also attend the elementary school. Which action by the school nurse is a priority?

The school nurse is performing developmental screenings for children who will be entering preschool. A 4-year-old girl excitedly tells the nurse about her recent birthday party. As she relates the details of the event, she frequently stutters. Which action by the nurse is most appropriate at this time?

The following neonates are admitted to the nursery. The nurse should withhold the scheduled initial feeding on which newborn?

The nurse hears the parents of a 26-week gestation newborn tell family members, “We’ll be ready to bring the baby home in a few weeks.” What is the most therapeutic response by the nurse?

While observing parents whose newborn is in the neonatal intensive care unit, the nurse interprets that teaching has been effective when the parents perform which activity?

Which of the following is a nurse priority of care for an infant with an intraventricular hemorrhage?

Which of the following is an appropriate nursing recommendation in preventing tooth decay in young children?

Which of the following is an important nursing action related to the use of tape or adhesives on premature neonates?

A parent phones the health care provider’s office stating that his 13-month-old has had diarrhea for 3 days and he is unsure what fluids to offer. Which suggestions would the nurse provide? Select all that apply.

Which of the following is an important nursing consideration in preventing injuries during middle childhood?

The nurse is caring for an infant with the following congenital anomaly at birth.

Which nursing interventions are helpful in feeding the 3-month-old prior to surgical repair (usually 3 to 6 months of age)? Select all that apply.

A 15-month-old has just received routine immunizations, including DTaP, IPV, and MMR. What information would the nurse give to the parents before they leave the office? Select all that apply.

A nurse is caring for a 34-month-old who is hospitalized for a lengthy illness. Which behaviors would the nurse identify as examples of expected developmental regression for the child’s age group? Select all that apply.

A nurse is caring for a group of toddlers in a large urban hospital. When considering providing care, which clients require contact precautions? Select all that apply.

The 6-year-old client who has undergone abdominal surgery is attempting to make a pinwheel spin by blowing on it with the nurse’s assistance. The child starts crying because the pinwheel won’t spin. Which action should the nurse implement first?

A 10-year-old child, without a history of previous seizures, experiences a tonic-clonic seizure at school that lasts more than 5 minutes. Breathing is not impaired. Some postictal confusion occurs. The most appropriate initial action by the school nurse is which of the following?

The nurse is caring for clients in the pediatric medical unit. Which client should the nurse assess first?

A 13-year-old boy comes to the school nurse complaining of sudden and severe scrotal pain. He denies any trauma to the scrotum. The most appropriate nursing action is which of the following?

A 17-year-old is returning to the surgical unit following Luque instrumentation for scoliosis repair. In addition to the usual postoperative care, the nurse knows that initially:

A 20 kg child is admitted to the pediatric intensive care unit in ketoacidosis. Which of the following orders would the nurse not implement until clarified with the physician?

Which data would warrant immediate intervention from the pediatric nurse?

Which client should the pediatric nurse assess first after receiving the a.m. shift report?

The parent of a 12-year-old male child with a left below-the-knee cast calls the pediatric clinic nurse and tells the nurse, “My son’s foot is cold and he told me it feels as if his foot is asleep.” Which action should the nurse implement first?

The charge nurse has assigned a staff nurse to care for an 8-year-old client diagnosed with cerebral palsy. Which nursing action by the staff nurse would warrant immediate intervention by the charge nurse?

A 4 y/o is brought to the ER for a laceration on the right foot. What action should the nurse implement to help the child in coping with the ER experience?

A 4-year-old child tells the nurse that she doesn’t want another blood sample drawn because “I need all of my insides and I don’t want anyone taking them out.” Which of the following is the nurse’s best interpretation of this?

A 4-year-old is placed in Buck extension traction for Legg-Calvé-Perthes disease. He is crying with pain as the nurse assesses his right foot’s skin and sees that it is pale with a pulse’s absence. What should the nurse do first?

A 5-year-old child is being prepared for surgery to remove a brain tumor. Nursing actions should be based on which of the following?

The RN on a pediatric unit has received the a.m. shift report and tells the unlicensed assistive personnel (UAP) to keep the 2-year-old child NPO for a procedure. At 0830, the nurse observes the mother feeding the child. Which action should the nurse implement first?

Which client should the charge nurse on the pediatric unit assign to the most experienced nurse?

A 7-year-old has just had a cast applied for a fractured arm with the wrist and elbow immobilized. Which of the following should be included in the home care instructions?

A 9 year-old is taken to the emergency room with right lower quadrant pain and vomiting. When preparing the child for an emergency appendectomy, what must the nurse expect to be the child’s greatest fear?

A child being seen in the clinic is found to have rubeola (measles), and the father asks the nurse how to care for the child. The nurse should tell the father that he should:

A nurse is caring for a 34-month-old who is hospitalized for a lengthy illness. Which behaviors would the nurse identify as examples of expected developmental regression for the child’s age group? Select all that apply.

A child has been in the hospital for several days for treatment of severe vomiting related his HIV-positive status. Which assessment finding is the best indication that the child’s condition is improving?

A child has been seizure-free for 2 years. A father asks the nurse how much longer the child will need to take the antiseizure medications. The nurse includes which of the following in the response?

A child is admitted to the hospital, where Wilms’ tumor is diagnosed. The primary nursing intervention is:

A child is admitted with a suspected diagnosis of Munchausen syndrome by proxy (MSBP). An important consideration in the care of this child is:

A child is receiving propylthiouracil for the treatment of Graves disease. The parents and child should be taught to recognize and report which of the following symptoms immediately?

After receiving the change-of-shift report, which patient should the nurse assess first?

The nurse is observing a preschool classroom of children between the ages of 3 to 4 years of age. When planning actions to ensure that each child meets normal developmental goals, which child will require the most immediate intervention?

A child who is experiencing wheezing during an acute asthma episode is brought to the emergency department by the parents. Which intervention does the nurse implement first?

A child with a history of sickle cell disease is seen in the emergency department, where acute sequestration crisis is diagnosed. The nurse should immediately prepare to: