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WC E3
QUIZ QUESTIONS
| Question | Answer |
|---|---|
| An infant is treated in the newborn nursery for hyperbilirubinemia using phototherapy lights. It is MOST important for the nurse to intervene in which situation? | The jaundice observed around the infant's eyes has begun to disappear.eyes must be covered completely shielded with patches or an opaque mask in order to prevent exposure to the light, which could result in eye damage, especially the retina. |
| A full term newborn weighed 10 pounds , 5 ounces at birth. A priority nursing diagnosis for this baby is: | Risk for injury related to macrosomia. |
| A newborn is admitted with a diagnosis of transient tachypnea of the newborn (TTN). When planning nursing care for this baby, the nurse's goal should be to: | Promote absorption of fetal lung fluid TTN is caused by delay absorption of fetal lung fluid. Nursing care is focused on suppporting oxygenation needs to allow the newborns body to reabsorb the fluid. |
| A nurse is admitting an infant of a diabetic mother (IDM). At 1 hour of age, the nurse notices that they newborn is very jittery. Which action by the nurse is most appropriate? | Assess the newborn's blood glucose IDM's are at risk for hypoglycemia after delivery. A primary sign of hypoglycemia is jitteriness. The newborn is not showing any signs of hypoxia so oxygen would not be appropriate. |
| A woman in labor is found to have meconium-stained amniotic fluid upon rupture of her membranes. At delivery, the nurse anticipates that the priority nursing intervention is to: | suction the oropharynx when the head has delivered After the birth of the head, whild the shoulders and chest are still in the birth canal, the newborns oropharynx is suctioned by the birth attendent. |
| A 38-week newborn is found to be small for gestational age (SGA). Which nursing interventions should be included in the care of this newborn? | Maintain a warm environment-Hypothermia is a common complication of the SGA newborn, therefore, the newborns environment must remain warm to decrease heat loss. |
| A nurse explains to new parents that their newborn has developed respiratory distress syndrome (RDS). The nurse bases this assessment on which data? | grunting with respirations, nasal flaring and chest retractions are characteristics of respiratory distress syndrome. A resp rate of 40 during sleep is normal, a heart rate of 110 is normal. A fever does not indicate RDS. |
| The nurse is caring for a two-hour-old newborn whose mother is diabetic. The nurse assesses that the newborn is experiencing tremors. What nursing action has the highest priority? | Obtain a blood calcium level- Tremors are a classic sign for hypocalcemia. Diabetic mothers tend to have a decreased serum magnesium level at term. This could cause secondary hypoparathyroidism in the infant. |
| An infant was born prematurely at 25 weeks' gestation. Due to lung immaturity, the baby has been exposed to prolonged oxygen therapy. The nurse should explain that their infant is at a higher risk for what condition due to the oxygen therapy? | Premature infants are at greater risk for developing complications related to prolonged O2 therapy, such as retinopathy, which can lead to visual impairments. Hypocalcemia is more common in premature infants, as is in absent or decreased gag reflex. Cer |
| In caring for the premature newborn, the nurse must assess hydration status continually. Assessment parameters should include: (Select all that apply) | to assess hydration status, volume of urine, weight, and stool must be evaluated. Blood pH, head circ and bowel sounds are not indicators of hydration. |
| For the past 3 days, an 8-year-old child has come to the school nurse's office complaining of "stomachaches." The school nurse notes that the abdominal pain subside when the child overhe ars the nurse contact the parent's at work. important for the nurse | Ask the parents how the child behaves prior to school-need to validate anxiety, especially separation anxiety, child may be worrying about parents and is relieved when nurse talks to the parent. |
| The mother of 11 year old fraternal twins tells the nurse at their well child check up that she is concerned because her daughter has gained more weight and height than her twin brother. The mother is concerned that there is something wrong with her son. | "It is normal for girls to grow a little taller and gain more weight than boys at this age."- it is normal for girls to grow taller and gain more weight than boys near the end of middle childhood. |
| The nurse cares for children at summer camp. Which children presenting at the infirmary should the camp nurse see first? | A child diagnosed with leukemia was stung by a bee and is complaining of feeling hot and itchy all over.-probably sign of anaphylactic reaction, which can proceed quickly to loss of consciousness, angioedema, bronchiolar constriction, pulmonary edema |
| The nurse is performing a physical assessment on a 6 month old baby. Which finding should the nurse understand as abdominal for this child? | The child's posterior fontanel is open-The posterior fontanel should close between 6 and 8 weeks |
| The nurse counsels the parents of a school-age children. One of the parents asks the nurse how they should teach their children about human sexuality. Which responses by the nurse is best? | "Find out what your children know before answering their questions."-First assess; children often have misinformation about human sexuality; if the misinformation is not identified, child will incorporate the misinformation into the parents answer. |
| The nurse prepares a 15-year-old girl for a pelvic exam because the client is complaining of sharp bilateral pelvic pain. Which actions by the nurse is most appropriate? | Give a brief explanation of the procedure- preparing a client for any procedure is priority. |
| The nurse is MOST likely to provide teaching regarding which to a 10-year-old boy and his parents? | Proper nutrition- because the threat of obesity and a diet-conscious society, children begin to diet; teach importance of body-building nutrients and regular physical activity. |
| The nurse is preparing to perform a physical assessment on a 13-year-old girl. The nurse gives her the option of her mother either staying in the room or leaving. This action is: | Appropriate, because of child's age |
| An ER nurse is assessing a 12 month old female. Which statement accurately describes the best method for assessing this child? | The nurse should assess the child while she is in her mother's lap-INfants are most secure when in proximity to the parent, the parents lap is an excellent place to assess the child. |
| The nurse is performing an ear exam on an infant. Which direction is the pinna pulled while examing a child's ear at this age? | You pull it down and back < 3 yrs and up and back > 3 years. |
| A child is being discharged from the hospital following a motor vehicle accident. The mother expresses concern about caring for the child’s wounds at home. She has demonstrated appropriate technique with medication administration and wound care. Which is | Parental anxiety related to care of the child at home |
| A 10-month-old has fallen out of the high chair and is brought to the emergency department. Put the following components of the nurse's assessment into the correct order. | __3__ Circulation __6__ Appetite __4__ Bleeding __2__ Breathing __1__ Airway __5__ Level of consciousness |
| The nurse is working with a hospitalized preschool-age child. The nurse is planning activities to reduce anxiety in this child. Which is the most appropriate action by the nurse? | Provide the child with a doll and safe medical equipment-Therapeutic play is a means of anxiety reduction in the hospitalized child. Allowing the child to play with safe medical equipment is an age-appropriate method through which the child can express fe |
| In planning care for a hospitalized school-age child, which action will promote a sense of industry in this child? | Allow the child to assist with her care-Allowing the child to participate in care will decrease the sense of loss of control and increase a sense of industry |
| A 7-year-old child is scheduled for surgery. Upon the child's admission to the hospital, the laboratory technician visits her to obtain a sample of blood. The child asks the nurse if the technician is going to hurt her. What is the nurse's best response? | "It will hurt a little bit, but we want to take good care of you."-This option gives the child realistic information,Straightforward, simple explanations are best. |
| An infant has been NPO for surgery for 4 hours, and does not have an intravenous line. The nurse receives a call from the operating room with the information that the surgery has been postponed due to an emergency. Which is the priority action for the nur | It is best to keep the infant NPO and consult the physician to see if an intravenous line is needed |
| The nurse is caring for a 1 -month-old in the hospital. What is the primary nursing intervention used to help a 1-month-old infant tolerate hospitalization? | Consistent caregivers, especially if an infant spends time without family is important |
| The nurse is needing to bathe the 2 year old she is caring for. What would be the most helpful nursing action when approaching a hospitalized toddler to bathe them if their mother is unavailable to help? | Sit at the bedside and spend time with him until his anxiety has decreased-Sitting at the bedside and spending time is a way to begin to build a trusting relationship so that he will want to come to the nurse. |
| After administering a narcotic, the nurse will monitor the child for pain relief. Which assessments should be a priority in addition to pain relief? | The primary purpose of administering an opoid analgesic is to relieve pain. Side effects placing the child at greatest risk are respiratory depression and decreased level of consciousness. |
| A mother tells the nurse that she will visit her 2-year-old son tomorrow about noon. During the child's bath, he asks for Mommy. Which would be the nurse's best reply? | "Mommy will be here after lunch."- This age group doesn't have a concept of time, they associate time with what they are doing. |
| The nurse cares for a 7-year-old child hospitalized with a diagnosis of staphylococcal pneumonia. It is most important for the nurse to encourage the child to perform which activity? | Blowing bubbles using a hand-held wand-blowing bubbles will promote lung expansion while not overexerting the child and not exposing him/her to other children on the unit. |
| The nurse is caring for a 4-year-old in the hospital. The nurse notices that the child's bed is wet from urine. What is the best action by the nurse? | Change her clothes and bed without comment-Children often regress to previous patterns when they are hospitalized; the 4-year-old child sleeps soundly and may sleep right through the urge to urinate. |
| Amoxicillin (Amoxil) 250 mg by mouth every 8 hours is prescribed for a child who weighs 42 lbs. The nurse knows that the safe pediatric dosage is 25 to 90 mg/kg/day. The nurse determines that: | The prescribed dose is within a safe range |
| The nurse is preparing to give an intramuscular injection to a 6-month-old. Which is the preferred site for intramuscular injections in infants? | Vastus lateralis- This is the prefered site because of the amount of muscle. In the buttocks it could potentially harm the nerves. It's given in the bottom only after the child has been walking atleast a year |
| The nurse needs to administer a medication in tablet form to a 4-year-old. Which action is appropriate? | Crush the tablet and mix it in a teaspoon of applesauce-The medication should be crushed and mixed with a very small amount of food, not juice |
| Which of the following statements best represents infectious mononucleosis? | Herpes-like Epstein-Barr virus is the principal cause |
| A child is diagnosed with erythema infectiosum (fifth disease). The nurse observes the mother crying, and the mother says, "I am afraid. Will my unborn baby die? I have planned a cesarian section next week." Which statement would be the most therapeutic r | "I understand you are afraid. Can we talk about your concerns?"- There is less risk of fetal death in the second half of pregnancy. It is more therapeutic to acknowledge a clients fears |
| Which is the nurse's best response when the mother of a 2-month-old who is going to get the IPV tells the nurse the older brother is immunocompromised? | "Your baby can be immunized with the IPV; he will not be contagious."- The infant sibling can and should be immunized as recommended. The infant will not shed the poliovirus. Shot doesn't contain live poliovirus |
| When is a child with chickenpox considered to be no longer contagious? | When lesions are crusted |
| The nurse is caring for a child with scarlet fever. What is the causative agent of scarlet fever? | Group A ß-hemolytic streptococci-Group B strep...this can lead to acute glomerulonephritis |
| The nurse is caring for a child with a fever and malaise. During the nurses assessment koplik spots are noticed. What disease might the nurse suspect the child has? | Measles (rubeola)- Koplic spots are one of the cardinal signs for measles. |
| The nurse is caring for a baby in the clinic. Which would be the nurse's best response if a mother asks if her baby still needs Hib vaccine because he already had Hib? | "Yes it is recommended that the baby still get the Hib vaccine."-The infant needs to Hib vaccine to ensure protection against many serious infections caused by Hib, such as bacterial meningitis, bacterial pnemonia, epiglottitis, septic arthritis, and seps |
| A child comes to the clinic for diphtheria, pertussis, and tetanus and inactivated poliovirus vaccines. The child has a temperature of 101 degrees F (38.3 C). The nurse should take which action? | Withhold the vaccines, and reschedule when the child is afebrile-Because fever is a side effect of the vaccine, the immunization should be withheld as it would be difficult to determine if the fever was due to the vaccine of another febrile illness. Immui |
| What is a common childhood communicable disease that may cause severe defects in the fetus when it occurs in its congenital form? | Roseola |
| An 18-year-old boy comes to the ER complaining of a rash and itching in the groin area. He is concerned that he has contracted a sexually transmitted disease and worries that his parents will find out. The nurse's best response is: | "We will not contact your parents regarding this visit."-An adolescent has every right to privacy as long as the situation is not life-threatening |
| A 14-year-old with cystic fibrosis suddenly becomes noncompliant with the medication regimen. The intervention by the nurse that would most likely improve compliance would be to: | Set up a meeting with some older teens with cystic fibrosis who have been managing their disease effectively- Providing an adolescent with positive role models who are in her peer group is the intervention most likely to improve compliance |
| A 17-year-old male has had some recent behavioral changes. His mother calls the nurse at the pediatrician's office and tells her that her son has been coming home from school every day, closing his door, and refraining from interaction with his parents. T | "Your son's behavior is normal. You should listen to him without being judegemental."-The child's behavior is typical of a teens response to developmental and psychosocial changes of adolescence |
| A mother of a 6-year-old boy who recently had surgery for the removal of his tonsils and adenoids complains that he has begun sucking his thumb again. The nurse caring for this child should assure the mother that this is a normal response for a child who | Regression to an earlier behavior after a major event is common |
| The school nurse is preparing a discussion on nutrition with the fourth-grade class. Based on the children's developmental level, what information should she include in her presentation? | Reviewing nutritional choices keeps the lesson on a positive note, and school-age chldren are very interested in how food affects their bodies. They are capable of understanding basic medical terminology |
| An 8-year-old girl is at the pediatrician's office for a well child checkup. Her mother tells the nurse that she has been having difficulty getting her daughter to complete her chores. The child's mother asks the nurse for techniques for gaining the child | Use a reward system as a technique- This age group usually respond very well to a reward system and often enjoy the rewards so much that they will continue chores without continual reminders |
| Two 3-year-olds are playing in a hospital playroom together. Once is working on a puzzle while the other is stacking blocks. The mother of one of the children scolds them for not sharing thier toys. The nurse counsels this mother that this is normal devel | Parallel play-is when two or more children play together, each engaging in his own activities |
| A 3-year-old girl is attending her grandfather's funeral. Her parents have told her that her grandfather is in heaven with God. The child is taken up to the open casket with her parents. Which statement by the child describes a 3-year-old child's understa | "Grandpa is in heaven. Is this heaven?"-Children 3 yrs old are literal thinkers. The child's parents told her that Grandpa was in heaven. She sees his body so she thinks they are all in heaven. |
| A 5-year-old girl has been brought to the ER for suspected abuse. What approach should the nurse use to gather information from the child? | Many young children believe abuse or illness is their fault, and they should be reminded they are not to blame. Many chlidren of this age believe they have acquired a disease or have been abused because they are bad people. |
| The parents of a 2-year-old express concern about their daughter's temper tantrums to the nurse. Which best describes temper tantrums? | Temper tantrums are the toddler's way of releasing tension and aggression and are used to gain control. They are normal, age-appropriate behavior. C/H, IM, H |
| The nurse is teaching the toddler about preoperative and postoperative care. What is the best method to do use for this age group? | Dolls and puppets are familiar object that the young child can actively manipulate, and thus they are good ways for the young child to learn. |
| The nurse is teaching a mother of an 18-month-old the best way to discipline her toddler. Which method is best for this age group? | Setting consistent limits leaches the child self-control and provides a sense of security. "Punishment" by removing the child from an undesirable situation is only effective if limits are known by the child beforehand. A toddler is unable to reason and ca |
| A 12-month-old boy weighed 8 pounds 2 ounces at birth. Understanding developmental milestones, what should the nurse caring for the child calculate his current weight as? | Approximately 24 lb 6 oz-Children should triple their birth weight by 12 months of age |
| The nurse is assessing an 8-week-old infant and discovers the posterior fontanel is closed. Which would be the most appropriate action by the nurse? | Document this as a normal finding-The bones surrounding the posterior fontanel fuse and close by age 8 to 12 weeks |
| The nurse is teaching the parents of a 11-month-old about appropriate play activities. Which play activity would be correct for this age group? | Placing objects in a container through holes- 3 is correct, the others occur in toddlerhood and after. |
| The nurse is guiding parents in selecting a daycare facility for their child. Which is most important to consider when making the selection? | Health practices of facility |
| A 12-month-old boy weighed 8 pounds 2 ounces at birth. Understanding developmental milestones, what should the nurse caring for the child calculate his current weight as? | Approximately 24 lb 6 oz,Children should triple their birth weight by 12 months of age |
| A 2-year-old girl has just become a big sister. Her mother has been a stay-at-home mother. Based on the developmental level of a 2-year-old, which comment should the child's mother expect from her toddler about her new baby brother? | "Mommy,--- Toddlers are very egocentric and do not consider the needs of other children.it is time to put him away so we can play.", |
| Which observation by the nurse best indicates that a 2-year-old is at their normal developmental level? | Undresses herself, but needs help getting dressed.,This is characteristic of the 24-month-old child |
| Two 3-year-olds are playing in a hospital playroom together. Once is working on a puzzle while the other is stacking blocks. The mother of one of the children scolds them for not sharing thier toys. The nurse counsels this mother that this is normal devel | Parallel play--Parellel play is when two or more children play together, each engaging in his own activities. |
| While being comforted in the Emergency Department, the 7-year-old sibling of a pediatric trauma victim blurts out to the nurse, "It's all my fault! When we were fighting yesterday, I told him I wished he was dead!" The nurse, realizing that the child is e | Reassuring the child that it is normal to get angry and say things that we do not mean, but that we have not control over whether an accident happens. |
| A 16-year-old girl is having a discussion with her nurse about her recent diagnosis of lupus. The nurse understands how to best answer the young woman's questions about her prognosis because she understands what congnitively? | Adolescents are able to understand and imagine possibilities for the future.,Adolescents are becoming abstract thinkers and are able to imagine possibilities of the future. |
| The mother has brought her 16-year-old daughter to the ER because she is concerned her daughter is anorexic. During the child's initial physical assessment, the nurse notes the daughter has signs and symptoms of nutritional deficit. Which assessment item | The child's hair and nails are brittle and dry,Dry and brittle hair and nails are common among people who have nutritional deficits. |
| The single parent of a child who has just been diagnosed with chickenpox tells the nurse that staying home with the child and missing work cannot be afforded. The parent asks the nurse if there is some medication that will shorten the course of the illnes | Explain the advantages of the medication acyclovir to treat chickenpox. |
| Which of the following is an appropriate intervention to provide comfort for the child with itching associated with chickenpox? | Give an antipruritic medication such as Benadryl. |
| The nurse is caring for a baby in the clinic. Which would be the nurse's best response if a mother asks if her baby still needs Hib vaccine because he already had Hib? | "Yes it is recommended that the baby still get the Hib vaccine." |
| Which is the nurse's best response when the mother of a 2-month-old who is going to get the IPV tells the nurse the older brother is immunocompromised? | "Your baby can be immunized with the IPV; he will not be contagious."-The infant sibling can and should be immunized as recommended. The infant will not shed the poliovirus. Shot doesn't contain live poliovirus. |
| The school nurse is concerned about an outbreak of chickenpox because there are two children at the school who have cancer and are immunodeficient from chemotherapy. What would be an important recommendation for the nurse to make? | Varicella-zoster immune globulin (VZIG) to prevent chickenpox-pts who are immunosuppressed can be vaccinated against varicella |
| Which may be given to high-risk children after exposure to chickenpox to prevent varicella? | Varicella-zoster immune globulin |
| Vitamin A supplementation may be recommended for the young child who has which of the following? | Measles (rubeola) |
| INFANTS (BIRTH-1YR) | TRUST VS MSITRUST |
| TODDLERS (1-3YR) | AUTONOMY VS SHAME/DOUBT |
| PRESCHOOL (3-6YR) | INITIATIVE VS GUILT |
| SCHOOL AGE (6-12YR) | INDUSTRY VS INFERIORITY |
| ADOLESCENT (12-18YR) | IDENTITY VS ROLE CONFUSION |
Created by:
vsykes