To safely administer IV therapy to an infant, it would be contraindicated for the nurse to:

A: Check the IV site hourly.

B: Apply wrist restraints bilaterally.

C: Obtain an infusion pump.

D: Use IV tubing with a metriset (soluset/burretrol).

B: Apply wrist restraints bilaterally.

This question asks for an inappropriate nursing action. Intravenous therapy is not an indication for application of wrist restraints. Peripheral IV lines can best be maintained in children by adequately taping the angiocath and restraining the site on an armboard securely.

The nurse admits a child with celiac disease. Which nursing observation is consistent with celiac disease?

A: Foul-smelling stool.

B: Jaundice.

C: Clubbing of the fingernails.

D: Elevated sweat chloride.

 A: Foul-smelling stool.

Foul, fatty stools (steatorrhea) are a manifestation of celiac disease, a malabsorption syndrome.

The nurse is caring for a three-year-old child newly diagnosed with diabetes. When writing the care plan, the nurse includes this goal: The child will be provided with opportunities for therapeutic play. the nurse knows the toy that best meets this goal is a:

A: Stuffed bear with bandages to apply.

B: Puppet dressed as a nurse.

C: Doll and a syringe with no needle.

D: Book about hospitalization.

C: Doll and a syringe with no needle.

a preschooler newly diagnosed with diabetes will have a lot of anxiety about the frequent needles required for finger sticks and insulin injections. The best use of therapeutic play will address this anxiety by giving the child an opportunity to give shots.

A client has had a tonsillectomy for recurrent strep throat infections. Which finding would the nurse give the most attention to eight hours after surgery?

A: Extreme thirst.

B: Frequent swallowing.

C: Sore throat.

D: Hoarse voice.

B: Frequent swallowing.

frequent swallowing is a classic sign of hemorrhage post-tonsillectomy, a major postoperative complication. The denuded tonsil sockets ooze blood, which pools in the back of the throat causing the child to clear their throat and swallow. The nurse reports this finding immediately.

The nurse is caring for a two-year-old client who was admitted for laryngotracheobronchitis. The client is placed in a crib with a croup tent. Which toy would be most suitable for the client at this time?

A: A cloth crib gym.

B: A stuffed teddy bear.

C: A cardboard picture book.

D: A plastic fire engine.

D: A plastic fire engine.

Acute laryngotracheobronchitis, or croup, is a condition of respiratory difficulty caused by infection, inflammation and swelling of the upper airway (larynx, trachea, and bronchus). Croup is characterized by a "barking" cough. The croup tent is ordered to provide a high-humidity environment to ease the client's work of breathing. Consequently, the nurse selects an age-appropriate toy made of plastic that can be easily wiped clean and dry.

A six-month-old infant is one day postoperative after receiving a colostomy. when the nurse positions the infant on its side, the infant stiffens and begins to cry. The initial nursing action is to:

A: Leave the baby to rest as infants' pain perception is not the same as older children.

B: Check when the last pain medication was given to see if able to give it now.

C: Call the parent in as this is a sign of separation anxiety.

D: Check the abdominal dressing as this may indicate an infection.

B: Check when the last pain medication was given to see if able to give it now.

Stiffening and crying may be indicators of pain. This infant is only one day postoperative; pain relief is essential for healing and recovery.

A three-year-old with a serum lead level of 15 g per dL is seen in the lead poison clinic. Which dietary modification does the clinic nurse recommend to the child's parent to help prevent the development of lead poisoning? "Make certain your child drinks a lot of:

A: Cranberry juice."

B: Milk."

C: Fluids of any kind."

D: Water."

B: Milk."

The clinic nurse should recommend increased intake of calcium and iron for the prevention of lead poisoning. Milk is a good source for calcium

A parent expresses concern over a four-year-old child's stuttering. Which response by the nurse would be least helpful?

A: "Look directly at your child while the child is speaking."

B: "It may help if you encourage your child to stop and begin the word over."

C: "Singing songs or nursery rhymes may ease stuttering."

D: "Vocal hesitancy is common in children younger than age seven."

B: "It may help if you encourage your child to stop and begin the word over."

Stuttering is a disorder of fluency characterized by repetition of sounds. It would not be appropriate to advise stopping the child mid-word or mid-sentence. Such an intervention often draws attention to the stuttering and may actually worsen it.

A six-week-old infant is admitted to the pediatric acute care unit following pyloromyotomy for correction of pyloric stenosis. The nurse admitting the child anticipates the feeding schedule in the postoperative period will be:

A: Small, frequent bottle feedings.

B: NPO with intravenous fluids only.

C: Continuous drip via a nasogastric tube.

D: Bolus feedings via a gastrostomy tube.

A: Small, frequent bottle feedings.

Pylorotomy is the release of a hypertrophied muscle around the pyloric sphincter that causes narrowing of the pyloric canal. It involves no surgical incision into the stomach itself. Consequently, infants will be fed shortly postoperatively (as soon as there is a return of bowel sounds) in small, frequent oral feeds.

The nurse evaluates a dehydrated infant's response to parenteral therapy by:

A: Measuring the head circumference twice a day.

B: Counting the number of wet diapers every shift.

C: Weighing the child at the same time every day.

D: Taking the child's vital signs every two hours.

C: Weighing the child at the same time every day.

Weight is the most sensitive indicator of hydration status in clients of all ages. Weight is the only measurement that reflects both measuable fluid balance changes (intake and output) and insensible fluid loss (skin and respiratory).

After beginning chemotherapy, a school-aged child with neuroblastoma becomes anorexic and has periods of nausea.The best nursing intervention is to:

A: Increase proteins and fats.

B: Encourage high-quality nutritious foods.

C: Force the client to eat balanced meals.

D: Allow the client to eat whatever the client wants, at any time.

D: Allow the client to eat whatever the client wants, at any time.

When the nausea is absent, offering small amounts of the child's favorite foods is the best way to improve intake.

The nurse is instructing an adolescent client with a fiberglass cast on proper care of the cast. To prevent damage to the cast, the nurse will instruct the client to:

A: Place plastic over the cast while bathing.

B: Take tub baths only.

C: Prevent writing on the cast.

D: Discontinue all sports activities.

A: Place plastic over the cast while bathing.

Even though fiberglass casts are less likely to break down from water than plaster casts, the client should still avoid getting the cast wet. Plastic prevents the cast from becomeing wet and irritated. Should the cast become wet by accident, the client is instructed to use a hair dryer on a cool low setting to dry it.

In planning care for a newborn with a surgical repair of a myelomeningocele, the nurse is aware that postoperatively the child is most prone to developing.

A: Osteomyelitis

B: Hydrocephalus

C: Otitis media

D: Decubitus

B: Hydrocephalus

In the surgical repair of the myelomeningocele, the pathway for the cerebral spinal fluid has been altered. Therefore, the child is at risk for hydrocephalus.

Following a course of chemotherapy, a six-year-old child with retinoblastoma has neutropenia. In planning the child's care, the appropriate nursing action is to:

A: Encourage quiet play and maintain bed rest.

B: Maintain protective isolation and monitor for fever.

C: Protect from injury and monitor for bleeding.

D: Monitor oximetry and administer oxygen for dyspnea.

B: Maintain protective isolation and monitor for fever.

Naurtopenia is a decreased white blood cell count, which puts the child at increased risk of infection. Therefore, the child should be isolated and monitored for fever (which indicates possible infection).

A child is admitted with a diagnosis of Wilms' tumor. Which nursing intervention takes priority?

A: Raising the head of the bed to ease breathing.

B: Checking vital signs every eight hours for incidence of hypertension.

C: Monitoring the urinary output every two hours.

D: Placing a sign over the bed that says "Do Not Palpate the Abdomen".

D: Placing a sign over the bed that says "Do Not Palpate the Abdomen".

Wilms' tumor is a cancerous tumor on the kidney which is also called nephroblastoma.

Wilms' tumors are usually encapsulated, and it is very important to protect this incapsulation to help contain the tumor. Decreasing palpation of the abdomen may protect this encapsulation.

An adolescent is placed on a patient-controlled analgesia pump (PCA). When the nurse checks the client's pain at 8 a.m., the client describes the pain at level 3 on a scale of 1 to 10. At 10 a.m., the client describes the pain at level 5. The nurse discovers the client has not pushed the button to deliver the medication in the past two hours. What is the nurse's best action to take?

A: Reinforce teaching about how to push the button to deliver the medication with the client.

B: Ask the physician to discontinue the PCA so the nurse can administer PRN pain medication.

C: Suggest the client's parent push the button for the client if the parent thinks the child has pain.

D: Assess the client again in an hour because a pain level of 5 is acceptable on a scale of 1 to 10.

A: Reinforce teaching about how to push the button to deliver the medication with the client.

The most appropriate action at t his time is to reinforce client teaching about the PCA. The nurse should remind the client about the availability of the medication, make sure the client knows how to use the equipment, and emphasize the importance of using it regularly to prevent the pain from getting intolerable and interfering with the client's ability to turn, cough, and deep breathe.

The nurse must start a preoperative IV for a child the evening before surgery. The nurse plans to use EMLA cream (eutectic mixture of local anesthetics) to numb the insertion site prior to the procedure. It would be contraindicated for the nurse to:

A: Wipe off the EMLA just prior to the IV insertion.

B: Apply a thin layer of EMLA to the skin.

C: Place a transparent dressing over the EMLA.

D: Apply the EMLA at least one hour before the procedure.

B: Apply a thin layer of EMLA to the skin.

EMLA Cream is a topical anesthetic that numbs the skin and decreases the sensation of pain. It is used to lessen the discomfort from medical procedures. EMLA cream must be applied in a thick dollop to the skin. A thin layer would be ineffective. This step would therefore be inappropriate for the nurse to take.

A two-year-old is brought to the emergency room by his parents after being discovered crying and holding a container of toilet bowl cleaner. The client's lips are peeled and oozing, and he is drooling. The nurse collecting data gives highest priority to:

A: Confirming the presence of a gag reflex.

B: Identifying the type of poisonous substance.

C: Determining the percentage of burned surface area.

D: Monitoring the respiratory status of the child.

D: Monitoring the respiratory status of the child.

The nurse observes that the child's lips are peeling and oozing and that he is drooling. All of these findings indicate that the child may have swelling of the oral cavity and pharynx, which can result in a compromised airway. Consequently, the nurse give hightest priority to monitorying the client's airway.

The parent of a toddler scheduled for surgery asks the nurse for advice on how to prepare the child for hospitalization. The nurse suggests the parent:

A: Explain the reason for the surgery.

B: Read books to the child about hospitalization.

C: Buy the child new toys to bring to the hospital.

D: Avoid mentioning the hospitalization.

B: Read books to the child about hospitalization.

There are many books available that explain hospitalization in age-appropriate, non-theatening language for toddlers using familiar characters from popular children's television shows. Reading books will introduce vocabulary and concepts related to hospitalization.

The nurse is planning care for a child with a diagnosis of autism. Which goal does the nurse prioritize as of primary importance in the care of the child? The child will:

A: Have adequate opportunity to socialize with other clients.

B: Remain free of infection.

C: Be stimulated for optimum growth and development.

D: Be protected from self-injury.

D: Be protected from self-injury.

Autism is a severe developmental disability significantly affecting verbal and non-verbal communication and social interaction, generally evident before age three. Characteristics often associated with autism are engagement in repetitive actvities and stereotyped movements, resistance to environmental change or change in daily routines, and unusual responses to sensory experiences. The child with autism has unusual responses to painful stimuli and may engage in self-injurious behaviors as a form of auto-stimulation. Consequently, the nurse's primary goal in the care of a child with autism is to protect the child from self-harm.

The nurse is preparing a three-year-old child for a lumbar puncture. In preparing the child for this procedure, which strategy does the nurse plan to use?

A: Describing the sensory aspects of the procedure.

B: Showing a video of the procedure.

C: Telling the child why it is being done.

D: Explaining the steps of the procedure.

A: Describing the sensory aspects of the procedure.

A brief general description in non-threatening, age-appropriate language immediately prior to the procedure should include information about the sensations that the child can expect to feel (cold soap, held tightly, etc.).

The nurse is assisting in the care of a child experiencing thrombocytopenia as a side effect of chemotherapy. An appropriate nursing goal to include in the child's care is to protect the child from:

A: Becoming fatigued.

B: Injury or trauma.

C: Sources of infection.

D: Exposure to sunlight.

B: Injury or trauma.

Thrombocytopenia means a decreased platelet count. This child will have a tendency toward bleeding and must be on bleeding precautions.

The physician orders a Milwaukee brace for a 13-year-old client diagnosed with idiopathic scoliosis. After educating the adolescent, the nurse evaluates the client understands the proper application and use of the brace when stating, "I can take my brace off:

A: Only when I come in for adjustments."

B: For about an hour to shower daily."

C: On special occasions only, like dances."
D: To sleep every night at bedtime."

B: For about an hour to shower daily."

The Milwaukee brace, worn for scoliosis (lateral curvature of the spine), stabilizes the spine from the neck to the pelvis. It must be removed daily for hygiene care, but that is all. Once the curve has stabilized and spinal growth is nearly complete (as determined by wrist x-rays of the epiphyseal growth plates), the orthopedic surgeon will begin to wean the client out of the brace. Typically, the client will go for progressively longer periods of time during the day (when wearing the brace is most objectionable) without the brace but continue to wear it in the evening and at night. The brace will often be worn at night several years after growth is complete to maintain the spinal correction.

The nurse is caring for an infant in a croup tent with oxygen flowing who may be taken out for bathing and feeding. Durning a feeding, the nurse notices that the infant becomes restless and respirations are 60 per minute. The initial action is to:

A: Auscultate breath sounds.

B: Return the infant to the croup tent.

C: Recheck the respiratory rate.

D: Change the infant's position.

B: Return the infant to the croup tent.

Restlessness is a sign of respiratory distress, and a respiratory rate of 60 per minute is above the normal range for an infant. The infant is exhibiting restlessness, an early sign of hypoxia.  The only treatment for lack of oxygen is giving oxygen. The return to the croup tent will provide oxygen to relieve the signs of respiratory distress and help to maintain satisfactory oxygenation.

According to Erikson's theory, which nursing action will meet the developmental needs of an eight-year-old client in skeletal traction?

A: Allow child to play with the computer video game daily.

B: Assign roommate for the client who are of similar ages.

C: Take the client daily to the playroom, in the bed, maintaining traction.

D: Have the hospital tutor visit daily to assist the client with homework.

D: Have the hospital tutor visit daily to assist the client with homework.

Erikson states that the developmental stage for the school-aged child is industry vs. inferiority. Children hospitalized for a long time in traction will often worry about falling behind their peers in their school work. It is important to make arrangements witht he child's school to provide homework for the child and to provide an opportunity for the child to complete the work as well.

The nurse is collecting data from a six-month-old infant in the well-child clinic. Which observation would concern the nurse? The infant's:

A: Legs stay crossed at the knees.

B: Birth weight has doubled.

C: Posterior fontanel is closed.

B: Able to sit unsupported for a few seconds.

A: Legs stay crossed at the knees.

Legs crossed at the knees would concern the nurse. At six months of age, an infant's legs should be straight and paralledl to each other. The legs flex at the knees. An infant of any age whose legs are crossed or scissored needs to be referred for evaluation Crossed or scissored legs are an indication of cerebral palsy.

The nurse collects data on a child with reactive airway disease (asthma) immediately after receiving an albuterol (Tentolin) treatment. The nurse evaluates that the treatment was effective when the observations reveal an increase in the client's:

A: Pulse rate.

B: Oxygen saturation.

C: Expiratory phase.

D: Wheezing.

B: Oxygen saturation.

Improved oxygen saturation following the administration of a bronchodilator, such as albuterol, indicates the treatment worked. It indicates the medication had the desided effect of easing work of respiration so that the child has improved oxygenation.

A child in kindergarten with a food allergy is brought to the school nurse with a suspected anaphylactic reaction from eating a cookie. The child suddenly goes into cardiac arrest. the nurse performs cardiopulmonary resuscitation (CPR) on the child by depressing the sternum:

A: 1/2 to 2/3 the depth of the chest.

B: 1 1/2 - 2 inches.

C: 1/3 to 1/2 the depth of the chest.

D: 1 inch to 1 1/2 inches.

C: 1/3 to 1/2 the depth of the chest.

chest compression in CPR for a child, as defined by both the American Heart Association and the American Red Cross as being between the ages of one to puberty, is performed by depressing the sternum 1/3 to 1/2 the depth of the chest. A kindergarton-aged child is typically 5 or 6 years of age and would clearly fall between that age range. This compression depth would be correct for an infant as well.

To meet the goal of adequate nutritional intake for a child with cystic fibrosis (CF), the nurse needs to include which implementation in the client's care?

A: Decrease salt intake.

B: Increase protien intake.

C: Decrease fat intake.

D: Increase fiber intake.

B: Increase protien intake.

the nurse needs to increase carbohydrates, protein, and minerals in the child's diet to promote weight gain. However, children with cystic fibrosis (CF) have difficulty absorbing nutrients due to a blockage of pancreatic enzymes by thick mucus secretions in the pancreas and liver. Pancreatic enzymes help break down ingested foods so the body can metabolize nutrients. Administering pancreatic enzymes (in granule or capsule form) before eating will enable children to metabolize nutrients so they can be used more effectively.

In the child with a ventricular septal defect, the would expect to observe:

A: Acrocyanosis.

B: Murmur.

C: Clubbing of the nail beds.

D: Polycythemia.

B: Murmur.

Ventricular septal defect, a hole in the septal wall between the ventricles, is an acyanotic heart defect. A systolic murmur may be best heard at the lower left sternal border. Sound is transmitted in the direction of blood flow, so any back flow of blood from the left to the rigth ventricle through the septal defect would be best heard in this area.

when admitting a toddler with acquired immune deficiency syndrome (AIDS), the nurse carefully checks the child's mouth. Which common manifestation of opportunistic infection is the nurse looking for?

A: Koplik spots.

B: Candidiasis.

C: Chancre.

D: Gingivitis.

B: Candidiasis.

Candidiasis, or oral thrush, is caused by the overgrowth of Candida albicans, an opportunistic fungus that commonly infects the oral cavity of infants, diabetics, and other clients with immature or compromised immune systems. Candidiasis appears as a cheesy, white plaque that may appear like milk curds on the Buccal mucosa and tongue. thrus is often the initial opportunistic infection noted int he human immunodeficiency virus (HIV) positive child developing AIDS.

The nurse's neighbor arrives at the nurse's home with a limp, blue infant yelling, "My baby has drowned in the tub!" The nurse performs cardiopulmonary resuscitation (CPR) on the infant at the ratio of:

A: 5 compressions to 1 respiration.

B: 15 compressions to 2 respirations.

C: 30 compressions to 2 respirations.

D: 15 compressions to 1 respiration.

C: 30 compressions to 2 respirations.

Lone rescuer CPR for an infant, defined by both the American Heart Associateion and the American Red Cross as being less than one year of age, is performed at the universal ratio of 30 chest compressions to 2 ventilations.

A child has been diagnosed with sickle cell anemia. During discharge teaching, which intervention will the nurse stress to the child and family?

A: Increase fat intake.

B: Increase fluid intake.

C: Eat leafy green vegetables daily.

D: Closely monitor bowel movements.

B: Increase fluid intake.

Sickle cell anemia is an inherited, chronic disease in which the red blood cells, normally disc-shaped, become crescent shape. As a result, they function abnormally and cause increase viscosity of the blood giving rise to recurrent painful episodes. Sickle cell anemia is caused by an abnormal type of hemoglobin (hemoglobin S). It is inherited as an autosomal recessive trait; that is, it occurs in someone who has inherited hemoglobin S from both parents. Due to the viscosity of the red blood cells as they change shape during a crisis, the child needs to increase fluid intake to help prevent dehydration.

the nursing assistant is helping admit a child who is blind for elective hernia repair. Which action alerts the nurse that the nursing assistant needs more teaching about the care of sensory-impaired children?

A: Places a sign that says VISUAL IMPAIRMENT at the head of the bed.

B: Takes the child to the playroom in a wheelchair.

C: Tells the child the location of each item on the dinner tray.

C: Allows the child to handle the electronic thermometer, before taking vital signs.

B: Takes the child to the playroom in a wheelchair.

This action is unnecessary. A visually-impaired child admitted for an elective surgery should be able to ambulate to the playroom with a cane or with the assistance of a guide.

The nurse is caring for a three-year-old child on the first postoperative day following revision of a malfunctioning ventriculo-peritoneal shunt. Which method would be the most accurate way for the nurse to determine of the child is having pain?

A: Use behavior indicator, such as whining or decreased mobility.

B: Utilize the pain rating scale, such as the faces scale", with the child.

C: Rely on vital sign changes, such as tachycardia or hypertension.

D: Ask the child's parent if he/she thinks the child is in pain.

B: Utilize the pain rating scale, such as the faces scale", with the child.

Pain is a subjective experience even for a three-year-old. The nurse should involve the parent in the data collection, for example, asking the parent what word the child uses for pain (most commonly: "owie" or "boo-boo"). But to most accurately determine if the child is in pain, the nurse must ask the child. Research has shown that pain rating scales, such as the "faces scale", can be used to accurately determine the presence of pain in children as young as three.

A four-year-old female is having frequent urinary tract infections (UTI). To prevent further recurrence, the nurse should instruct the child's parent to:

A: Obtain a clean catch urine specimen monthly for laboratory analysis.

B: Give the child frequent bubble baths to keep the perineum clean.

C: Teach the child to wipe her perineum from front to back after urinating.

D: Restrict the child's fluids so the urien will be more concentrated.

C: Teach the child to wipe her perineum from front to back after urinating.

The child needs to be taught to wipe the perineum from front to back. This prevents bacterial contamination from the anal area from entering the urethra.

A toddler had the first measles-mumps-rubella (MMR) immunization yesterday. Today, the parent calls the clinic to report that the child has a fever of 100 degrees F (37.8 degrees C), and the area around the injection site is warm and tender. What is the appropriate nursing action?

A: Instruct the parent to keep a close observation on the site.

B: Assure the client's parent that this is a normal response.

C: Suggest the parent apply a hot pack to the site.

D: Make an appointment for the child to be see at the clinic.

B: Assure the client's parent that this is a normal response.

This reaction is within normal expectations for the day following the injection; the temperature and warmth at the site are the signs of a mild response.

In planning care for a four-year-old admitted to the hospital, the nurse would include providing the child with a:

A: Plastic stethoscope.

B: Helium filled latex ballon.

C: Jigsaw puzzle.

B: Brightly colored mobile.

A: Plastic stethoscope.

Preschool play centers on imitation of adults. Providing a stethoscope allows the child an opportunity for therapeutic play. Imitating health care personnel helps to ease the fear of unfamiliar equipment.

A four-month-old infant is seen in the well child clinic for treatment of otitis media. After teaching the parent measures to prevent reoccurrence, the nurse evaluates the teaching has been effective when the parent states:

A: "I will call the clinic promptly if my baby starts pulling at the ears again."

B: "I will save any leftover antibiotics in case my baby starts showing manifestations again."

C: "I will make sure my baby is sitting upright when drinking a bottle."

D: "I will use ear plugs to keep my baby's ears from getting wet in the bath tub."

C: "I will make sure my baby is sitting upright when drinking a bottle."

The stem of this question asks for preventative measures. Having the child sit upright for feedings promotes drainage of the inner ear away from the eustachian tube and prevents pooling of food and bacteria in the ora-nasopharynx.

when preparing to administer an immunization to a two-month-old infant, the nurse knows the preferred site for administration is:

A: Vastus lateralis.

B: Deltoid.

C: Dorsogluteal.

D: Ventrogluteal.

A: Vastus lateralis.

The vastus lateralis is a large developed muscle, even in a small infant. It can tolerate the volume of the injection, and no important nerves or blood vessels are located in this muscle. In addition, this site is easily located and isolated, and restraining the child is less difficult than for other sites.

When preparing to administer an immunization to a perschool-aged child, the best nursing action is to:

A: Ask the parent where he/she would like the nurse to administer the injection.

B: Notify the parent of what adverse reactions to expect.

C: Ask the parent to wait outside the examining room.

D: Have the parent hold the child during and immediately after the injection.

D: Have the parent hold the child during and immediately after the injection.

Having the parent hold the child during and immediately after the injection has been shown to significantly reduce the stress of the situation for the child.

A hospitalized three-year-old child had been completely toilet trained prior to admission but is now having some accidents. When the nurse wakes the child up after a nap, the child's bed is soaking wet. The appropriate response by the nurse at this time is:

A: "Let's put a diaper on you to help you stay dry."

B: "I can't believe a big child like you wet your bed."

C: "Let's get you cleaned up so you can go to the playroom."

D: "Your mom is going to be very disappointed in you."

C: "Let's get you cleaned up so you can go to the playroom."

Regression is perfectly normal in the hospitalized child, and a recently toilet-trained three-year-old will likely respond to the stress of hospitalization with accidents. The less attention the nurse brings to the situation, the better the child will feel.

Prednisone (Deltasone) is ordered for a two-year-old client with nephrotic syndrome. The nurse confirms the effectiveness of the prednisone therapy when the child's:

A: Food intake increases.

B: Respiratory rate decreases from 25 to 16 breaths per minute.

C: Rectal temperature returns to 37 degrees C.

D: Weight drops 500 grams.

D: Weight drops 500 grams.

In nephrotic syndrome, prednisone acts on the body to decrease the excretion of protein and thus help fluids shift back to their normal spaces. The extra fluid is excreted in the urine. A decrease in edema can be measured by weight loss.

A six-week-old infant is admitted to the pediatric unit following repair of a cleft lip. Which comfort measure does the nurse use to keep the infant from crying?

A: Offer a bottle every two hours for hunger.

B: Provide a pacifier to meet sucking needs.

C: Sedate the infant to promote sleep.

D: Rock the infant when awake and irritable.

D: Rock the infant when awake and irritable.

Rocking the infant provides diversion and kensthetic (motion) stimulation, which are non-pharmacologic pain relief measures that are very effective with infants.

The nurse is providing anticipatory guidance to the parents of a toddler. Regarding accidental ingestion of a poison, the nurse instructs the parent to first:

A: Induce vomiting.

B: Administer syrup of ipecac.

C: Get to an emergency facility.

D: Call the poison control center.

D: Call the poison control center.

The parent should call the poison control center first to find out which action to take immediately. The poison control center will be able to guide the parent on what to do next because treatment depends on the type of poison ingested.

A dehydrated toddler must recieve 100 mL of normal saline over the next four hours. Because the IV is on microdrip tubing delivering 60 gtt per mL, the nurse regulates the IV to deliver.

A: 60 gtt per minute.

B: 100 gtt per minute.

C: 15 gtt per minute.

D: 25 gtt per minute.

D: 25 gtt per minute.

The child has to receive 100 mL in 4 hours so 100 mL/4 hours = 25 mL per hour. For microdrip tubing, drips (gtt) per minute equals mL per hour. Therefore, to administer 25 mL per hour, the nurse regulates the IV at 25 gtt per minute.

A six-week-old infant is admitted with pyloric stenosis. The infant has an IV of D5 and 0.2 N/S at 22 mL per hour and is n.p.o. awaiting surgery. Which nursing observation takes priority?

A: Elastic skin turgor.

B: Erythema at the IV site.

C: Irritability.

D: Urine output of 30 mL in two hours.

B: Erythema at the IV site.

Erythema (redness) at the IV site may indicate infiltration or phlebitis. Because the child is NPO, maintaining IV access is critical. Children with pyloric stenosis often come into the hospital with fluid and electrolyte imbalances because of the vomiting. The IV fluids are essential.

A child with a periorbital cellulitis has a rectal temperature of 102.2 degress F (39 degrees C). The child has an order for acetaminophen (Tylenol) 280 mg by mouth. The label on the bottle reads 160 mg per 5 mL. How many mL should the nurse dispense to the child?

A: 8.8 mL.

B: 9.8 mL.

C: 6.4 mL.

D: 1.8 mL.

A: 8.8 mL.

The nurse needs to administer 280 mg. Available is 160 mg per 5 mL. Set up an equation: 160 mg/5 mL = 280 mg / X mL. Solve for X. 160 x X = 280 x 5. 160x= 1400. X = 8.75 mL. Using round rules, 8.75 mL = 8.8 mL. The nurse dispenses 8.8 mL.

The nurse takes vital signs on a three-month-old infant and obtains these results: temperature 99.3 degrees F (37.4 degees C), heart rate 122 beats per minute, respiratory rate 32 breaths per minute, and blood pressure 88/54. Which nursing action would be appropriate at this time?

A: Obtain an oximetry because of the respiratory rate.

B: Recheck the heart rate and blood pressure in 15 minutes.

C: Chart the vital signs on the bedside graphics sheet.

D: Administer ecetaminophen (Tylenol) for the temperature.

C: Chart the vital signs on the bedside graphics sheet.

These vital signs are perfectly normal for a three-month-old infant. All the nurse needs to do is chart them on the bedside sheet.

The nurse is preparing a six-year-old child for surgery. Which finding by the nurse is most important to report to the surgeon?

A: An oral temperature of 98 degrees F (36.7 degrees C).

B: The absence of drug allergies.

C: A loose lower front tooth.

B: Blood pressure 94/56.

C: A loose lower front tooth.

Around six years of age, children begin to lose their deciduous or baby teeth. The condition of the child's teeth should be checked if surgery is to be done. A tooth that falls out during surgery could cause airway obstruction.