NUR 254 Exam 4 | Nursing 254
Maternal Exam 4 Exam Questions &
Answers, Explained Solutions
The nurse is caring for a child who has leukemia with a white blood cell (WBC)
count of < 1000 mm. Which of the following should the nurse include in the
child's plan of care? - CORRECT ANSWER Administer prescribed
influenza vaccination
QUESTION :The nurse is providing a teaching session to the health care staff
regarding osteosarcoma. Which of the following statements by an attendee
indicates a need for additional teaching? - CORRECT ANSWER "In the
early stage, the symptoms of this disease are usually attributed to normal
growing pains.
QUESTION :The nurse is caring for a child who is suspected of having a Wilm's
tumor. Which of the following actions by the nurse indicates the need for
additional training? - CORRECT ANSWER Palpating the child's
abdomen
QUESTION :The nurse is caring for a 5-year-old child who has sickle cell disease
(SCD). An assessment of the child includes the following: respirations 10 and
unarousable. The child is currently on intravenous (IV) fluids and continuous IV
morphine sulfate Based on the assessment information, which of the following
actions should the nurse take first? - CORRECT ANSWER Administer
naloxone to reverse the effect of the morphine.
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QUESTION :The nurse is admitting a child who has a vaso-occlusive sickle cell
crisis. Which of the following interventions should the nurse anticipate to be
prescribed for the child? - CORRECT ANSWER Hydration and pain
management
QUESTION :The nurse working in the emergency department (ED) is caring for a
child who has hemophilia and developed a swollen knee after falling off a
bicycle. The nurse is teaching the child's parents about care when similar
incidents occur at home in the future. Which of the following actions should the
nurse teach the parents? - CORRECT ANSWER Apply an ice pack and
compression dressings to the knee.
QUESTION :The newly hired nurse is talking with the nurse preceptor about the
prevention of irondeficiency anemia in infants. Which of the following
statements by the newly hired nurse is correct regarding prevention of this
condition? - CORRECT ANSWER "Iron-fortified commercial formula
should be given for the first 6 months of life
QUESTION :The nurse is assessing a child who has severe iron deficiency
anemia. Which of the following assessment finds should the nurse expect to
observe? - CORRECT ANSWER Pallor
QUESTION :The nurse is caring for 4-year-old child who is 36 hours
postoperative following a removal of a Wilm'stumor. Which of the following
requires immediate follow up by the nurse? - CORRECT ANSWER
Incision site is pink at the edges.
QUESTION :The nurse is providing discharge instructions to the parents of a
child who had surgical resection of a neuroblastoma 4 days ago. Which of the
following statements by the parents indicates teaching has been effective? -
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CORRECT ANSWER We will provide pain relief using pain medication
and rest."
QUESTION :The nurse is caring for a child who has increased intracranial
pressure (ICP) and is in stable condition. Which of the following
interventionsshould the nurse implement to decrease ICP in the child? -
CORRECT ANSWER Limit number of visitors inside the child's room.
QUESTION :The nurse is caring for a child who has Reye's syndrome. Which of
the following should the nurse include in the child's plan of care - CORRECT
ANSWER Provide the child a quiet atmosphere with dimmed lighting
QUESTION :The nurse is caring for a child who is suspected of having bacterial
meningitis. The results of the lumbar puncture are still pending. Which of the
following actions by the nurse is the priority? - CORRECT ANSWER
Assessing neurological status every 2-4 hours.
QUESTION :The nurse is screening infants for early warning signs of cerebral
palsy. Which of the following should the nurse recognize as 1 of the early
warning signs of cerebral palsy? - CORRECT ANSWER Poor head
control
QUESTION :The nurse is assessing a 6-year-old for manifestations of autism
spectrum disorder. Which of the following manifestations should the nurse
expect to observe in this child? - CORRECT ANSWER Monotone speech
QUESTION :. The nurse is developing a plan of care for a child diagnosed with
attention-deficit hyperactivity disorder (ADHD). Which of the following
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information should the nurse include in the plan of care? - CORRECT
ANSWER Psychostimulant medications and behavior modification.
QUESTION :The nurse preceptor is observing a newly hired nurse care for a child
who has Down syndrome. Which of the following manifestations, if documented
by the newly hired nurse, requires follow up by the nurse preceptor? -
CORRECT ANSWER Protruding tongue
QUESTION :The nurse is caring for a child who had a ventricular shunt
placement 24 hours ago. The child is sitting up in bed crying and has vomited a
small amount on the bed linens. Which of the following actions should the nurse
take first? - CORRECT ANSWER Complete a neurological assessment.
QUESTION :The nurse working in the emergency department (ED) is caring for a
2-month-old child who presents with intraocular bleeding, bradycardia, and
bulging fontanels, but no trauma to the head, face, or neck. Health history and
physical examination is incongruent, and abuse is suspected. Which of the
following actions should the nurse perform? - CORRECT ANSWER
Notify child protective services (CPS)
QUESTION :The nurse is caring for a child who is hospitalized for 24-hour
observation following a head injury. Which of the following actions by the nurse
is the priority? - CORRECT ANSWER Checking pupil reaction every 4
hours
QUESTION :The nurse is assessing a child in a coma and notes that the child has
decorticate posturing. Which of the following findings should the nurse expect
the child to demonstrate? - CORRECT ANSWER Rigid flexion with
elbows, wrists and fingers flexed, and legs extended and rotated inward