2027 HESI RN PEDIATRICS EXAM V2
1. The nurse is planning postoperative care for a child who has had a cleft lip repair. What is the most important
reason to minimize this child's crying during the recovery period?
A. Tear formation increases salivation.
B. This behavior increases respirations.
C. Excessive hysteria can lead to vomiting.
D. Crying stresses the suture line
Rationale:
Prevention of stress on the lip suture line is essential for optimum healing and the cosmetic appearance of a cleft
lip repair. Although crying also causes options A, B, and C, these conditions do not create a problem for the child
with a cleft lip repair.
2. An infant is receiving digoxin for congestive heart failure. The apical heart rate is assessed at 80
beats/min. What intervention should the nurse implement?
A. Call for a portable chest radiograph.
B. Obtain a therapeutic drug level.
C. Reassess the heart rate in 30 minutes.
D. Administer digoxin immune Fab stat.
Rationale:
Sinus bradycardia (heart rate <90 to 110 beats/min in an infant) is an indication of digoxin toxicity, so assessment
of the client's digoxin level has the highest priority. Option A is not indicated at this time. Option C provides
helpful assessment data but does not address the cause of the problem and delays needed intervention. Option D
is indicated for a serious, life-threatening overdose with digoxin.
3. The nurse admits a child to the intensive care unit with a possible diagnosis of Wilms tumor - What is the
most safety precaution for child?
A. maintain NPO status
B. Limit visitors to the immediate family
C. Place a do not palpate abdomen sign on head of bed
D. Encourage ambulation in the pre-operative period
Rationale:
Protect child from injury; place a sign on bed stating "no abdominal palpation" (to prevent accidental
fragmentation and dislodging into the abdominal cavity). The other option choices are not relevant at this time.
4. The nurse is preparing a teaching plan for the mother of a child who has been diagnosed with
celiac disease. Choosing which lunch will be within the therapeutic management of a child with celiac
disease?
A. Turkey salad, milk, and oatmeal cookies
B. Baked chicken, coleslaw, soda, and frozen fruit
dessert
C. Tuna salad sandwich on whole wheat bread, milk, and ice cream
D. Turkey sandwich on rye bread, orange juice, and fresh fruit
Rationale:
A child with celiac disease is managed on a gluten-free diet, which eliminates food products containing oats,
wheat, rye, or barley.
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, 5. A 6-month-old male infant is admitted to the postanesthesia care unit with elbow restraints in place. He
has an endotracheal tube and is ventilator-dependent but will be extubated soon following recovery from
anesthesia. Which nursing intervention should be included in this child's plan of care?
A. Keep restraints on at all times to prevent unplanned extubation.
B. Remove restraints one at a time and provide range-of-motion exercises.
C. Remove all restraints simultaneously and provide play activities.
D. Document the reason for application of the restraints every 72 hours.
Rationale:
Removing restraints one at a time is safer than option C. The infant should have the restrained extremities
assessed frequently for signs of neurologic or vascular impairment, and range-of-motion exercises should be
performed with these assessments. Under no circumstances should restraints be applied to the client
continuously. Documentation of assessment findings regarding the restrained extremities must occur much more
frequently than every 72 hours; however, the reason for using restraints must be justified and should be stated in
the medical
record.
6. The nurse assigns an unlicensed assistive personnel (UAP) to provide morning care to a newly admitted
child with bacterial meningitis. What is the most important instruction for the nurse to review with the UAP?
A. Use designated isolation precautions.
B. Keep the lighting in the room dim.
C. Allow the parents to assist with care.
D. Report any pain that the child experiences.
Rationale:
All these are important measures to review with the UAP, but the most important is option A. Improper use of
isolation precautions can place other staff and clients at risk for infection. Options B, C, and D promote client
comfort and reduce anxiety but are of a lower priority than option A.
7. The nurse is caring for a child with intussusception who is scheduled for a barium enema prior to a
surgical procedure. Which action should the nurse take first?
A. Evacuate the bowel of impacted feces
B. Administer magnesium sulfate
C. Place the child on a clear liquid diet
D. Assess the stool for white color
Rationale:
Intussusception, an invagination or telescoping of one portion of the intestine into another, causes intestinal
obstruction in children (usually occurs between 3 months and 5 years of age). Nonsurgical treatment is attempted
with hydrostatic pressure created by barium instillation, which often reduces the area of bowel intussusception. In
preparation for a barium enema, the client should first be placed on a clear liquid diet for the entire day; then
magnesium sulfate is administered for bowel evacuation. A barium enema is likely to cause option A. After the
enema, white stool may be seen as the body naturally removes any remaining barium.
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1. The nurse is planning postoperative care for a child who has had a cleft lip repair. What is the most important
reason to minimize this child's crying during the recovery period?
A. Tear formation increases salivation.
B. This behavior increases respirations.
C. Excessive hysteria can lead to vomiting.
D. Crying stresses the suture line
Rationale:
Prevention of stress on the lip suture line is essential for optimum healing and the cosmetic appearance of a cleft
lip repair. Although crying also causes options A, B, and C, these conditions do not create a problem for the child
with a cleft lip repair.
2. An infant is receiving digoxin for congestive heart failure. The apical heart rate is assessed at 80
beats/min. What intervention should the nurse implement?
A. Call for a portable chest radiograph.
B. Obtain a therapeutic drug level.
C. Reassess the heart rate in 30 minutes.
D. Administer digoxin immune Fab stat.
Rationale:
Sinus bradycardia (heart rate <90 to 110 beats/min in an infant) is an indication of digoxin toxicity, so assessment
of the client's digoxin level has the highest priority. Option A is not indicated at this time. Option C provides
helpful assessment data but does not address the cause of the problem and delays needed intervention. Option D
is indicated for a serious, life-threatening overdose with digoxin.
3. The nurse admits a child to the intensive care unit with a possible diagnosis of Wilms tumor - What is the
most safety precaution for child?
A. maintain NPO status
B. Limit visitors to the immediate family
C. Place a do not palpate abdomen sign on head of bed
D. Encourage ambulation in the pre-operative period
Rationale:
Protect child from injury; place a sign on bed stating "no abdominal palpation" (to prevent accidental
fragmentation and dislodging into the abdominal cavity). The other option choices are not relevant at this time.
4. The nurse is preparing a teaching plan for the mother of a child who has been diagnosed with
celiac disease. Choosing which lunch will be within the therapeutic management of a child with celiac
disease?
A. Turkey salad, milk, and oatmeal cookies
B. Baked chicken, coleslaw, soda, and frozen fruit
dessert
C. Tuna salad sandwich on whole wheat bread, milk, and ice cream
D. Turkey sandwich on rye bread, orange juice, and fresh fruit
Rationale:
A child with celiac disease is managed on a gluten-free diet, which eliminates food products containing oats,
wheat, rye, or barley.
1|Pa g e
,2|Pa g e
, 5. A 6-month-old male infant is admitted to the postanesthesia care unit with elbow restraints in place. He
has an endotracheal tube and is ventilator-dependent but will be extubated soon following recovery from
anesthesia. Which nursing intervention should be included in this child's plan of care?
A. Keep restraints on at all times to prevent unplanned extubation.
B. Remove restraints one at a time and provide range-of-motion exercises.
C. Remove all restraints simultaneously and provide play activities.
D. Document the reason for application of the restraints every 72 hours.
Rationale:
Removing restraints one at a time is safer than option C. The infant should have the restrained extremities
assessed frequently for signs of neurologic or vascular impairment, and range-of-motion exercises should be
performed with these assessments. Under no circumstances should restraints be applied to the client
continuously. Documentation of assessment findings regarding the restrained extremities must occur much more
frequently than every 72 hours; however, the reason for using restraints must be justified and should be stated in
the medical
record.
6. The nurse assigns an unlicensed assistive personnel (UAP) to provide morning care to a newly admitted
child with bacterial meningitis. What is the most important instruction for the nurse to review with the UAP?
A. Use designated isolation precautions.
B. Keep the lighting in the room dim.
C. Allow the parents to assist with care.
D. Report any pain that the child experiences.
Rationale:
All these are important measures to review with the UAP, but the most important is option A. Improper use of
isolation precautions can place other staff and clients at risk for infection. Options B, C, and D promote client
comfort and reduce anxiety but are of a lower priority than option A.
7. The nurse is caring for a child with intussusception who is scheduled for a barium enema prior to a
surgical procedure. Which action should the nurse take first?
A. Evacuate the bowel of impacted feces
B. Administer magnesium sulfate
C. Place the child on a clear liquid diet
D. Assess the stool for white color
Rationale:
Intussusception, an invagination or telescoping of one portion of the intestine into another, causes intestinal
obstruction in children (usually occurs between 3 months and 5 years of age). Nonsurgical treatment is attempted
with hydrostatic pressure created by barium instillation, which often reduces the area of bowel intussusception. In
preparation for a barium enema, the client should first be placed on a clear liquid diet for the entire day; then
magnesium sulfate is administered for bowel evacuation. A barium enema is likely to cause option A. After the
enema, white stool may be seen as the body naturally removes any remaining barium.
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