exit k 8 GRADE A Q&A
A nurse in the pediatric clinic is assessing an infant who had a revision of a
ventriculoperitoneal shunt. What clinical finding alerts the nurse that intracranial
pressure has increased? - (correct answer)Tension of the anterior fontanel.
A nurse is caring for an infant who has just undergone myelomeningocele repair. What
should the nursing plan of care include? - (correct answer)Monitoring for cerebrospinal
fluid leakage.
Which observation during a developmental appraisal of a 6-month-old infant is most
important to the nurse in light of a diagnosis of hydrocephalus? - (correct answer)Head
lag.
A nurse arrives at the scene of an accident and finds a 5-month-old infant unconscious.
After performing the initial steps of cardiopulmonary resuscitation, the nurse plans to
locate the infant's pulse. Which pulse site in the accompanying figure should be
palpated? - (correct answer)C (BRACHIAL PULSE)
Children's patterns of play change as they grow from infancy through school-age. Rank
the order of appearance of each type of play, starting with infant play: - (correct
answer)Solitary/ Parallel/ Associative/ Cooperative
A newborn with a cleft lip is fed with a special nipple. What instructions should the nurse
give the parents to reduce the incidence of regurgitation of the feedings? - (correct
answer)Burp frequently during feedings.
Because of a measles epidemic a 6-month-old infant receives measles immunoglobulin.
The nurse should help the parents understand that to ensure continuous protection
against measles the infant should be revaccinated around the age of - (correct
answer)12 months.
A nurse is assessing an infant for developmental dysplasia of the hip. How does the
nurse identify the Ortolani sign? - (correct answer)Audible click on hip manipulation
,A community health nurse discusses with a group of parents in the well-baby clinic the
appropriate car restraints to be used for children. The nurse determines that one of the
parents understands the teaching about car restraints for newborns when the parent
says that infants should be buckled into an infant car seat and that the car seat must be
in the: - (correct answer)Back seat, facing backward.
What is the priority nursing intervention for an infant during the immediate postoperative
period after surgical repair of a cleft lip? - (correct answer)Minimize crying.
To prevent skin breakdown on the scalp of an infant with hydrocephalus, how should the
nurse position the infant? - (correct answer)Supine, with the head elevated about 45
degrees.
The nurse is teaching a parent group about the reason to adhere to the immunization
schedule. What complication of mumps is important for adolescents to avoid? - (correct
answer)Sterility.
A nurse is planning to teach activities of daily living to a developmentally disabled 3-
year-old child. What activity should the nurse plan to teach to the child first? - (correct
answer)Self-feeding
A nurse is obtaining the health history from the mother of a preschooler with Reye
syndrome. The nurse should ask the mother if the child has recently had - (correct
answer)Chickenpox
The nurse is planning care for a preschooler with Kawasaki disease. Which intervention
should the nurse plan to implement? - (correct answer)Administering intravenous
immune globulin (IVIG) as prescribed
A 4-year-old child is admitted to the pediatric unit for a tonsillectomy. During
preoperative planning a nurse reviews the child's laboratory report. Which lab value is of
most significance in this situation? - (correct answer)Coagulation studies
, A child undergoes tonsillectomy and adenoidectomy for numerous recurrent respiratory
tract infections. After the surgery, the nurse should teach the parents to: - (correct
answer)Offer ice chips on which to suck.
What findings should a nurse expect when examining the laboratory report of a
preschooler with rheumatic fever? - (correct answer)Positive antistreptolysin titer
A mother brings her 6-month-old infant to the emergency department with a 3-day
history of gastroenteritis. What priority intervention does the nurse anticipate? - (correct
answer)Insertion of an intravenous catheter
An infant with tetralogy of Fallot becomes cyanotic and dyspneic after a crying episode.
In what position should the nurse place the infant to relieve the cyanosis and dyspnea?
- (correct answer)Knee-chest
A nurse is teaching a parent how to prevent accidents while caring for a 6-month-old
infant. What ability should be emphasized with regard to the infant's motor
development? - (correct answer)Rolls over.
A 17-year-old client at 38 weeks' gestation is being prepared for an emergency
cesarean birth because of abruptio placentae and severe fetal compromise. The client
received nalbuphine (Nubain) 10 mg IV 30 minutes ago. Because the client is too
sedated to sign the consent form, the nurse should: - (correct answer)Have the surgeon
and attending practitioner sign the consent form.
A client who is admitted for surgery for a ruptured tubal pregnancy tells the nurse that
she has shoulder pain. The nurse concludes that the pain is caused by: - (correct
answer)Blood accumulation under the diaphragm.
After a client's membranes rupture spontaneously, the nurse visualizes the umbilical
cord protruding from the vagina. Place the nursing interventions in order of priority -
(correct answer)Call for assistance and don sterile gloves.
A nurse in the pediatric clinic is assessing an infant who had a revision of a
ventriculoperitoneal shunt. What clinical finding alerts the nurse that intracranial
pressure has increased? - (correct answer)Tension of the anterior fontanel.
A nurse is caring for an infant who has just undergone myelomeningocele repair. What
should the nursing plan of care include? - (correct answer)Monitoring for cerebrospinal
fluid leakage.
Which observation during a developmental appraisal of a 6-month-old infant is most
important to the nurse in light of a diagnosis of hydrocephalus? - (correct answer)Head
lag.
A nurse arrives at the scene of an accident and finds a 5-month-old infant unconscious.
After performing the initial steps of cardiopulmonary resuscitation, the nurse plans to
locate the infant's pulse. Which pulse site in the accompanying figure should be
palpated? - (correct answer)C (BRACHIAL PULSE)
Children's patterns of play change as they grow from infancy through school-age. Rank
the order of appearance of each type of play, starting with infant play: - (correct
answer)Solitary/ Parallel/ Associative/ Cooperative
A newborn with a cleft lip is fed with a special nipple. What instructions should the nurse
give the parents to reduce the incidence of regurgitation of the feedings? - (correct
answer)Burp frequently during feedings.
Because of a measles epidemic a 6-month-old infant receives measles immunoglobulin.
The nurse should help the parents understand that to ensure continuous protection
against measles the infant should be revaccinated around the age of - (correct
answer)12 months.
A nurse is assessing an infant for developmental dysplasia of the hip. How does the
nurse identify the Ortolani sign? - (correct answer)Audible click on hip manipulation
,A community health nurse discusses with a group of parents in the well-baby clinic the
appropriate car restraints to be used for children. The nurse determines that one of the
parents understands the teaching about car restraints for newborns when the parent
says that infants should be buckled into an infant car seat and that the car seat must be
in the: - (correct answer)Back seat, facing backward.
What is the priority nursing intervention for an infant during the immediate postoperative
period after surgical repair of a cleft lip? - (correct answer)Minimize crying.
To prevent skin breakdown on the scalp of an infant with hydrocephalus, how should the
nurse position the infant? - (correct answer)Supine, with the head elevated about 45
degrees.
The nurse is teaching a parent group about the reason to adhere to the immunization
schedule. What complication of mumps is important for adolescents to avoid? - (correct
answer)Sterility.
A nurse is planning to teach activities of daily living to a developmentally disabled 3-
year-old child. What activity should the nurse plan to teach to the child first? - (correct
answer)Self-feeding
A nurse is obtaining the health history from the mother of a preschooler with Reye
syndrome. The nurse should ask the mother if the child has recently had - (correct
answer)Chickenpox
The nurse is planning care for a preschooler with Kawasaki disease. Which intervention
should the nurse plan to implement? - (correct answer)Administering intravenous
immune globulin (IVIG) as prescribed
A 4-year-old child is admitted to the pediatric unit for a tonsillectomy. During
preoperative planning a nurse reviews the child's laboratory report. Which lab value is of
most significance in this situation? - (correct answer)Coagulation studies
, A child undergoes tonsillectomy and adenoidectomy for numerous recurrent respiratory
tract infections. After the surgery, the nurse should teach the parents to: - (correct
answer)Offer ice chips on which to suck.
What findings should a nurse expect when examining the laboratory report of a
preschooler with rheumatic fever? - (correct answer)Positive antistreptolysin titer
A mother brings her 6-month-old infant to the emergency department with a 3-day
history of gastroenteritis. What priority intervention does the nurse anticipate? - (correct
answer)Insertion of an intravenous catheter
An infant with tetralogy of Fallot becomes cyanotic and dyspneic after a crying episode.
In what position should the nurse place the infant to relieve the cyanosis and dyspnea?
- (correct answer)Knee-chest
A nurse is teaching a parent how to prevent accidents while caring for a 6-month-old
infant. What ability should be emphasized with regard to the infant's motor
development? - (correct answer)Rolls over.
A 17-year-old client at 38 weeks' gestation is being prepared for an emergency
cesarean birth because of abruptio placentae and severe fetal compromise. The client
received nalbuphine (Nubain) 10 mg IV 30 minutes ago. Because the client is too
sedated to sign the consent form, the nurse should: - (correct answer)Have the surgeon
and attending practitioner sign the consent form.
A client who is admitted for surgery for a ruptured tubal pregnancy tells the nurse that
she has shoulder pain. The nurse concludes that the pain is caused by: - (correct
answer)Blood accumulation under the diaphragm.
After a client's membranes rupture spontaneously, the nurse visualizes the umbilical
cord protruding from the vagina. Place the nursing interventions in order of priority -
(correct answer)Call for assistance and don sterile gloves.
