NCLEX Pediatrics questions and answers verified 100%

NCLEX Pediatrics questions and answers verified 100% Which of the following is the most appropriate location for assessing the pulse of an infant who is less than 1 year old? - 1. Radial 2. Carotid *3. Brachial* 4. Popliteal *Rationale:* To assess a pulse in an infant (i.e., a child 1 year old), the pulse is checked at the brachial artery. The infant's relatively short, fat neck makes palpation of the carotid artery difficult. The popliteal and radial pulses are also difficult to palpate in an infant. A nurse is teaching cardiopulmonary resuscitation to a group of nursing students. The nurse asks a student to describe the reason why blind finger sweeps are avoided in infants. The nurse determines that the student understands the reason if the student makes which statement? - 1. "The object may have been swallowed." 2. "The infant may bite down on the finger" 3. "The mouth is too small to see the object." *4. "The object may be forced back further into the throat."* *Rationale:* Blind finger sweeps are not recommended for infants and children because of the risk of forcing the object further down into the airway. Options 1, 2, and 3 are not related directly to the subject of the question. A nurse is collecting data about a child who has been admitted to the hospital with a diagnosis of seizures. The nurse checks for causes of the seizure activity by: - 1. Testing the child's urine for specific gravity 2. Asking the child what happens during a seizure 3. Obtaining a family history of psychiatric illness *4. Obtaining a history regarding factors that may occur before the seizure activity* *Rationale:* Fever and infections increase the body's metabolic rate. This can cause seizure activity among children who are less than 5-years-old. Dehydration and electrolyte imbalance can also contribute to the occurrence of a seizure. Falls can cause head injuries, which would increase intracranial pressure or cerebral edema. Some medications could cause seizures. Specific gravity would not be a reliable test, because it varies, depending on the existing condition. Psychiatric illness has no impact on seizure occurrence or cause. Children do not remember what happened during the seizure itself. A child has a basilar skull fracture. Which of the following health care provider's prescriptions should the nurse question? - 1. Restrict fluid intake. 2. Insert an indwelling urinary catheter. 3. Keep an intravenous (IV) line patent. *4. Suction via the nasotracheal route as needed.* *Rationale:* Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture. Because of the location of the injury, the suction catheter may be introduced into the brain. Fluids are restricted to prevent fluid overload. The child may require a urinary catheter for the accurate monitoring of intake and output. An IV line is maintained to administer fluids or medications, if necessary. Which of the following represents a primary characteristic of autism? - 1. Normal social play 2. Consistent imitation of others' actions *3. Lack of social interaction and awareness* 4. Normal verbal and nonverbal communication *Rationale:* Autism is a severe form of an autism spectrum disorder. A primary characteristic is a lack of social interaction and awareness. Social behaviors in autism include a lack of or an abnormal imitation of others' actions and a lack of or abnormal social play. Additional characteristics include a lack of or impaired verbal communication and markedly abnormal nonverbal communication. A nurse is assisting with data collection from an infant who has been diagnosed with hydrocephalus. If the infant's level of consciousness diminishes, a priority intervention is: - 1. Taking the apical pulse 2. Taking the blood pressure 3. Testing the urine for protein *4. Palpating the anterior fontanel* *Rationale:* A full or bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle. Apical pulse and blood pressure changes and proteinuria are not specifically associated with increasing cerebrospinal fluid in the brain tissue in an infant. A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected, and a nurse is monitoring the child continuously for signs of increased intracranial pressure (ICP). Which of the following is a late sign of increased ICP in this child? - 1. Nausea *2. Bradycardia* 3. Bulging fontanel 4. Dilated scalp veins *Rationale:* Late signs of increased ICP include a significant decrease in the level of consciousness, bradycardia, and fixed and dilated pupils. Nausea is an early sign of increased ICP. A bulging fontanel and dilated scalp veins are early signs of increased ICP and would be noted in an infant rather than in a 5-year-old child. A child has been diagnosed with Reye's syndrome. The nurse understands that a major symptom associated with Reye's syndrome is: - *1. Persistent vomiting* 2. Protein in the urine 3. Symptoms of hyperglycemia 4. A history of a Staphylococcus infection *Rationale:* Persistent vomiting is a major symptom that is associated with increased intracranial pressure (ICP). Options 2, 3, and 4 are incorrect. Protein is not present in the urine. Reye's syndrome is related to a history of viral infections, and hypoglycemia is a symptom of this disease. A nurse is developing a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? *Select all that apply.* - *1. Time the seizure.* 2. Restrain the child. *3. Stay with the child.* 4. Place the child in a prone position. *5. Move furniture away from the child.* 6. Insert a padded tongue blade into the child's mouth. *Rationale:* During a seizure, the child is placed on his or her side in a lateral position. This type of positioning will prevent aspiration, because saliva will drain out of the corner of the child's mouth. The child is not restrained, because this could cause injury. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure, because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for the observation and timing of the seizure. The appropriate child position after a tonsillectomy is which of the following? - 1. Supine position *2. Side-lying position* 3. High Fowler's position 4. Trendelenburg's position *Rationale:* The child should be placed in a semi-prone or side-lying position after tonsillectomy to facilitate drainage. Options 1, 3, and 4 will not achieve this goal. After a tonsillectomy, the child begins to vomit bright red blood. The initial nursing action would be to: - *1. Turn the child to the side.* 2. Notify the RN or health care provider (HCP). 3. Administer the prescribed antiemetic. 4. Maintain nothing-by-mouth (NPO) status. *Rationale:* After a tonsillectomy, if bleeding occurs, the child is turned to the side, and the RN or HCP is notified. An NPO status would be maintained, and an antiemetic may be prescribed; however, the initial nursing action would be to turn the child to the side. After a tonsillectomy, which of the following fluid or food items would be appropriate to offer to the child? - *1. Yellow Jell-O* 2. Cold ginger ale 3. Vanilla pudding 4. Cherry Popsicle *Rationale:* After a tonsillectomy, clear, cool liquids should be administered. Citrus, carbonated, and extremely hot or cold liquids need to be avoided, because they may irritate the throat. Milk and milk products (pudding) are avoided, because they coat the throat and cause the child to clear the throat, thus increasing the risk of bleeding. Red liquids need to be avoided, because they give the appearance of blood if the child vomits. A nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further instruction? - *1. "I will place a steam vaporizer in my child's room."* 2. "I will take my child out into the cool, humid night air." 3. "I will place a cool-mist humidifier in my child's room." 4. "I will place my child in a closed bathroom and allow my child to inhale steam from the running water." *Rationale:* Steam from warm running water in a closed bathroom and cool mist from a bedside humidifier are effective for reducing mucosal edema. Cool-mist humidifiers are recommended as compared with steam vaporizers, which present a danger of scalding burns. Taking the child out into the cool, humid night air may also relieve mucosal swelling. Remember, however, that a cold mist may precipitate bronchospasm. A nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which of the following statements, if made by the mother, would indicate the need for further instruction? - *1. "I will give my child cough syrup if a cough develops."* 2. "During an attack, I will take my child to a cool location." 3. "I will give acetaminophen (Tylenol) if my child develops a fever." 4. "I will be sure that my child drinks at least three to four glasses of fluids every day." *Rationale:* Cough syrups and cold medicines are not to be given, because they may dry and thicken secretions. During a croup attack, the child can be taken to a cool basement or garage. Acetaminophen is used if a fever develops. Adequate hydration of 500 to 1000 mL of fluids daily is important for thinning secretions. A nurse who is working in the emergency department is caring for a child who has been diagnosed with epiglottitis. Indications that the child may be experiencing airway obstruction include which of the following? - 1. Nasal flaring and bradycardia *2. The child thrusts the chin forward and opens the mouth* 3. A low-grade fever and complaints of a sore throat 4. The child leans backward, supporting himself or herself with the hands and arms *Rationale:* Clinical manifestations that are suggestive of airway obstruction include tripod positioning (leaning forward supported by the hands and arms with the chin thrust out and the mouth open), nasal flaring, tachycardia, a high fever, and a sore throat. A nurse is caring for a hospitalized infant with bronchiolitis. Diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which of the following would be the appropriate nursing action? - 1. Initiate strict enteric precautions. 2. Wear a mask when caring for the child. *3. Plan to move the infant to a room with another child with RSV.* 4. Leave the infant in the present room, because RSV is not contagious. *Rationale:* RSV is a highly communicable disorder, but it is not transmitted via the airborne route. It is usually transferred by the hands, and meticulous handwashing is necessary to decrease the spread of organisms. The infant with RSV is isolated in a single room or placed in a room with another child with RSV. Enteric precautions are not necessary; however, the nurse should wear a gown when the soiling of clothing may occur. A nurse is instructing the mother of a child with cystic fibrosis (CF) about the appropriate dietary measures. Which of the following meals best illustrates the most appropriate diet for a client with cystic fibrosis? - 1. A veggie salad and a caramel apple 2. A strawberry jelly sandwich and pretzels 3. A plate of nachos and cheese and a cupcake *4. A piece of fried chicken and a loaded baked potato* *Rationale:* Children with CF are managed with a high-calorie, high-protein diet. Pancreatic enzyme replacement therapy is undertaken, and fat-soluble vitamin supplements are administered. Fats are not restricted unless steatorrhea cannot be controlled by increased levels of pancreatic enzymes. A piece of fried chicken and a loaded baked potato provides a high-calorie and high-protein meal that includes fat. A nurse reviews the results of a Mantoux test performed on a 3-year-old child. The results indicate an area of induration that measures 10 mm. The nurse would interpret these results as: - *1. Positive* 2. Negative 3. Inconclusive 4. Definitive, requiring a repeat test *Rationale:* An induration that measures 10 mm or more is considered to be a positive result for children who are younger than 4 years old and for those with chronic illness or with a high risk for environmental exposure to tuberculosis. A reaction of 5 mm or more is considered to be a positive result for those in the highest-risk groups. Repeat tests are not done, especially when a positive reaction occurs. Isoniazid (INH) is prescribed for a 2-year-old child with a positive Mantoux test. The mother of the child asks the nurse how long the child will need to take the medication. The appropriate response is: - 1. 6 months *2. 9 months* 3. 15 months 4. 18 months *Rationale:* Isoniazid is given to prevent tuberculosis (TB) infection from progressing to active disease. A chest x-ray film is obtained before the initiation of preventive therapy. In infants and children, the recommended duration of INH therapy is 9 months. For children with human immunodeficiency virus infection, a minimum of 12 months is recommended. A day care nurse is observing a 2-year-old child and suspects that the child may have strabismus. Which of the following observations may be indicative of this condition? - 1. The child has difficulty hearing. 2. The child does not respond when spoken to. *3. The child consistently tilts his or her head to see.* 4. The child consistently turns his or her head to see. *Rationale:* The nurse may suspect strabismus in a child when the child complains of frequent headaches, squints, or tilts the head to see. Options 1, 2, and 4 are not indicative of this condition. A nurse has provided instructions to the mother of a child who has been diagnosed with bacterial conjunctivitis. Which of the following, if stated by the mother, would indicate the need for further instructions? - 1. "I need to wash my hands frequently." 2. "I need to clean the eye, as prescribed." *3. "It is OK to share towels and washcloths."* 4. "I need to give the eyedrops, as prescribed." *Rationale:* Bacterial conjunctivitis is highly contagious, and infection control measures should be taught; these include frequent handwashing and not sharing towels and washcloths. Options 1, 2, and 4 are correct measures.