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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 - Answer ✅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.
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. - Answer ✅B. Obtain a therapeutic drug level.
@2025 Exam Material 1
,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
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 - Answer ✅C. Place a do not palpate
abdomen sign on head of bed
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 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 - Answer ✅B. Baked chicken,
coleslaw, soda, and frozen fruit dessert
Rationale:
@2025 Exam Material 2
, A child with celiac disease is managed on a gluten-free diet, which eliminates food products
containing oats, wheat, rye, or barley.
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. - Answer ✅B. Remove
restraints one at a time and provide range-of-motion
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
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. - Answer ✅A. Use designated isolation
precautions.
@2025 Exam Material 3