A 2-year-old child with trisomy 21 (Down syndrome) is brought to the clinic for a routine evaluation.
Which assessment finding suggests the presence of a common complication often experienced by
those with Down syndrome?
A. Presence of a systolic murmur
B. New onset of patchy alopecia
C. Complaints of long bone pain
D. Recent projectile vomiting - CORRECT ANSWER - A. Presence of a systolic murmur
Rationale:
Congenital heart disease occurs in 40% to 50% of children with trisomy 21 (Down syndrome).
Defects of the atrial or ventricular septum that create systolic murmurs are the most common heart
defects associated with this congenital anomaly.
A 3-month-old infant returns from surgery with elbow restraints and a Logan bow over a cleft lip
suture line. Which intervention should the nurse implement to maintain suture line integrity during
the initial postoperative period?
A. Place the infant upright in an infant seat position.
B. Provide mittens with the use of elbow restraints.
,C. Use soft rubber catheters for nasal suctioning. - CORRECT ANSWER - A. Place the infant
upright in an infant seat position.
Rationale:
The use of an infant seat simulates a supine position with the head elevated and also prevents
aspiration. Prone positioning should be avoided to prevent disruption of the protective Logan bow
and prevent the infant from rubbing the face on the bed surface. Mittens are not necessary and
decrease the ability to provide sensory comfort, such as hand holding. Nasal suctioning should be
avoided to prevent trauma or dislodging clots at the surgical site. Water-soluble lubricant will dry
the suture line and cause crusting, which predisposes the suture line to poor healing and scarring.
A 3-month-old infant weighing 10 lb 15 oz has an axillary temperature of 98.9° F. What caloric
amount does this child need?
a 400 calories/day
b 500 calories/day
c 600 calories/day
d 700 calories/day - CORRECT ANSWER - c 600 calories/day
A 3-week-old infant is referred to an orthopedic clinic because the pediatrician heard a click when
flexing the child's right hip during a routine physical examination. The orthopedic physician suspects
that the child might have developmental dysplasia of the hip (DDH). The parents ask the nurse to
identify risk factors commonly associated with DDH. Which response is accurate?
,B. Male gender
C. Breech presentation
D. Second-born child - CORRECT ANSWER - C. Breech presentation
Rationale:
Developmental dysplasia of the hip (DDH) occurs more often in infants who present in the breech
position, not the vertex (head-first) position. Twice as many females as males present in the breech
position; thus, 80% of children with DDH are females, not males. Of breech presentations, 60%
occur with first-born children, not subsequent siblings, possibly because of the unstretched uterus
and compaction of the surrounding abdominal contents, which tend to increase compression on
the uterus in the nulliparous woman.
A 4-year-old child has cystic fibrosis. Which stage of Erikson theory of psychosocial development is
the nurse addressing when teaching inhalation therapy?
A. Autonomy
B. Industry
C. Trust
D. Initiative - CORRECT ANSWER - D. Initiative
Rationale:
Children 4 to 5 years of age are in the "Initiative vs. Guilt" stage of Erikson theory of psychosocial
, Doubt" occurs at 1 to 3 years of age. "Industry vs. Inferiority" occurs at 6 to 11 years; "Trust vs.
Mistrust" occurs from birth to 1 year of age.
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. - CORRECT 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
A 7-month-old infant with a rotavirus causing severe diarrhea is admitted for treatment. Which
intervention should the nurse implement first?
Which assessment finding suggests the presence of a common complication often experienced by
those with Down syndrome?
A. Presence of a systolic murmur
B. New onset of patchy alopecia
C. Complaints of long bone pain
D. Recent projectile vomiting - CORRECT ANSWER - A. Presence of a systolic murmur
Rationale:
Congenital heart disease occurs in 40% to 50% of children with trisomy 21 (Down syndrome).
Defects of the atrial or ventricular septum that create systolic murmurs are the most common heart
defects associated with this congenital anomaly.
A 3-month-old infant returns from surgery with elbow restraints and a Logan bow over a cleft lip
suture line. Which intervention should the nurse implement to maintain suture line integrity during
the initial postoperative period?
A. Place the infant upright in an infant seat position.
B. Provide mittens with the use of elbow restraints.
,C. Use soft rubber catheters for nasal suctioning. - CORRECT ANSWER - A. Place the infant
upright in an infant seat position.
Rationale:
The use of an infant seat simulates a supine position with the head elevated and also prevents
aspiration. Prone positioning should be avoided to prevent disruption of the protective Logan bow
and prevent the infant from rubbing the face on the bed surface. Mittens are not necessary and
decrease the ability to provide sensory comfort, such as hand holding. Nasal suctioning should be
avoided to prevent trauma or dislodging clots at the surgical site. Water-soluble lubricant will dry
the suture line and cause crusting, which predisposes the suture line to poor healing and scarring.
A 3-month-old infant weighing 10 lb 15 oz has an axillary temperature of 98.9° F. What caloric
amount does this child need?
a 400 calories/day
b 500 calories/day
c 600 calories/day
d 700 calories/day - CORRECT ANSWER - c 600 calories/day
A 3-week-old infant is referred to an orthopedic clinic because the pediatrician heard a click when
flexing the child's right hip during a routine physical examination. The orthopedic physician suspects
that the child might have developmental dysplasia of the hip (DDH). The parents ask the nurse to
identify risk factors commonly associated with DDH. Which response is accurate?
,B. Male gender
C. Breech presentation
D. Second-born child - CORRECT ANSWER - C. Breech presentation
Rationale:
Developmental dysplasia of the hip (DDH) occurs more often in infants who present in the breech
position, not the vertex (head-first) position. Twice as many females as males present in the breech
position; thus, 80% of children with DDH are females, not males. Of breech presentations, 60%
occur with first-born children, not subsequent siblings, possibly because of the unstretched uterus
and compaction of the surrounding abdominal contents, which tend to increase compression on
the uterus in the nulliparous woman.
A 4-year-old child has cystic fibrosis. Which stage of Erikson theory of psychosocial development is
the nurse addressing when teaching inhalation therapy?
A. Autonomy
B. Industry
C. Trust
D. Initiative - CORRECT ANSWER - D. Initiative
Rationale:
Children 4 to 5 years of age are in the "Initiative vs. Guilt" stage of Erikson theory of psychosocial
, Doubt" occurs at 1 to 3 years of age. "Industry vs. Inferiority" occurs at 6 to 11 years; "Trust vs.
Mistrust" occurs from birth to 1 year of age.
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. - CORRECT 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
A 7-month-old infant with a rotavirus causing severe diarrhea is admitted for treatment. Which
intervention should the nurse implement first?
