NURS 328 Exam #2 UPDATED ACTUAL Questions and
CORRECT Answers
A 10 month old is admitted after receiving a b. is irritable and vomiting
ventriculoperitoneal shunt. Which assessment would
indicate malfunction in this shunt? The infant...
a. cries but quiets when held
b. is irritable and vomiting
c. has an increased abdominal girth
d. has a fontanel that is full and soft
A newborn is being delivered with a known a, b, d, and e
myelomeningocele. The nurse attending the delivery will
perform the following activities. Select all that apply.
a. Sterile saline and gauze dressings
b. Latex free environment
c. NGT to straight drainage
d. Lay the child prone
e. Establish IV access
f. Rectal temperature
A 4 month old infant has a tonic clonic seizure. It is a, c, and e
important during this time for the nurse to do which of
the following interventions. Select all that apply.
a. Time and observe the infant's reactions
b. Place an oral airway during the infant's seizure
c. Administer anticonvulsants as ordered
d. Restrain the infant
e. Ensure a bag and mask is at bedside
A 3 year child ,admitted to the pediatric floor for seizure a. Place child on his side and assess the child.
control, has a generalized tonic-clonic seizure. The initial
action the nurse should perform is:
a. Place child on his side and assess the child.
b. Take off the child's clothes and administer oxygen.
c. Hold the child down and try to communicate with the
patient.
d. Call the MD.
,A nurse is expecting a delivery of a baby with b. Lower extremity paralysis
myelomeningocele. The nurse is aware that this defect in
comparison to a meningocele is that this infant will have:
a. An open sac over the lumbar area
b. Lower extremity paralysis
c. Infections of the spinal fluid
d. Meningitis
A 5 month old infant with RSV bronchiolitis is in c. Suction secretions, provide 100% oxygen via mask, and anticipate respiratory
respiratory distress. The baby has copious secretions, failure.
increased work of breathing, cyanosis, and a respiratory
rate of 78. What is the most appropriate initial nursing no oral feeds rr over 60
intervention?
a. Attempt to calm the infant by placing him in his
mother's lap and offering him a bottle.
b. Alert the physician to the situation and ask for an order
for a stat chest x-ray.
c. Suction secretions, provide 100% oxygen via mask, and
anticipate respiratory failure.
d. Bring the emergency equipment to the room and
begin bag-valve-mask ventilation
When caring for a child following a tonsillectomy, what a. Watch for continuous swallowing.
should the nurse do?
a. Watch for continuous swallowing.
b. Encourage gargling to reduce discomfort.
c. Position the child on the back for sleeping.
d. Apply warm compresses to the throat.
A 4-year old girl is brought to the ED. She has "froglike" d. Notify the physician immediately and be prepared to assist with a tracheostomy
croaking sounds on inspiration, is agitated, and is or intubation
drooling. She insists on sitting upright. what should the
nurse do?
a. Examine her oral pharynx and report to the physician
b. Make her lie down and rest quietly
c. Auscultate her lungs, and make preparations for
placement in a mist tent.
d. Notify the physician immediately and be prepared to
assist with a tracheostomy or intubation
, Apnea of infancy has been diagnosed in an infant who a. Cardiopulmonary resuscitation
will soon be discharged with home monitoring. Which
information should the nurse include when teaching the
parents about the infant's care?
a. Cardiopulmonary resuscitation
b. Importance of adequate fluids
c. Reassurance that the infant cannot be electrocuted
during monitoring
d. Advice that the infant not be left with other caretakers,
such as babysitters
The mother of a 20-month old boy tells the nurse that he b. Try a cool-mist vaporizor at night and watch for signs of difficulty breathing
has a barking cough at night. His temperature is 37
degrees C (98.6 F). The nurse suspects croup. What
should she recommend?
a. Control fever with acetaminophen and call if cough
gets worse tonight
b. Try a cool-mist vaporizor at night and watch for signs
of difficulty breathing
c. Try over-the-counter medicine and come to the clinic
tomorrow if no improvement
d. Admit to the hospital and observe for impending
epiglottitis
A 4-year-old boy needs to use a metered-dose inhaler to a. spacer
treat asthma. He cannot coordinate the breathing to use
it effectively. The nurse should suggest that he use a :
a. spacer
b. nebulizer
c. peak expiratory flowmeter
d. trial of chest physiotherapy
A 7 month old infant is brought into the ER for injuries c and d
stemming from a bookcase falling on her immediately
prior to arrival to the hospital. The parents reported the
child was pulling herself up using the bookcase when it
toppled over. Which clinical findings would lead the
nurse to suspect child maltreatment? Select all that
apply?
a. Crying
b. Hugging the mother tightly.
c. Spiral Fracture of the leg
d. A yellow color bruise on the buttock
CORRECT Answers
A 10 month old is admitted after receiving a b. is irritable and vomiting
ventriculoperitoneal shunt. Which assessment would
indicate malfunction in this shunt? The infant...
a. cries but quiets when held
b. is irritable and vomiting
c. has an increased abdominal girth
d. has a fontanel that is full and soft
A newborn is being delivered with a known a, b, d, and e
myelomeningocele. The nurse attending the delivery will
perform the following activities. Select all that apply.
a. Sterile saline and gauze dressings
b. Latex free environment
c. NGT to straight drainage
d. Lay the child prone
e. Establish IV access
f. Rectal temperature
A 4 month old infant has a tonic clonic seizure. It is a, c, and e
important during this time for the nurse to do which of
the following interventions. Select all that apply.
a. Time and observe the infant's reactions
b. Place an oral airway during the infant's seizure
c. Administer anticonvulsants as ordered
d. Restrain the infant
e. Ensure a bag and mask is at bedside
A 3 year child ,admitted to the pediatric floor for seizure a. Place child on his side and assess the child.
control, has a generalized tonic-clonic seizure. The initial
action the nurse should perform is:
a. Place child on his side and assess the child.
b. Take off the child's clothes and administer oxygen.
c. Hold the child down and try to communicate with the
patient.
d. Call the MD.
,A nurse is expecting a delivery of a baby with b. Lower extremity paralysis
myelomeningocele. The nurse is aware that this defect in
comparison to a meningocele is that this infant will have:
a. An open sac over the lumbar area
b. Lower extremity paralysis
c. Infections of the spinal fluid
d. Meningitis
A 5 month old infant with RSV bronchiolitis is in c. Suction secretions, provide 100% oxygen via mask, and anticipate respiratory
respiratory distress. The baby has copious secretions, failure.
increased work of breathing, cyanosis, and a respiratory
rate of 78. What is the most appropriate initial nursing no oral feeds rr over 60
intervention?
a. Attempt to calm the infant by placing him in his
mother's lap and offering him a bottle.
b. Alert the physician to the situation and ask for an order
for a stat chest x-ray.
c. Suction secretions, provide 100% oxygen via mask, and
anticipate respiratory failure.
d. Bring the emergency equipment to the room and
begin bag-valve-mask ventilation
When caring for a child following a tonsillectomy, what a. Watch for continuous swallowing.
should the nurse do?
a. Watch for continuous swallowing.
b. Encourage gargling to reduce discomfort.
c. Position the child on the back for sleeping.
d. Apply warm compresses to the throat.
A 4-year old girl is brought to the ED. She has "froglike" d. Notify the physician immediately and be prepared to assist with a tracheostomy
croaking sounds on inspiration, is agitated, and is or intubation
drooling. She insists on sitting upright. what should the
nurse do?
a. Examine her oral pharynx and report to the physician
b. Make her lie down and rest quietly
c. Auscultate her lungs, and make preparations for
placement in a mist tent.
d. Notify the physician immediately and be prepared to
assist with a tracheostomy or intubation
, Apnea of infancy has been diagnosed in an infant who a. Cardiopulmonary resuscitation
will soon be discharged with home monitoring. Which
information should the nurse include when teaching the
parents about the infant's care?
a. Cardiopulmonary resuscitation
b. Importance of adequate fluids
c. Reassurance that the infant cannot be electrocuted
during monitoring
d. Advice that the infant not be left with other caretakers,
such as babysitters
The mother of a 20-month old boy tells the nurse that he b. Try a cool-mist vaporizor at night and watch for signs of difficulty breathing
has a barking cough at night. His temperature is 37
degrees C (98.6 F). The nurse suspects croup. What
should she recommend?
a. Control fever with acetaminophen and call if cough
gets worse tonight
b. Try a cool-mist vaporizor at night and watch for signs
of difficulty breathing
c. Try over-the-counter medicine and come to the clinic
tomorrow if no improvement
d. Admit to the hospital and observe for impending
epiglottitis
A 4-year-old boy needs to use a metered-dose inhaler to a. spacer
treat asthma. He cannot coordinate the breathing to use
it effectively. The nurse should suggest that he use a :
a. spacer
b. nebulizer
c. peak expiratory flowmeter
d. trial of chest physiotherapy
A 7 month old infant is brought into the ER for injuries c and d
stemming from a bookcase falling on her immediately
prior to arrival to the hospital. The parents reported the
child was pulling herself up using the bookcase when it
toppled over. Which clinical findings would lead the
nurse to suspect child maltreatment? Select all that
apply?
a. Crying
b. Hugging the mother tightly.
c. Spiral Fracture of the leg
d. A yellow color bruise on the buttock
