Peds 2 ATI Practice Exam 2024

Nurse is reviewing lab results of a school age child 1 week postop following an open fracture repair. Which findings should nurse ID as indication of potential complication? Erythrocyte sedimentation rate 18 mm/hr WBC count 6,200/mm3 C-reactive protein 1.4 mg/L RBC count 4.7 million/mm3 - ANS: Erythrocyte sedimentation rate 18 mm/hr: - above the expected reference range of up to 10 mm/hr and is an indication of osteomyelitis. WBC count 6,200/mm3: - within the expected reference range of 5,000 to 10,000/mm3. An elevated WBC count is an indication of osteomyelitis. C-reactive protein 1.4 mg/L: - within the expected reference range of <10.0 mg/L. An elevated C-reactive protein level is an indication of osteomyelitis. RBC count 4.7 million/mm3: - within the expected reference range of 4.0 to 5.5 million/mm3. A decreased RBC count can indicate hemorrhage. Nurse planning care for school age child with tunneled CVA device. Which interventions should the nurse include in plan? Use sterile scissors to remove the dressing from the site. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use Access the site using a noncoring angled needle Use a semipermeable transparent dressing to cover the site - Use sterile scissors to remove the dressing from the site: - The nurse should avoid the use of scissors when performing dressing changes because this can result in accidental cutting of the catheter. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use: - The nurse should flush each lumen of the catheter with a heparin solution daily when not in use. Access the site using a noncoring angled needle: - The nurse should use a noncoring angled or straight needle when accessing an implanted port. ANS: Use a semipermeable transparent dressing to cover the site.: - The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection. Nurse is planning care to address nutritional needs for preschooler with cystic fibrosis. Which interventions should the nurse include in plans? Administer pancreatic enzymes 2 hr after meals. Discontinue the use of pancreatic enzymes if steatorrhea develops. Limit fluid intake to 750 mL per day. Increase fat content in the child's diet to 40% of total calories. - Administer pancreatic enzymes 2 hr after meals: - The nurse should plan to administer pancreatic enzymes within 30 min of meals and snacks to replace the enzymes lost with cystic fibrosis. Discontinue the use of pancreatic enzymes if steatorrhea develops: - A child who has cystic fibrosis and develops steatorrhea, or fatty stools, might need to have their dosage of pancreatic enzyme increased by their provider until the steatorrhea resolves. Limit fluid intake to 750 mL per day: - The nurse should encourage fluid intake, rather than restrict it, to prevent dehydration caused by the loss of sodium and chloride through perspiration. ANS: Increase fat content in the child's diet to 40% of total calories: - A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to 35% to 40% of total caloric intake. Nurse in ED auscultates lungs of adolescent experiencing dyspnea. Nurse should ID sound as what? Wheezes Crackles Pleural friction rub Rhonchi - ANS: Wheezes: - high-pitched, musical or whistling-like sounds heard primarily on expiration as air passes through and vibrates narrowed airways. Crackles: - high-pitched, short, and noncontinuous sounds usually heard at the end of inspiration. Crackles occur when air expands deflated alveoli or when the passage of air through small airways is disrupted. Pleural friction rub: - a loud, rough, grating sound that can be heard during inspiration or expiration. A pleural friction rub occurs when the pleurae are inflamed and the surfaces rub together. Rhonchi: - low-pitched, continuous sounds that have a snore-like quality and are usually louder during expiration. Rhonchi occur when the larger airways are obstructed. Nurse assesses school age child with infratentorial brain tumor. Which findings should the nurse ID as manifestation of IICP? Hypotension Reports insomnia Difficulty concentrating Tachycardia - Hypotension: - HTN is a late manifestation of IICP due to compression of the brain vessels. Reports insomnia: - somnolence and lethargy are manifestations of IICP. ANS: Difficulty concentrating: - The nurse should identify that irritability, inability to follow commands, and difficulty concentrating are manifestations of IICP due to decreased blood flow within the brain and pressure on the brainstem. Tachycardia: - bradycardia is a late manifestation of IICP. Nurse assesses infant with PNA. Which findings is priority for nurse to report to HCP? Nasal flaring WBC count 11,300/mm3 Diarrhea Abdominal distension - ANS: Nasal flaring: - When using the ABC approach to client care, the nurse should determine that the priority finding to report to the provider is nasal flaring. Nasal flaring indicates the infant is experiencing acute respiratory distress. WBC count 11,300/mm3: - The nurse should report a WBC count of 11,300/mm3 because it is above the expected reference range of 5,000 to 10,000/mm3 and indicates infection. However, there is another finding that is the priority for the nurse to report. Diarrhea: - The nurse should report diarrhea because it is a manifestation of pneumonia in infants and indicates the current treatment is not effective. However, there is another finding that is the priority for the nurse to report. Abdominal distension: - The nurse should report abdominal distension because it is a manifestation of pneumonia in infants and indicates the current treatment is not effective. However, there is another finding that is the priority for the nurse to report. Nurse in health department is caring for emancipated adolescent with STI and unaccompanied by guardian. Which actions should the nurse take? Have the adolescent sign a consent form for treatment. Instruct the adolescent to return with a guardian. Obtain consent from the adolescent's guardian over the phone Treat the adolescent without a consent form - ANS: Have the adolescent sign a consent form for treatment: - The nurse should identify that an emancipated minor can sign the consent form for treatment of an STI or any other form of medical treatment requiring consent. Instruct the adolescent to return with a guardian: - *Adolescents or emancipated minors can provide their own consent for any medical treatment. Obtain consent from the adolescent's guardian over the phone: - * Treat the adolescent without a consent form: - * Nurse teaches adolescent about how to manage tinea pedis. Which statements by adolescent indicates understanding of teaching? "I should buy plastic shoes to wear at the swimming pool." "I should wear sandals as much as possible." "I should place the permethrin cream between my toes twice daily." "I should seal my nonwashable shoes in plastic bags for a couple of weeks." - "I should buy plastic shoes to wear at the swimming pool.": - The use of plastic shoes increases the occurrence of tinea pedis. The nurse should instruct the adolescent to avoid wearing plastic shoes. ANS: "I should wear sandals as much as possible.": - Sandals allow air to circulate around the feet, decreasing perspiration and eliminating the medium for bacteria and fungus to grow. The nurse should inform the adolescent that wearing sandals, open-toed, or well-ventilated shoes will promote healing of the fungal infection. "I should place the permethrin cream between my toes twice daily.": - Permethrin 5% cream is a scabicide used to treat scabies. This treatment is not indicated for tinea pedis. "I should seal my nonwashable shoes in plastic bags for a couple of weeks.": - Sealing nonwashable items in plastic bags for 14 days is a recommended practice for clients who have pediculosis. This practice is not indicated for tinea pedis. Nurse assesses 8 y/o child with early indications of shock. After establishing airway and stabilizing child's resp, which actions should the nurse take next? Insert an indwelling urinary catheter. Measure weight and height. Initiate IV access. Maintain ECG monitoring. - Insert an indwelling urinary catheter: - The nurse should insert an indwelling urinary catheter for a child who has early indications of shock. Strict intake and output monitoring is needed because UO decreases during shock due to reduced blood flow to the kidneys as the body attempts to conserve body fluids. However, there is another action that the nurse should take first. Measure weight and height: - The nurse should measure weight and height of a child who has early indications of shock to calculate weight-based medication dosages. However, there is another action that the nurse should take first. ANS: Initiate IV access: - After establishing an airway and stabilizing the child's respirations, the next action the nurse should take when using the ABC approach to client care is to establish IV access to maintain the child's circulatory volume. Maintain ECG monitoring: - The nurse should maintain ECG monitoring for a child who has early indications of shock to continually assess for changes in cardiac status. However, there is another action that the nurse should take first. Charge nurse prepares to make room assignment for newly admitted school age child. Which considerations is the nurse's priority? Length of stay Treatment schedule Disease process Self-care ability - Length of stay: - some client rooms might be larger, and thus more comfortable for families during long hospitalizations. However, this is not the nurse's priority consideration. Treatment schedule: - children requiring frequent monitoring and treatment should be assigned a room close to the nurses' station, if possible. However, this is not the nurse's priority consideration. ANS: Disease process: - The transmission of infectious diseases is the greatest risk to this child and other children on the unit. Therefore, the child's disease process is the nurse's priority consideration. Self-care ability: - children who require more assistance from nurses or assistive personnel should be assigned a room close to the nurses' station, if possible. However, this is not the nurse's priority consideration. Nurse in ED assesses 3 month old infant with rotavirus and experiences acute vomiting and diarrhea. Which manifestations should nurse ID as indication that infant has moderate to severe dehydration? Heart rate 124/min Increased tear production Sunken anterior fontanel Cap refill 2 secs - Heart rate 124/min: - within the expected reference range of 106 to 186/min for a 3- to 5-month-old infant. The nurse should expect the infant who has moderate to severe dehydration to have tachycardia. Increased tear production: - An infant who has moderate to severe dehydration is more likely to have absence of tears rather than increased tear production. ANS: Sunken anterior fontanel: - The nurse should recognize that a sunken anterior fontanel is an indication of moderate to severe dehydration due to the acute loss of fluid. Capillary refill 2 sec: - within the expected reference range of 2 seconds or less for a 3-month-old infant. An infant who has moderate to severe dehydration is more likely to have delayed capillary refill of greater than 2 seconds. Nurse provides dietary teaching to guardian of school age child with cystic fibrosis. Which statements should nurse make? "You should offer your child high-protein meals and snacks throughout the day." "You should decrease your child's dietary fat intake to less than 10% of their caloric intake." "You should restrict your child's calorie intake to 1,200 per day." "You should give your child a multivitamin once weekly." - ANS: "You should offer your child high-protein meals and snacks throughout the day.": - The nurse should instruct the guardian to provide a diet that is well-balanced and high in protein and calories. Children who have cystic fibrosis require a higher percentage of the recommended dietary allowances of all nutrients to meet their energy requirements. Children who have good nutritional intake have improved lung function and decreased risk of infection. "You should decrease your child's dietary fat intake to less than 10% of their caloric intake.": - Children who have cystic fibrosis need a diet that is unrestricted in fat. They also require 35% to 40% of their calories to come from fats due to decreased absorption from the intestines. "You should restrict your child's calorie intake to 1,200 per day.": - Children who have cystic fibrosis require a high-calorie diet and should consume at least 2,000 calories per day. "You should give your child a multivitamin once weekly.": - Children who have cystic fibrosis should be given a multivitamin once daily. Nurse reviews dietary choices of adolescent with iron deficiency anemia. Nurse should ID which menu items has highest amount of nonheme iron? ½ cup whole milk 1 cup orange juice 1/2 cup raisins 1 cup raw carrots - ½ cup whole milk: - Whole milk does not contain the highest amount of nonheme iron. However, it does contain high amounts of calcium. 1 cup orange juice: - Orange juice does not contain the highest amount of nonheme iron. However, it does contain ascorbic acid, which increases the amount of nonheme iron absorbed by the body. ANS: ½ cup raisins: - The nurse should encourage the adolescent to eat raisins because they contain the highest amount of nonheme iron. 1 cup raw carrots: - Raw carrots do not contain the highest amount of nonheme iron. Nurse provides discharge teaching to parents of 6 month old infant postop following hypospadias repair with stent placement. Which instructions should the nurse include in teaching? "You may bathe your infant in an infant bathtub when you go home." "Apply hydrocortisone cream to your infant's penis daily." "You should clamp your infant's stent twice daily." "Allow the stent to drain directly into your infant's diaper." - "You may bathe your infant in an infant bathtub when you go home.": - Submerging the stent in water can cause infection at the operative site. The parents should avoid placing the infant in an infant bathtub until after the provider removes the stent. "Apply hydrocortisone cream to your infant's penis daily.": - Following surgical repair of a hypospadias, the infant is at increased risk for infection at the operative site. The nurse should instruct the parents to administer a prophylactic antibiotic as prescribed to help prevent infection. "You should clamp your infant's stent twice daily.": - The stent in place following hypospadias repair allows urine to drain from the body. The nurse should instruct the parents to avoid blocking the stent to prevent urinary stasis and potential injury to the infant. ANS: "Allow the stent to drain directly into your infant's diaper.": - The nurse should instruct the parents to ensure that the stent drains directly into the infant's diaper to prevent kinking or twisting that can interfere with urine flow. Nurse in ED cares for school age child with epiglottis. Which actions should the nurse take? Obtain a throat culture from the child. Monitor the child's oxygen saturation. Put a warm mist humidifier in the child's room. Place the child in the supine position. - Obtain a throat culture from the child: - Obtaining a throat culture places the child at risk for complete airway obstruction. The nurse should wait until an airway is established for the child before performing any diagnostic testing. ANS: Monitor the child's oxygen saturation: - The nurse should monitor the child's oxygen saturation level because the child is experiencing acute respiratory distress and it is necessary to determine if the child is responding to treatment. Put a warm mist humidifier in the child's room: - The nurse should administer humidified oxygen by face mask or blow-by, rather than place a warm mist humidifier in the child's room. Place the child in the supine position: - Placing the child in the supine position increases the child's risk for complete airway obstruction. The nurse should allow the child to be in whatever position they feel provides the most help with breathing. This is usually an upright position, and sometimes it is helpful for the child to lean forward to help with breathing. Nurse in HCP office is caring for school age child with varicella. Parent asks nurse when their child will no longer be contagious. Which response should the nurse make? "When your child no longer has an increased temperature." "Three days after you first noticed the rash appear on your child." "When your child's lesions are crusted, usually 6 days after they appear." "Two to three weeks, when your child's lesions completely disappear." - "When your child no longer has an increased temperature.": - The nurse should inform the parent that an absence of a fever does not indicate the child is no longer contagious. "Three days after you first noticed the rash appear on your child.": - The nurse should inform the parent that the child will remain contagious longer than 3 days after the rash appears. ANS: "When your child's lesions are crusted, usually 6 days after they appear.": - The nurse should inform the parent that the child is contagious 1 day prior to lesion eruption and until the vesicles have crusted over, which usually takes about 6 days. "Two to three weeks, when your child's lesions completely disappear.": - The incubation period of varicella is two to three weeks. However, this is not related to the appearance and disappearance of the lesions. Nurse teaches family of school age child with juvenile idiotpathic arthritis. Which instructions should the nurse include in teaching? "Limit movement of the child's large joints." "Encourage the child to perform independent self-care." "Provide the child with a soft mattress for sleeping." "Schedule a 2-hour daily nap for the child in the afternoon." - "Limit movement of the child's large joints.": - Large joints should be exercised regularly to maintain mobility and strengthen muscles. ANS: "Encourage the child to perform independent self-care.": - The nurse should teach the family the importance of encouraging the child to perform independent self-care. This will minimize the child's pain while maximizing mobility. Encouraging and praising the child's efforts for independence will also increase their self-esteem. "Provide the child with a soft mattress for sleeping.": - Children who have juvenile idiopathic arthritis should sleep on a firm mattress to provide support in maintaining joints in a functional position. "Schedule a 2-hour daily nap for the child in the afternoon.": - Daytime naps are discouraged because stiffness can occur quickly and easily with inactivity, and naps can interfere with nighttime sleeping. School nurse provides in service for faculty about improving education for students with ADHD. Which statements by faculty member indicates understanding of teaching? "I will plan to increase the amount of homework I assign to students who have ADHD." "I will give students who have ADHD the same amount of time as other students to complete tests." "I will allow students who have ADHD one rest break throughout the day." "I will teach challenging academic subjects to students who have ADHD in the morning." - "I will plan to increase the amount of homework I assign to students who have ADHD.": - Faculty should decrease the amount of school work and homework given to a child who has ADHD to maintain their attention. "I will give students who have ADHD the same amount of time as other students to complete tests.": - Students who have ADHD should be given additional time to take tests due to decreased attention. "I will allow students who have ADHD one rest break throughout the day.": - Faculty should allow frequent breaks throughout the day for students who have ADHD to modify their learning environment. ANS: "I will teach challenging academic subjects to students who have ADHD in the morning.": - Faculty should plan to teach challenging academic subjects in the morning when students who have ADHD are most able to focus and their medication is most likely to be effective. Nurse is planning educational program to teach parents about protecting children from sunburns. Which instructions should the nurse plan to include? "Allow your child to play outside during the hours between 10:00 a.m. and 2:00 p.m." "Choose a waterproof sunscreen with a minimum SPF of 15." "Dress your child in loose weave polyester fabric prior to sun exposure." "Reapply sunscreen every 4 hours." - "Allow your child to play outside during the hours between 10:00 a.m. and 2:00 p.m.": - The nurse should instruct parents to avoid allowing their children to play outside during the hours between 1000 and 1400 because the child is at greatest risk for developing a sunburn during this time. ANS: "Choose a waterproof sunscreen with a minimum SPF of 15.": - The nurse should instruct parents to apply a waterproof sunscreen with a minimum SPF of 15 for children. The parents should apply the sunscreen prior to sun exposure to reduce the risk of sunburn. "Dress your child in loose weave polyester fabric prior to sun exposure.": - The nurse should instruct parents to dress their children in tight weave cotton fabric prior to sun exposure to protect the skin from the sun. "Reapply sunscreen every 4 hours.": - The nurse should instruct parents to reapply sunscreen every 2 to 3 hr. Nurse planning care for newly admitted school-age child with generalized seizure disorder. Which interventions should the nurse plan to include? Ensure that a padded tongue blade is at the child's bedside. Allow the child to play video games on a tablet computer. Allow the child to take a tub bath independently. Ensure the oxygen source is functioning in the child's room. - Ensure that a padded tongue blade is at the child's bedside.: - Nothing should be placed in the child's mouth during or after a seizure. Allow the child to play video games on a tablet computer: - Bright or flashing lights from video games can trigger seizure activity. The nurse should decrease environmental stimuli and offer other play activities, such as reading a book or playing with a stuffed animal. Allow the child to take a tub bath independently: - The nurse should allow the child to take a tub bath with supervision, but not independently. There should be someone available to assist the child if they experience a seizure. ANS: Ensure the oxygen source is functioning in the child's room.: - The nurse should recognize that maintaining the child's airway is important during a seizure. The nurse should ensure that the oxygen source is functioning because the child might require supplemental oxygen following a seizure. Nurse caring for newly admitted school age child with hypopituitarism. Which meds should the nurse expect the HCP to prescribe? Desmopressin Luteinizing hormone-releasing hormone Recombinant growth hormone Levothyroxine - Desmopressin: - used to treat hyposecretion of ADH. Luteinizing hormone-releasing hormone: - used in the treatment of precocious puberty to slow prepubertal growth in children and in the treatment of advanced prostate cancer in adult clients. ANS: Recombinant growth hormone: - used to treat hypopituitarism, which inhibits cell growth and results in growth failure. The nurse should expect the provider to prescribe this treatment. Levothyroxine: - used to treat various hypothyroid conditions. Nurse creating POC (plan of care) for preschooler with Wilms' tumor and scheduled for surgery. Which interventions should the nurse include? Avoid palpating the abdomen when bathing the child before surgery. Refrain from auscultating the child's bowel sounds during the postoperative assessment. Encourage the child to play with other children on the unit prior to surgery. Explain to the child that their pain will be managed after the surgery. - ANS: Avoid palpating the abdomen when bathing the child before surgery: - The nurse should avoid palpating the abdomen when bathing the child before surgery because movement of the tumor can cause cancer cells to disseminate to other sites, adjacent and distant to the tumor site. Refrain from auscultating the child's bowel sounds during the postoperative assessment: - Auscultation of the child's bowel sounds to monitor for an obstruction is an important part of the postoperative assessment. Therefore, the nurse should auscultate bowel sounds following the surgery. Encourage the child to play with other children on the unit prior to surgery: - The child's risk for injury increases with physical activity. Therefore, the nurse should not encourage the child to play with other children on the unit. Explain to the child that their pain will be managed after the surgery: - Telling the child about pain prior to surgery will likely increase their fear and anxiety level. Therefore, the nurse should not explain to the child that pain will be managed after surgery. Nurse discussing organ donation with parents of school age child who has sustained brain death due to bicycle crash. Which actions should the nurse take first? Inform the parents that written consent is required prior to organ donation. Provide written information to the parents about organ donation. Ask the provider to explain misconceptions of organ donation to the parents. Explore the parents' feelings and wishes regarding organ donation. - Inform the parents that written consent is required prior to organ donation: - The nurse should inform the parents that written consent is required prior to organ donation to document that the parents have consented to organ donation and that the provider has addressed any questions or concerns the parents might have. However, there is another action the nurse should take first. Provide written information to the parents about organ donation: - The nurse should provide written information to the parents to enhance their understanding about organ donation. However, there is another action the nurse should take first. Ask HCP to explain misconceptions of organ donation to the parents: - The nurse should ask the provider to explain misconceptions of organ donation to the parents, because it is important that they have accurate information before making a final decision. However, there is another action the nurse should take first. ANS: Explore the parents' feelings and wishes regarding organ donation: - The first action the nurse should take when using the nursing process is assessment. The nurse should first explore the parents' feelings and wishes regarding organ donation to assist in determining if organ donation is the right choice for the family. Nurse planning developmental activities for newly admitted 10 y/o child with neutropenia. Which actions should the nurse plan to take? Provide the child with a book about adventure. Arrange frequent visits from family members and peers. Give the child a large-piece puzzle. Use puppets to entertain the child. - ANS: Provide the child with a book about adventure: - The nurse should provide a school-age child with a book about adventure as a developmental activity because children are expanding their knowledge and imagination during this age. Through reading, school-age children can feel powerful and skillful as they imagine themselves in the stories they read. Arrange frequent visits from family members and peers: - The nurse should limit visitors for a child who has neutropenia because this places the child at an increased risk for infection. Give the child a large-piece puzzle: - The nurse should provide a large-piece puzzle to a preschooler. School-age children tend to be challenged mentally with complex board and video games. Use puppets to entertain the child: - The nurse should use puppets to entertain toddlers. School-age children are not typically entertained for very long or challenged mentally with puppets. Instead, they tend to prefer complex board and video games. Community health nurse assesses 18 month old toddler in community day care. Which findings should the nurse ID as potential indication of physical neglect? Resists having an axillary temperature taken Exhibits withdrawal behaviors when their parent leaves Has multiple bruises on their knees Poor personal hygiene - Resists having an axillary temperature taken: - A toddler has begun to develop a sense of body image and boundaries and can be resistant to intrusive assessments such as assessing the mouth or ears, or taking an axillary temperature. Exhibits withdrawal behaviors when their parent leaves: - Separation anxiety is an expected finding for a toddler. Toddlers can become fearful and exhibit regressive behaviors when left alone with strangers and separated from their parents. Has multiple bruises on their knees: - An 18-month-old toddler has typically accomplished the gross motor skills of standing and walking, and has likely started trying to run, which can result in them falling and bruising their knees. ANS: Poor personal hygiene: - A toddler who has poor personal hygiene can be a potential indication of physical neglect. Because toddlers are still dependent on their parents or guardians for help with hygiene needs, poor personal hygiene can indicate a lack of supervision. Nurse admitting a 4 month old infant with heart failure. Which findings is the nurse's priority? Exhibit: Temperature 37.5° C (99.5° F) Heart rate 70/min Respiratory rate 30/min Birth weight 3.2 kg (7 lb) Current weight 5.9 (13 lb) 3 episodes of vomiting 6 wet diapers in 24 hr Consumed 3 oz concentrated formula every 3 hr Digoxin 0.5 mcg PO Q12H Furosemide 20 mg PO Q12H Episodes of vomiting Formula consumption Weight Temperature - ANS: Episodes of vomiting: - When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is three episodes of vomiting. This can indicate digoxin toxicity, which requires immediate intervention. Therefore, this is the nurse's priority finding. Formula consumption: - A 4-month-old infant who has heart failure requires 3 to 4 oz of formula every 3 hr to adequately address caloric needs. A feeding schedule of every 2 hr does not allow sufficient rest time between feedings, and a feeding schedule of every 4 hr requires consumption of a higher volume, which is often not tolerated by the infant. An intake of 3 to 4 oz of formula every 3 hr indicates that the infant is tolerating the current feeding schedule. Therefore, there is another finding that is the nurse's priority. The infant who has heart failure is at risk for inadequate nutrition; therefore, the nurse should closely monitor the infant's intake. Weight: - A weight of 5.9 kg (13 lb) is an expected finding for a 4-month-old infant who weighed 3.2 kg (7 lb) at birth. Therefore, there is another finding that is the nurse's priority. The infant should gain 680 g (1.5 lb) per month until the age of 5 months. Temperature: - A temperature of 37.5º C (99.5º C) is within the expected reference range of 37º to 37.5º C (98.6º to 99.5º F) for a 4-month-old infant. Therefore, there is another finding that is the nurse's priority. Nurse teaches parents of preschooler with heart failure and new prescription for digoxin 2x daily. Which instructions should the nurse include in teaching? "Use a kitchen teaspoon to measure the medication." "Brush the child's teeth after giving the medication." "Double the next dose if the child misses a dose." "Repeat the dose if the child vomits." - "Use a kitchen teaspoon to measure the medication.": - The nurse should instruct the parents to use the calibrated device that comes with the medication when measuring the medication to avoid accidental overdose. ANS: "Brush the child's teeth after giving the medication.": - The nurse should instruct the parents to brush the child's teeth after administering digoxin to prevent tooth decay caused by the medication, which comes as a sweetened liquid to enhance the taste. "Double the next dose if the child misses a dose.": - The parent should administer digoxin at regular intervals, usually twice daily, or every 12 hr. The nurse should instruct the parents not to double the medication amount if they miss a dose because this can result in digoxin toxicity. "Repeat the dose if the child vomits.": - N/V, and decreased appetite are common manifestations of digoxin toxicity in children. The nurse should instruct the parents not to administer a second dose if the child vomits and to notify the provider. Nurse assesses pain level of 3 y/o toddler. Which pain assessments should the nurse use? FACES Numeric CRIES Visual analog - ANS: FACES: - The nurse should use the FACES pain rating scale for pediatric clients who are 3 years old and older. This scale allows the toddler to point to the face that depicts their current level of pain. The nurse can then determine the need for pain management. Numeric: - The nurse should use the numeric pain rating scale when assessing the need for pain management in pediatric clients who are 8 years old and older. The nurse should identify that a 3-year-old toddler does not yet possess a concept of numbers and numerical value to effectively use this pain rating scale. CRIES: - The nurse should use the CRIES pain assessment scale when assessing the need for pain management in infants who are less than 40 weeks of age. Visual analog: - The nurse should use the visual analog scale to assess pain for a child who is greater than 8 years of age. The visual analog scale allows the child to mark their pain on a centimeter ruler. Nurse teaches guardian of 6 month old infant about teething. Which statements should the nurse make? "Your baby might pull at their ears when they are teething." "Rub your baby's gums with an aspirin to decrease discomfort." "Place a beaded teething necklace around your baby's neck." "Your baby's upper middle teeth will erupt first." - ANS: "Your baby might pull at their ears when they are teething.": - The nurse should inform the guardian that teething can result in discomfort for the infant. Therefore, the guardian should look for indications such as pulling on the ears, difficulty sleeping, increased drooling, or increased fussiness. "Rub your baby's gums with an aspirin to decrease discomfort.": - The guardian should avoid using aspirin or teething powders due to the risk of aspiration, infection, or irritation of the gum tissues. The nurse should recommend cold teething rings or gently rubbing the infant's gums with a cold cloth to minimize discomfort. "Place a beaded teething necklace around your baby's neck.": - Necklaces can result in suffocation and choking. Therefore, the nurse should instruct the guardian to avoid placing these on the infant. "Your baby's upper middle teeth will erupt first.": - The nurse should inform the guardian that the eruption of an infant's teeth begins with the lower central incisors. Nurse performs hearing screenings for children at community health fair. Which children should the nurse refer to HCP for more extensive hearing evaluation? An 18-month-old toddler who has unintelligible speech A 3-month-old infant who has an exaggerated startle response A 4-year-old preschooler who prefers playing with others rather than alone An 8-month-old infant who is not yet making babbling sounds - An 18-month-old toddler who has unintelligible speech: - The nurse should refer a toddler who does not possess intelligible speech by the age of 24 months to a provider for a more extensive evaluation of hearing. A 3-month-old infant who has an exaggerated startle response: - The nurse should refer infants who are under the age of 4 months and lack a startle response to a provider for a more extensive evaluation of hearing. A 4-year-old preschooler who prefers playing with others rather than alone: - The nurse should refer a preschooler who prefers playing alone and avoids interaction with others to a provider for a more extensive evaluation of hearing. ANS: An 8-month-old infant who is not yet making babbling sounds: - The nurse should refer an infant who is not making babbling sounds by the age of 7 months to a provider for a more extensive evaluation of hearing. Nurse teaching parents of toddler with cognitive impairment about toilet training. Which instructions should the nurse include in teaching? "Scold your child when they have a toileting accident." "Award your child with a sticker when they sit on the potty chair." "Play your child's favorite song while teaching them to use the potty chair." "Teach multiple steps of the skill at the same time." - "Scold your child when they have a toileting accident.": - The parents should use positive reinforcement when teaching their child a new task. Reinforcing positive behaviors, such as remaining dry through the night, will have a greater effect on the child than the negative reinforcement of scolding. ANS: "Award your child with a sticker when they sit on the potty chair.": - A child who has a cognitive impairment learns through shaping behaviors. The parents should reward the child for sitting on the potty chair as a reinforcement of the desired behavior of continence. As the child repeats this action, the parents can gradually decrease this reward and then give rewards for the next step in the task, such as voiding while sitting on the potty chair. "Play your child's favorite song while teaching them to use the potty chair.": - A child who has a cognitive impairment has difficulty discriminating between two or more cues or stimuli. The nurse should instruct the parents to eliminate all other stimuli when teaching the child the task of toilet training. "Teach multiple steps of the skill at the same time.": - Children who have a cognitive impairment have difficulty remembering multiple steps. The nurse should instruct the parents to teach one step at a time to the child. The child should master each step before the parents introduce the next step. Nurse teaching school age child and parent about postop care following cardiac catheterization. Which instructions should the nurse include? "Stay home from school for 1 week following the procedure." "Follow a diet that is low in fiber for 1 week." "Wait 3 days before taking a tub bath." "Apply a pressure dressing to the site for 3 days." - "Stay home from school for 1 week following the procedure.": - The child can attend school the next day but they should avoid strenuous activities to prevent bleeding at the insertion site. "Follow a diet that is low in fiber for 1 week.": - The child can resume their regular diet after the procedure. ANS: "Wait 3 days before taking a tub bath.": - The child should keep the site clean and dry for at least 3 days to reduce the risk of infection. Tub baths should be avoided for 3 days to avoid immersion of the incision in water. "Apply a pressure dressing to the site for 3 days.": - The parent can remove the pressure dressing the day after the procedure and should apply a new adhesive bandage strip daily to the site for at least the next 2 days.