NR328 Introduction to Pediatric Nursing- EDAPT: Pediatric Nursing
A 16-year-old girl comes to the pediatric clinic for information on birth control. The nurse knows that
before this young woman can be examined, consent must be obtained from which source? -
ANSWER:Herself
The nurse needs to take the blood pressure of a preschool boy for the first time. What action would be
best in gaining his cooperation? - ANSWER:Permit him to handle the equipment and see the cuff inflate
and deflate before putting the cuff in place.
A 4-year-old girl is admitted to outpatient surgery for removal of a cyst on her back. Her mother puts the
hospital gown on her, but the child is crying because she wants to leave on her underpants. What is the
most appropriate nursing action at this time?? - ANSWER:Allow her to wear her underpants.
Using knowledge of child development, what approach is best when preparing a toddler for a
procedure? - ANSWER:Demonstrate on a doll how the procedure will be done.
The nurse is preparing a 9-year-old boy before obtaining a blood specimen by venipuncture. The child
tells the nurse he does not want to lose his blood. What approach is best by the nurse? -
ANSWER:Discuss with him how his body is always in the process of making blood.
A bone marrow biopsy will be performed on a 7-year-old girl. She wants her mother to hold her during
the procedure. How should the nurse respond? - ANSWER:Holding may help your child relax.
A 6-year-old child needs to drink 1 L of GoLYTELY in preparation for a computed tomography scan of the
abdomen. To encourage the child to drink, what should the nurse do? - ANSWER:Use little cups and
make a game to reward him for each cup he drinks.
A toddler is being sent to the operating room for surgery at 9 AM. As the nurse prepares the child, what
is the priority intervention? - ANSWER:Verifying that the child and procedure are correct
A 5-year-old child returns from the pediatric intensive care unit after abdominal surgery. The orders state
to monitor vital signs every 2 hours. On assessment, the nurse observes that the childs heart rate is 20
beats/min less than it was preoperatively. What should be the nurses next action? - ANSWER:Recheck
the pulse and blood pressure in 15 minutes.
A 10-year-old child requires daily medications for a chronic illness. Her mother tells the nurse that the
child continually forgets to take the medicine unless reminded. What nursing action is most appropriate
to promote adherence to the medication regimen? - ANSWER:Establish a contract with her, including
rewards.
A 7-year-old is identified as being at risk for skin breakdown. What intervention should the nursing care
plan include? - ANSWER:Ensuring that nutritional intake meets requirements
A 6-year-old boy is hospitalized for intravenous antibiotic therapy. He eats very little on his regular diet
trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. What nursing action is the
most appropriate? - ANSWER:Request these favorite foods for him.
,A 14-year-old adolescent is hospitalized with cystic fibrosis. What nursing note entry represents best
documentation of his breakfast meal? - ANSWER:One pancake, eggs, and 240 ml OJ
A child, age 7 years, has a fever associated with a viral illness. She is being cared for at home. What is the
principal reason for treating fever in this child? - ANSWER:Relief of discomfort
A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as
acetaminophen. How should the nurse respond to the parents? - ANSWER:Antipyretics are of no value in
treating hyperthermia.
The nurse gives an injection in a patients room. How should the nurse dispose of the needle? -
ANSWER:Dispose of the syringe and needle in a rigid, puncture-resistant container in the patients room.
A child who has cystic fibrosis is admitted to the pediatric unit with methicillin-resistant Staphylococcus
aureus (MRSA) infection. The nurse recognizes that in addition to a private room, the child is placed on
what precautions? - ANSWER:Contact
An 11-month-old hospitalized boy is restrained because he is receiving intravenous (IV) fluids. His
grandmother has come to stay with him for the afternoon and asks the nurse if the restraints can be
removed. What nurses response is best? - ANSWER:That is fine as long as you are with him.
A nurse must do a venipuncture on a 6-year-old child. What consideration is important in providing
atraumatic care? - ANSWER:Show the child the equipment to be used before the procedure.
A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When preparing for
a lumbar puncture, what should the nurse do? - ANSWER:Prepare the child for conscious sedation being
used for the procedure.
Frequent urine tests for specific gravity are required on a 6-month-old infant. What method is the most
appropriate way to collect small amounts of urine for these tests? - ANSWER:Aspirate urine from cotton
balls inside the diaper with a syringe without a needle.
A child has a central venous access device for intravenous (IV) fluid administration. A blood sample is
needed for a complete blood count, hemogram, and electrolytes. What is the appropriate procedure to
implement for this blood sample? - ANSWER:Withdraw a blood sample equal to the amount of fluid in
the device, discard, and then withdraw the sample needed.
The nurse has just collected blood by venipuncture in the antecubital fossa. What should the nurse do
next? - ANSWER:Keep the childs arm extended and apply pressure to the site for a few minutes.
An appropriate method for administering oral medications that are bitter to an infant or small child
should be to mix them with which? - ANSWER:One teaspoon of something sweet-tasting such as jam
The practitioner has ordered a liquid oral antibiotic for a toddler with otitis media. The prescription reads
1 1/2 tsp four times per day. What should the nurse consider in teaching the mother how to give the
medicine? - ANSWER:A hollow-handled medication spoon is advisable, and the medication should be
equally spaced while the child is awake.
Guidelines for intramuscular administration of medication in school-age children include what standard?
- ANSWER:Insert needle quickly, using a dartlike motion.
,What is an advantage of the ventrogluteal muscle as an injection site in young children? - ANSWER:Free
of significant nerves and vascular structures
When teaching a mother how to administer eye drops, where should the nurse tell her to place them? -
ANSWER:In the conjunctival sac when the lower eyelid is pulled down
What is the best method to verify the placement of a nasogastric tube before each use? -
ANSWER:Aspiration of stomach contents
Parents are being taught how to feed their infant using a newly placed gastrostomy tube (G-tube). What
is essential information for the parents to receive? - ANSWER:Position the infant on the right side during
and after the feeding.
What is a priority intervention for an infant with a temporary colostomy for Hirschsprung disease? -
ANSWER:Protecting the skin around the colostomy
A 1-month-old infant is admitted to the hospital. The infants mother is 17 years old and single and lives
with her parents. Who signs the informed consent for the 1-month-old infant? - ANSWER:The infants
mother
A preschool child needs a dressing change. To prepare the child, what strategy should the nurse
implement? - ANSWER:Give choices when possible but avoid delay.
The nurse on a pediatric unit is writing guidelines for age-specific preparation of children for procedures
based on developmental characteristics. What guideline is accurate? - ANSWER:Use simple diagrams of
anatomy and physiology to explain a procedure to a school-age child.
A laboratory technician is performing a blood draw on a toddler. The toddler is holding still but crying
loudly. The nurse should take which action? - ANSWER:Do nothing. Its Okay for a child to cry during a
painful procedure.
At which age should a nurse keep teaching time short (5 minutes)? - ANSWER:Toddler
The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever. What nursing action is
appropriate? - ANSWER:Check to be sure the Tylenol dose does not exceed 15 mg/kg.
The nurse is administering an IM injection into a vastus lateralis muscle of a 6-month-old infant. What
should the length of the needle and amount to be given be? - ANSWER:5/8 to 1 inch; 0.5 to 1.0 ml
The nurse needs to start an intravenous (IV) line on an 8-year-old child to begin administering
intravenous antibiotics. The child starts to cry and tells the nurse, Do it later, okay? What action should
the nurse take? - ANSWER:Start the IV line and then allow for expression of feelings.
The nurse is preparing to administer a liquid medication by a nasogastric feeding tube. What is the first
thing the nurse should do? - ANSWER:Check the pH of the gastric aspirate.
To facilitate the administration of an oral medication to a preschool-age child, what action should the
nurse take? - ANSWER:Set limits about the need to take medication and offer praise immediately after
the task is accomplished.
, A 2-year-old child has to receive Rocephin IM injections every 12 hours. What nursing intervention
should be implemented for the child? - ANSWER:Hold the child while rocking in a chair after each
injection.
When checking the intravenous (IV) site on a child, the nurse should take which action? - ANSWER:Look
at the site while palpating the area.
The nurse is caring for a 12-year-old child who is on fall precautions secondary to seizures. What
interventions should be included in the childs care plan? - ANSWER:-Place a call light and desired items
within reach.
-Have the child wear an appropriate-size gown and nonskid footwear.
. What methods should the nurse use to measure compliance to a treatment plan? - ANSWER:Pill counts
Chemical assays
Direct observation
Monitoring therapeutic response
What interventions should the nurse implement to prevent a pressure ulcer in a critically ill child? -
ANSWER:Nutrition consult
Using skin moisturizers
Turning the child every 2 hours
Using draw sheets to minimize shear
The nurse is preparing to obtain a nasal washing from a child. What equipment should the nurse gather
for the procedure? - ANSWER:Syringe with tubing
Sterile normal saline
The clinic nurse is teaching parents about when to call the office immediately for a child with a fever.
What should the nurse include in the teaching session? - ANSWER:The child has a stiff neck.
The fever is over 40.6 C (105 F).
The child is younger than 2 months.
What strategies should the nurse implement to assist in feeding a sick child? - ANSWER:Make mealtimes
pleasant.
Avoid foods that are highly seasoned.
Provide finger foods for young children.
Ensure a variety of foods, textures, and colors.
What disease processes require contact isolation? - ANSWER:Rotavirus
Hepatitis A
A 16-year-old girl comes to the pediatric clinic for information on birth control. The nurse knows that
before this young woman can be examined, consent must be obtained from which source? -
ANSWER:Herself
The nurse needs to take the blood pressure of a preschool boy for the first time. What action would be
best in gaining his cooperation? - ANSWER:Permit him to handle the equipment and see the cuff inflate
and deflate before putting the cuff in place.
A 4-year-old girl is admitted to outpatient surgery for removal of a cyst on her back. Her mother puts the
hospital gown on her, but the child is crying because she wants to leave on her underpants. What is the
most appropriate nursing action at this time?? - ANSWER:Allow her to wear her underpants.
Using knowledge of child development, what approach is best when preparing a toddler for a
procedure? - ANSWER:Demonstrate on a doll how the procedure will be done.
The nurse is preparing a 9-year-old boy before obtaining a blood specimen by venipuncture. The child
tells the nurse he does not want to lose his blood. What approach is best by the nurse? -
ANSWER:Discuss with him how his body is always in the process of making blood.
A bone marrow biopsy will be performed on a 7-year-old girl. She wants her mother to hold her during
the procedure. How should the nurse respond? - ANSWER:Holding may help your child relax.
A 6-year-old child needs to drink 1 L of GoLYTELY in preparation for a computed tomography scan of the
abdomen. To encourage the child to drink, what should the nurse do? - ANSWER:Use little cups and
make a game to reward him for each cup he drinks.
A toddler is being sent to the operating room for surgery at 9 AM. As the nurse prepares the child, what
is the priority intervention? - ANSWER:Verifying that the child and procedure are correct
A 5-year-old child returns from the pediatric intensive care unit after abdominal surgery. The orders state
to monitor vital signs every 2 hours. On assessment, the nurse observes that the childs heart rate is 20
beats/min less than it was preoperatively. What should be the nurses next action? - ANSWER:Recheck
the pulse and blood pressure in 15 minutes.
A 10-year-old child requires daily medications for a chronic illness. Her mother tells the nurse that the
child continually forgets to take the medicine unless reminded. What nursing action is most appropriate
to promote adherence to the medication regimen? - ANSWER:Establish a contract with her, including
rewards.
A 7-year-old is identified as being at risk for skin breakdown. What intervention should the nursing care
plan include? - ANSWER:Ensuring that nutritional intake meets requirements
A 6-year-old boy is hospitalized for intravenous antibiotic therapy. He eats very little on his regular diet
trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. What nursing action is the
most appropriate? - ANSWER:Request these favorite foods for him.
,A 14-year-old adolescent is hospitalized with cystic fibrosis. What nursing note entry represents best
documentation of his breakfast meal? - ANSWER:One pancake, eggs, and 240 ml OJ
A child, age 7 years, has a fever associated with a viral illness. She is being cared for at home. What is the
principal reason for treating fever in this child? - ANSWER:Relief of discomfort
A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as
acetaminophen. How should the nurse respond to the parents? - ANSWER:Antipyretics are of no value in
treating hyperthermia.
The nurse gives an injection in a patients room. How should the nurse dispose of the needle? -
ANSWER:Dispose of the syringe and needle in a rigid, puncture-resistant container in the patients room.
A child who has cystic fibrosis is admitted to the pediatric unit with methicillin-resistant Staphylococcus
aureus (MRSA) infection. The nurse recognizes that in addition to a private room, the child is placed on
what precautions? - ANSWER:Contact
An 11-month-old hospitalized boy is restrained because he is receiving intravenous (IV) fluids. His
grandmother has come to stay with him for the afternoon and asks the nurse if the restraints can be
removed. What nurses response is best? - ANSWER:That is fine as long as you are with him.
A nurse must do a venipuncture on a 6-year-old child. What consideration is important in providing
atraumatic care? - ANSWER:Show the child the equipment to be used before the procedure.
A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When preparing for
a lumbar puncture, what should the nurse do? - ANSWER:Prepare the child for conscious sedation being
used for the procedure.
Frequent urine tests for specific gravity are required on a 6-month-old infant. What method is the most
appropriate way to collect small amounts of urine for these tests? - ANSWER:Aspirate urine from cotton
balls inside the diaper with a syringe without a needle.
A child has a central venous access device for intravenous (IV) fluid administration. A blood sample is
needed for a complete blood count, hemogram, and electrolytes. What is the appropriate procedure to
implement for this blood sample? - ANSWER:Withdraw a blood sample equal to the amount of fluid in
the device, discard, and then withdraw the sample needed.
The nurse has just collected blood by venipuncture in the antecubital fossa. What should the nurse do
next? - ANSWER:Keep the childs arm extended and apply pressure to the site for a few minutes.
An appropriate method for administering oral medications that are bitter to an infant or small child
should be to mix them with which? - ANSWER:One teaspoon of something sweet-tasting such as jam
The practitioner has ordered a liquid oral antibiotic for a toddler with otitis media. The prescription reads
1 1/2 tsp four times per day. What should the nurse consider in teaching the mother how to give the
medicine? - ANSWER:A hollow-handled medication spoon is advisable, and the medication should be
equally spaced while the child is awake.
Guidelines for intramuscular administration of medication in school-age children include what standard?
- ANSWER:Insert needle quickly, using a dartlike motion.
,What is an advantage of the ventrogluteal muscle as an injection site in young children? - ANSWER:Free
of significant nerves and vascular structures
When teaching a mother how to administer eye drops, where should the nurse tell her to place them? -
ANSWER:In the conjunctival sac when the lower eyelid is pulled down
What is the best method to verify the placement of a nasogastric tube before each use? -
ANSWER:Aspiration of stomach contents
Parents are being taught how to feed their infant using a newly placed gastrostomy tube (G-tube). What
is essential information for the parents to receive? - ANSWER:Position the infant on the right side during
and after the feeding.
What is a priority intervention for an infant with a temporary colostomy for Hirschsprung disease? -
ANSWER:Protecting the skin around the colostomy
A 1-month-old infant is admitted to the hospital. The infants mother is 17 years old and single and lives
with her parents. Who signs the informed consent for the 1-month-old infant? - ANSWER:The infants
mother
A preschool child needs a dressing change. To prepare the child, what strategy should the nurse
implement? - ANSWER:Give choices when possible but avoid delay.
The nurse on a pediatric unit is writing guidelines for age-specific preparation of children for procedures
based on developmental characteristics. What guideline is accurate? - ANSWER:Use simple diagrams of
anatomy and physiology to explain a procedure to a school-age child.
A laboratory technician is performing a blood draw on a toddler. The toddler is holding still but crying
loudly. The nurse should take which action? - ANSWER:Do nothing. Its Okay for a child to cry during a
painful procedure.
At which age should a nurse keep teaching time short (5 minutes)? - ANSWER:Toddler
The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever. What nursing action is
appropriate? - ANSWER:Check to be sure the Tylenol dose does not exceed 15 mg/kg.
The nurse is administering an IM injection into a vastus lateralis muscle of a 6-month-old infant. What
should the length of the needle and amount to be given be? - ANSWER:5/8 to 1 inch; 0.5 to 1.0 ml
The nurse needs to start an intravenous (IV) line on an 8-year-old child to begin administering
intravenous antibiotics. The child starts to cry and tells the nurse, Do it later, okay? What action should
the nurse take? - ANSWER:Start the IV line and then allow for expression of feelings.
The nurse is preparing to administer a liquid medication by a nasogastric feeding tube. What is the first
thing the nurse should do? - ANSWER:Check the pH of the gastric aspirate.
To facilitate the administration of an oral medication to a preschool-age child, what action should the
nurse take? - ANSWER:Set limits about the need to take medication and offer praise immediately after
the task is accomplished.
, A 2-year-old child has to receive Rocephin IM injections every 12 hours. What nursing intervention
should be implemented for the child? - ANSWER:Hold the child while rocking in a chair after each
injection.
When checking the intravenous (IV) site on a child, the nurse should take which action? - ANSWER:Look
at the site while palpating the area.
The nurse is caring for a 12-year-old child who is on fall precautions secondary to seizures. What
interventions should be included in the childs care plan? - ANSWER:-Place a call light and desired items
within reach.
-Have the child wear an appropriate-size gown and nonskid footwear.
. What methods should the nurse use to measure compliance to a treatment plan? - ANSWER:Pill counts
Chemical assays
Direct observation
Monitoring therapeutic response
What interventions should the nurse implement to prevent a pressure ulcer in a critically ill child? -
ANSWER:Nutrition consult
Using skin moisturizers
Turning the child every 2 hours
Using draw sheets to minimize shear
The nurse is preparing to obtain a nasal washing from a child. What equipment should the nurse gather
for the procedure? - ANSWER:Syringe with tubing
Sterile normal saline
The clinic nurse is teaching parents about when to call the office immediately for a child with a fever.
What should the nurse include in the teaching session? - ANSWER:The child has a stiff neck.
The fever is over 40.6 C (105 F).
The child is younger than 2 months.
What strategies should the nurse implement to assist in feeding a sick child? - ANSWER:Make mealtimes
pleasant.
Avoid foods that are highly seasoned.
Provide finger foods for young children.
Ensure a variety of foods, textures, and colors.
What disease processes require contact isolation? - ANSWER:Rotavirus
Hepatitis A
