Solutions
A 28-year-old multipara delivered a 9-pound, 3-ounce baby girl
an hour ago after a 22-hour labor with a forceps-assisted birth.
As the patient is holding her daughter, she keeps shifting
position and is becoming increasingly irritable and annoyed with
everyone in the room. What action should the nurse initially
take? Correct Answers Check her perineum
A 3-year-old toddler is being discharged post-tonsillectomy, and
the parents ask what he or she should be allowed to eat and
drink. Teaching by the nurse has been effective if the parents
choose which foods and fluids for the first few days at home?
Correct Answers Scrambled eggs, banana popsicles, mashed
potatoes, sweetened ice tea, and apple juice
A 3.5-year-old boy talks to himself and sometimes talks to the
toys. The child has telegraphic speech. What should the nurse
tell the parent of the boy? Correct Answers "Read stories to
your child as it programs words into the memory bank.
A 4-year-old boy needs to use a metered-dose inhaler to treat
asthma. He cannot coordinate the breathing to use it effectively.
What should the nurse suggest that he use? Correct Answers A
spacer
A 4-year-old child is seen in a clinic for a hearing impairment.
What action does the nurse observe in the child to confirm
hearing impairment? Select all that apply Correct Answers The
child points at his tummy to indicate hunger.
,The child screeches happily when looking at a toy
The child does not respond when an alarm sounds
A 5-month pregnant female reports to
the nurse that she feels dizzy after
waking up in the morning. What
advice does the nurse give to the
patient? Correct Answers "Try sleeping in the side-lying
(lateral)
position."
A 5-year-old child is brought to the Emergency Department with
abrupt onset of sore throat, pain with swallowing, fever, and
sitting upright and forward. Acute epiglottitis is suspected. What
are the most appropriate nursing interventions? Select all that
apply Correct Answers Vital signs
Medical history
Assessment of breath sounds
Emergency airway equipment readily available
A 5-year-old child presents with a fever, cough, and flu-like
symptoms. On examination, the nurse finds that the child's
temperature is elevated and respiratory rate is increased. The
nurse also notices wheezing on auscultation, a fracture in right
forearm, and bruises near the elbows and knees. What should be
the most appropriate response of the nurse? Select all that apply
Correct Answers Report to the child welfare department as it
can be a case of child abuse
,Confer with the health care provider and admit the child into the
hospital immediately
A 5-year-old child presents with common cold and infrequent
coughing. The child's mother tells the nurse, "I'm using cough
suppressants because they bring my child so much comfort."
What is an appropriate response by the nurse? Correct Answers
"It is better to avoid cough suppressants."
A 5-year-old male child has bilateral eye patches that were put
in place after surgery yesterday morning. Today he can be
allowed to get out of bed. What is the most important nursing
intervention? Correct Answers Orient him to his immediate
surroundings
A 7-month-old with hearing impairment is diagnosed with
chronic otitis media. What treatment should the nurse
recommend for this child? Correct Answers Insertion of
tympanostomy tubes
A blunt abdominal trauma causes fetal hemorrhage in a pregnant
patient. The nurse finds that the patient is Rh negative. What
action does the nurse take? Correct Answers Administer
prescribed Rho(D) immunoglobulin.
A child has been admitted to the emergency department after
falling off a horse. The first responders stabilized the child using
a rigid cervical collar with supportive blocks on a rigid
backboard. What is the most appropriate explanation for the
nursing team to give regarding why the child was stabilized in
, this manner? Correct Answers "It immobilizes the entire
spine."
A child has been admitted with symptoms of hypersecretion of
gastric acid, intractable ulcer disease, and intestinal
malabsorption. What can the nurse infer that the child has from
these symptoms? Correct Answers Zollinger-Ellison syndrome
A child in eighth grade is unable to participate in the classroom
discussion because of difficulty hearing the teacher's lecture.
What would be the best nursing intervention for this child?
Correct Answers The child should be referred for further
evaluation
A child in the hospital complains about difficulty raising the
arms over the head, lack of facial mobility, and a forward slope
of the shoulders. The primary health care provider identifies
facioscapulohumeral condition in the child. Which response
from the nurse is most appropriate in explaining the condition to
the child's parents? Correct Answers "It is an autosomal
dominant disorder, with slow progression and unaffected life
span."
A child in the school frequently puts foreign objects in their
mouth. What should be the most appropriate action by the
nurse? Correct Answers Educate parents alone or in groups
about hazards of aspiration
A child is admitted to the emergency department (ED) with
profuse diarrhea, nausea, and vomiting. During assessment, the
nurse observes the patient also has hypothermia. The parents