A nurse is collecting data from a 9-month-old infant. Which of the following findings would require further intervention?
a. Positive Babinski reflex
R
... [Show More] The Babinski reflex disappears after 1 year of age. Therefore, a 9-month-old infant with a positive Babinski reflex is a
finding that does not require further intervention.
b. Positive Moro reflex
R The Moro reflex disappears approximately at 3-4 months of age. Therefore, a 9- month-old infant with a positive Moro
reflex is a finding that requires further intervention
c. Negative Doll’s eye reflex
R A negative Doll’s eye reflex is a normal finding. Therefore, a 9-month-old infant with a negative Doll’s eye reflex is a
finding that does not require further intervention.
d. Negative Crawl reflex
R A negative Crawl reflex disappears after 6 months of age. Therefore, a 9-month-old infant with a negative Crawl reflex
is a finding that does not require further intervention.
2. A nurse working in a pediatric clinic is collecting data on a preschool-age child who has a rash on his arm. The mother reports that the
child was recently exposed to impetigo contagiosa. Which of the following manifestations should the nurse expect to find with this skin
infection?
a. Scaling patches that are clear in the center.
R This finding is associated with tinia corporis (ringworm), not impetigo.
b. Honey-colored crusts caused by dried exudate.
R This finding is associated with impetigo contagiosa. Honey-colored crusts develop when vesicles rupture and the
exudate dries.
c. Firm papules with a roughened, finely papillomatous texture.
R This finding is associated with verruca (warts), not impetigo.
d. Lines of small blisters surrounding one large blister.
R This finding is associated with poison ivy, not impetigo.
3. A nurse is collecting data from an 11-month-old infant. Which of the following clinical manifestations is suggestive of a central nervous
system infection?
a. Oliguria
R Oliguria is a clinical manifestation of shock or kidney disease. However, it is not a clinical manifestation of a central
nervous system infection.
b. Bulging fontanel
R A central nervous system infection causes increased intracranial pressure. Therefore, bulging fontanels are a clinical
manifestation of a central nervous system infection.
c. Negative Brudzinski sign
R A positive Brudzinski sign is a clinical manifestation of a central nervous system infection.
d. Jaundice
R Jaundice is a clinical manifestation of liver disease. However, not a clinical manifestation of a central nervous system
infection.
4. A nurse is reinforcing teaching to an adolescent client regarding administration of Gardasil vaccine. For which of the following sexually
transmitted infections does the vaccine provide immunity?
a. Human papillomavirus (HPV)
R Gardasil is the only HPV vaccine that helps provide immunity against 4 types of HPV. These include type 6, 11, 16, and
18. The immunization schedule for Gardasil is 3 injections over a 6 month period. Clients should receive this vaccine
between the ages of 9 and 26.
b. Herpes simplex virus (HSV-2)
R Gardasil does not provide immunity against HSV-2.
c. Chlamydia trachomatis
R Gardasil does not provide immunity against chlamydia trachomatis.
d. Gonorrhea
R Gardasil does not provide immunity against gonorrhea.
5. A nurse is caring for a 4-year-old child who had hydrocephalus as an infant and is admitted with a malfunctioning ventriculoperitoneal
shunt. Following new shunt placement, the nurse conducts a postoperative check. Which of the following findings requires immediate
action by the nurse?
a. Sleepy and very difficult to arouse
R The child may be sleepy following surgery but should be easily aroused. Lethargy could indicate a decreased level of
consciousness or increasing intracranial pressure and should be reported immediately.
b. Lying flat on the unaffected side
R The child should be positioned on the unaffected side to avoid pressure on the shunt valve. Lying flat is often
prescribed after initial shunt placement, not necessarily after elective replacement. If the child has signs of increasing
intracranial pressure, the provider might prescribe upright positioning.
c. BP 100/60, apical pulse rate of 90
R These vital signs are within the expected range for a 4-year-old child.
d. Urine output 50 mL in 2 hr
R A urine output of 50 mL in 2 hr indicates adequate renal function for a 4-year-old child.
6. A nurse is caring for a toddler scheduled to have a lumbar puncture (LP) to rule out meningitis. The nurse who is planning to assist with
the procedure should
a. have another nurse to help hold the toddler.
R One nurse should be able to assist with the procedure.
b. sit the toddler on the side of bed.
R This is not an appropriate position for a toddler who is being prepared for a lumbar puncture.
c. place the toddler in a side-lying, knee-chest position.
R A lumbar puncture (LP) is a procedure in which a small amount of the fluid that surrounds the brain and spinal cord
called the cerebrospinal fluid, or CSF, is removed and examined. The client is positioned on the side in a fetal position
(knees curled to abdomen and chin tucked to chest).
d. use a mummy restraint.
R Mummy restraints may be used when performing a procedure such as suturing a facial laceration, but it would place
the child in an inappropriate position when performing an lumbar puncture.
7. A nurse is caring for a child who just underwent insertion of a ventriculoperitoneal shunt. Which of the following positions would be
appropriate for the client?
a. On the operative side
R On the operative side is not an appropriate position for this client.
b. A 45-degree head elevation
R A 45-degree elevation of the head of bed is not [Show Less]