A mother brings her 8 mo. old baby boy to clinic bc he has been vomitting and had
diarrhea for last 3 days. Which assessment is most important for nurse
... [Show More] to make?
a. Assess infant abdomen for tenderness
b. Determine if the infant was exposed to a virus
c. Measure the infant’s pulse
d. Evaluate the infant’s cry
2. While obtaining the vital signs of a 10 year old who had a tonsillectomy this morning,
the nurse observes the child swallowing every 2-3 minutes. Which assessment should
the nurse implement?
a. Inspect the posterior oropharynx
b. Assess for teeth clenching or grinding
c. Touch the tonsillar pillars to stimulate the gag reflex
d. Ask the child to speak to evaluate change in voice tone
3. The parents of a 3-year old boy who has Duchenne muscular dystrophy ask, “How can
our son have this disease? We are wondering if we should have any more children.”
What information should the nurse provide to parents?
a. This is an inherited X-linked recessive disorder, which
primarily affects male children in the family
b. The striated muscle groups of males can be impacted by a lack of the
protein dystrophin in their mothers
c. The male infant had a viral infection that went unnoticed and untreated so
muscle damage was incurred
d. Birth trauma with a breech vaginal birth causes damage to the spinal cord,
thus weakening the muscles
4. A 2-week-old female infant is hospitalized for the surgical repair of an umbilical hernia.
After returning to the postoperative neonatal unit, her RR and HR have increased
during the last hour. Which intervention should the nurse implement?
a. Notify the HCP of these findings
b. Administer a PRN analgesic prescription
c. Record the findings in the child’s record
d. Wrap the infant tightly and rock in rocking chair
5. A 2-year-old girl is brought to the clinic by her 17 year old mother. When the nurse
observes that the child is drinking sweetened soda from her bottle, what
information should the nurse discuss with this mother?
a. A 2-year old should be speaking in 2 word phrases
b. Dental caries are associated with drinking soda
c. Drinking soda is related to childhood obesity
d. Toddlers should be sleeping 10 hours a night
e. Toddlers should be drinking from a cup by age 2
6. A mother brings her 3 month old infant to the clinic because the baby does
not sleep through the night. Which finding is most significant in planning
care for this family?
a. The mother is a single parent and lives with her parents
b. The mother states the baby is irritable during feedings
c. The infant’s formula has been changed twice
d. The diaper area shows severe skin
breakdown
7. The nurse determines that an infant admitted for surgical repair of an inguinal
hernia voids a urinary stream from the ventral surface of the penis. What action
should the nurse take?
a. Document the finding
b. Palpate scrotum for testicular descent
c. Assess for bladder distension
d. Auscultate bowel sounds
8. A 16 year old with acute myelocytic leukemia is receiving chemotherapy
(CT) via an implanted medication port at the out-patient oncology clinic.
What action should the nurse implement when the infusion is complete?
a. Administer Zofran
b. Obtain blood samples for RBCs, WBCs, and platelets
c. Flush mediport w/ saline and heparin solution
d. Initiate an infusion of normal saline
9. A mother brings her 3-week old infant to the clinic because the baby vomits
after eating and always seems hungry. Further assessment indicates that the
infant’s vomiting is projectile, and the child seems listless. Which additional
assessment finding indicates the possibility of a life threatening complication?
a. Irregular palpable pulse
b. Hyperactive bowel sounds
c. Underweight for age
d. Crying without tears
10. The nurse is performing a routine assessment of a 3-year old at a community
health center. Which behavior by the child should alert the nurse to request a
follow-up for a possible autistic spectrum disorder?
a. Performs odd repetitive behaviors
b. Shows indifference to verbal stimulation
c. Strokes the hair of a hand held doll
d. Has a history of temper tantrums
1) A child with iron deficiency anemia is ordered ferrous sulfate (Ferralyn), an oral
iron supplement. When teaching the child and parent how to administer this
preparation, the mother asks why she needs to mix the supplement with citrus juice.
Which response by the nurse is best?
a. "The vitamin C in the citrus juice helps with iron absorption."
b. "Having food and juice in the stomach helps with iron absorption."
c. "The citrus juice counteracts the unpleasant taste of the ir [Show Less]