PN VATI Nursing Care of Children 2020 - Answered with Rationales A nurse is preparing to perform a heel stick on an infant. Which of the following
... [Show More] actions should the nurse take? A. Use an automated lancet device to puncture the heel. B. Apply limb restraints to the infant C. Puncture the heel at the inner aspect of the heel D. Cleanse the area with povidone iodine. Rationale: The nurse should use an automated lancet device to puncture the heel to obtain a more precise puncture depth and to cause less pain. A nurse is making a home visit to a 5-year-old child who has cerebral palsy and uses the wheelchair. Which of the following observations made by the nurse indicates that the family needs support and resources to cope with the child's condition? A. A grandparent is assisting the child in performing ADLs. B. The child is playing a game with their siblings. C. The parent is withdrawn and rarely interacts with the child. D. The step-parent is helping the child prepare to transition into school. Rationale: The parent is exhibiting avoidance behavior in response to the child's condition. This is an unexpected finding that requires intervention by the nurse. A nurse is reviewing the medical record of a school-age child who is current on recommended immunizations. Which of the following immunizations should the nurse plan to administer at the 11-year-old well-child visit? A. Tetanus, diphtheria, acellular pertussis (Tdap) B. Haemophilus influenzae type b (Hib) C. Inactivated poliovirus (IPV) D. Rotavirus (RV) Rationale: The nurse should plan to administer the Tdap booster. The booster is administered to a school-aged child between 11 and 12 years of age when the child has previously received recommended immunizations. A nurse in a clinic is caring for group of infants. Which of the following findings should the nurse report as a possible indication of physical maltreatment? A. A hemangioma on the infant's torso B. A burn with splash marks on the lower right leg C. A large, irregular, brownish-blue area on the infant's buttocks D. An abrasion on the back of the infant's arm Rationale: The nurse should identify that an abrasion on the back of an infant's arm is a possible finding of maltreatment and should be reported to the provider. A nurse is preparing to percuss an adolescent's chest and abdomen. Which of the following areas should the nurse expect to hear a dull sound? (Select only the Hot Spot that corresponds to your answer.) B is correct! =) When percussing over dense tissue, such as the liver, the nurse should hear dullness, which is a thud-like sound. A is incorrect because- The nurse will hear resonance, which is a hollow sound when percussing over tissue filled with air, such as the lungs. C. is incorrect because- The nurse will hear tympany, which is a loud, musical sound when percussing over an air-filled organ, such as the stomach. A nurse is collecting data from an 8-month-old infant. Which of the following findings indicates expected growth and development? A. Inability to hold a bottle B. Uses palmar grasp C. Sits unsupported D. Forces tongue outward when it is touched Rationale: The nurse should identify that by 8 months of age, the infant is expected to sit unsupported on the floor for up to 10 min. A nurse is caring for an infant who has a cleft palate and is having trouble bottle feeding. Which of the following actions should the nurse take? A. Select a bottle with a one-way valve B. Choose a bottle with a narrow nipple C. Burp the infant every 90 mL (3 oz.) D. Use the football hold when feeding the child Rationale: The nurse should use a bottle with a one-way valve to prevent reflux of liquid back into the infant's mouth. A nurse is reinforcing teaching with the parent of a child who is newly diagnosed with diabetes mellitus. Which of the following guidelines should the nurse include? A. "Your child should increase carbohydrate intake when sick." B. "You should omit your child's bedtime snack." C. "Your child's meal plan should consist mainly of proteins." D. "Your child's meal plan should include a snack before physical activity." Rationale: The nurse should instruct the parent that a child who has diabetes should consume a snack before an increase in physical activity to prevent hypoglycemia. A nurse is preparing to obtain a blood pressure reading from a school-age child. Which of the following actions should the nurse take? A. Record the diastolic value as the first Korotkoff sound (K1). B. Release the cuff pressure at a rate of about 5 min Hg/second. C. Position the child's arm at the level of the heart. D. Select a cuff with a bladder size that is approximately 20% of the child's upper arm circumference. Rationale: The nurse should position the child's arm at the level of the heart because this will help ensure an accurate blood pressure reading. Lowering the arm below heart level will cause a false high reading. Elevating the arm above heart level will cause a false low reading. A nurse is assisting with the care of a hospitalized toddler who has congenital heart disease. The parent calls the nurse to the room to ask for fresh linens and states. "My child never wets the bed at home. I am not sure why this is happening now." Which of the following responses should the nurse make to the parent? A. "I know this must be embarrassing for you. I have kids myself, and I would be concerned too." B. "Regression is a common reaction to stress when toddlers are hospitalized. This is temporary." C. "Your child appears to be just fine. If they aren't worried about it, then you shouldn't be either." D. "I will talk to the provider about this. It could indicate worsening of your child's condition." Rationale: Stressful situations, such as hospitalization or illness, can result in regressive behaviors, such as bed-wetting in a toddler who has been previously toilet trained. The nurse should provide reassurance to the parent of the child that the child will regain control of their bladder once they are feeling better and the stress of hospitalization is decreased. A nurse is reviewing the medical records of several children in an outpatient clinic. The nurse should identify that which of the following infections is included on the list of nationally notifiable conditions? A. Scarlet fever B. Rotavirus C. Erythema infectiosum (fifth disease) D. Pertussis [Show Less]