Uworld Pediatric Nursing A A A TEST BANK LATEST 2020/2021
PEDDIATRIA
A A A
The nurse planning teaching for the parents of a child newly diagnosed with
... [Show More] hemophilia
will include information about which long-term complication?
1. Heart valve injury [33%]
2. Intellectual disability [3%]
3. Joint destruction [54%]
4. Recurrent pneumonia [8%]
Explanation: Hemophilia is a bleeding disorder caused by a deficiency in coagulation
proteins. Clients with classic hemophilia, or hemophilia A, lack factor VIII. Clients with
hemophilia B (Christmas disease) lack factor IX. When injured, clients with hemophilia
should be monitored closely for external as well as internal bleeding. The most frequent
sites of bleeding are the joints (80%), especially the knee. Hemarthrosis can occur with
minimal or no trauma, with episodes beginning during toddlerhood when the child is active
and ambulatory. Over time, chronic swelling and deformity can occur.
(Option 1) Heart valve injury is common with rheumatic heart disease not hemophilia.
(Option 2) Intellectual disability in children is commonly seen with fetal alcohol syndrome,
Down syndrome, hypothyroidism, and lead poisoning. In rare cases, hemophilia can cause
life-threatening intracranial bleeding. However, isolated intellectual disability is not seen.
(Option 4) Recurrent pneumonia is commonly seen with cystic fibrosis not hemophilia.
Educational objective:
Clients with hemophilia are at risk for permanent joint destruction due to frequent bleeds
into the joint spaces. Assisting clients with decreasing the incidence of bleeding episodes
and prompt treatment when bleeding occurs can help minimize joint destruction.
A A A
The clinic nurse supervises a graduate nurse who is teaching the parents of a 2-year-old
with acute diarrhea about home management. The nurse would need to intervene when
the graduate nurse provides which instruction?
1. "Do not administer antidiarrheal medications to your child." [26%]
2. "Follow the bananas, rice, applesauce, and toast diet for the next few days." [32%]
3. "Record the number of wet diapers and return to the clinic if you notice a decrease."
[28%]
4. "Use a skin barrier cream such as zinc oxide in the diaper area until diarrhea
subsides." [12%]
Explanation: During bouts of acute diarrhea and dehydration, treatment focuses on
maintaining adequate fluid and electrolyte balance. The first-line treatment is oral
rehydration therapy, using oral rehydration solutions (ORSs) to increase reabsorption of
water and sodium. Even if the diarrhea is accompanied by vomiting, ORS should still be
offered in small amounts at frequent intervals. Continuing the child's normal diet (solid
foods) is encouraged as it shortens the duration and severity of the diarrhea. The BRAT
(bananas, rice, applesauce, and toast) diet is not recommended as it does not provide
sufficient protein or energy.
(Option 1) Use of antidiarrheal medications is discouraged as these have little effect in
controlling diarrhea and may actually be harmful by prolonging some bacterial infections
and causing fatal paralytic ileus in children.
(Option 3) Parents should be taught to monitor their child for signs of dehydration by
checking the amount of fluid intake, number of wet diapers, presence of sunken eyes, and
the condition of the mucous membranes.
(Option 4) Protecting the perineal skin from breakdown during bouts of diarrhea can be
accomplished by using skin barrier creams (eg, petrolatum or zinc oxide).
Educational objective:
When a child is experiencing acute diarrhea, the priority is to monitor for dehydration.
Treatment is accomplished with oral rehydration solutions and early reintroduction of the
child's normal diet (usual foods).
A A A
The mother of a 6-year-old child with cystic fibrosis (CF) has received instruction on the
use of pancreatic enzymes. Which statement made by the mother indicates a need for
further teaching?
1. "I need to monitor the total amount of this medication that I give to my child every
day." [6%]
2. "I should give this medication with or just before my child has a meal or snack."
[10%]
3. "It is okay for my child to chew this medication." [61%]
4. "It is okay to open the capsule and sprinkle the medicine on a tablespoon of
applesauce." [21%]
Explanation: In CF, unusually thick mucus obstructs the pancreatic ducts, preventing
pancreatic enzymes (amylase, trypsin, and lipase) from reaching the small intestine. The
result is malabsorption of carbohydrates, fats, and proteins; the inability to absorb fatsoluble vitamins (A, D, E, and K) is of particular concern. Gastrointestinal signs and
symptoms of CF include flatulence, abdominal cramping, ongoing diarrhea, and/or
steatorrhea.
Nutritional therapy includes the administration pancreatic enzyme supplements with or
just before every meal or snack (Option 2). These enzymes are enteric-coated beads
designed to dissolve only in an alkaline environment similar to that of the small intestine.
They must not be mixed with a substance that would cause them to dissolve prior to
reaching the jejunum. Capsule contents may be sprinkled on applesauce, yogurt, or acidic,
soft, room-temperature foods with pH <4.5. Capsules should be swallowed whole and not
crushed or chewed; chewing the capsules could cause irritation of the oral mucosa.
Excessive intake of pancreatic enzymes can result in fibrosing colonopathy (Option 1).
(Option 4) This is a true statement; some children have difficulty taking a whole capsule.
Capsule contents can be sprinkled in acidic substances such as applesauce. Capsules
should not be taken with milk as they can cause it to curdle.
Educational objective:
Pancreatic enzyme supplements are used to aid the absorption of carbohydrates, fats, and
proteins in a child with CF. They are taken with or just before every meal (not as needed);
should be swallowed whole or sprinkled on an acidic food; and should not be crushed or
chewed. They should not be taken with milk. Excessive intake could result in fibrosing
colonopathy.
A A A
An 8-month-old infant is scheduled for a balloon angioplasty of a congenital pulmonic
stenosis in the cardiac catheterization laboratory. Which finding should the nurse report to
the health care provider (HCP) that could possibly delay the procedure?
1. Auscultation of a loud heart murmur [8%]
2. Infant has been NPO for 4 hours [9%]
3. Infant has polycythemia [52%]
4. Infant has severe diaper rash [29%]
Explanation: The presence of severe diaper rash should be reported to the HCP. This could
potentially delay the procedure if the rash is in the groin area where access is planned for
arterial cannulation. Candida, yeast, or bacteria may be present on the rash and could be
introduced into the bloodstream with the arterial stick.
(Option 1) A loud heart murmur can be an expected finding in a child with pulmonic
stenosis.
(Option 2) Children are allowed nothing by mouth for 4-6 hours or longer before the
procedure. Younger children and infants may have a shorter period of NPO status and
should be feed right up to the time recommended by the HCP.
(Option 3) Infants and children with polycythemia may need IV fluids to prevent
dehydration and hypoglycemia. Polycythemia will not cause a delay in the procedure.
Educational objective:
The nurse should report the presence of severe diaper rash to the HCP in an infant who has
an interventional catheterization procedure planned. If the rash is near the groin area, the
procedure may be delayed due to possible contamination at the insertion site.
A A A
When monitoring an infant with a left-to-right-sided heart shunt, which findings would the
nurse expect during the physical assessment? Select all that apply.
1. Clubbing of fingertips
2. Cyanosis when crying
3. Diaphoresis during feedings
4. Heart murmur
5. Poor weight gain
Explanation: Congenital heart defects that cause blood to shunt from the higher pressure
left side of the heart to the lower pressure right side (eg, patent ductus arteriosus, atrial
septal defect, ventricular septal defect) increase pulmonary blood flow.
Left-to-right shunting results in pulmonary congestion, causing increased work of
breathing and decreased lung compliance. Compensatory mechanisms (eg, tachycardia,
diaphoresis) result from sympathetic stimulation. Clinical manifestations of acyanotic
defects may include:
Tachypnea
Tachycardia, even at rest
Diaphoresis during feeding or exertion (Option 3)
Heart murmur or extra heart sounds (Option 4)
Signs of congestive heart failure
Increased metabolic rate with poor weight gain (Option 5)
(Option 1) Clubbing of the fingertips is associated with chronic hypoxia caused by
decreased pulmonary circulation as occurs with right-to-left heart defects.
(Option 2) Right-to-left congenital heart defects (eg, cyanotic defects) impede pulmonary
blood flow (eg, tetralogy of Fallot, transposition of the great vessels) and cause cyanosis,
which is evident shortly after birth and during periods of physical exertion.
Educational objective:
Left-to-right cardiac shunts (eg, patent ductus arteriosus, atrial septal defect, ventricular
septal defect) result in excess blood flow to the lungs. Manifestations include heart
murmur, poor weight gain, diaphoresis with exertion, and signs of heart failure.
A A A
A 12-month-old with Kawasaki disease received IV immunoglobulin (IVIG) 2 months ago.
The child is in the clinic for follow-up and scheduled immunizations. Which vaccine should
be delayed? Select all that apply.
1. Haemophilus influenzae type b (Hib)
2. Hepatitis B (Hep B)
3. Measles, mumps, rubella (MMR)
4. Pneumococcal conjugate (PCV)
5. Varicella
Explanation: Kawasaki disease is treated with aspirin and IVIG to prevent coronary artery
aneurysms. Antibodies acquired from the IVIG therapy will remain in the body for up to 11
months and may interfere with the desired immune response to live vaccines. Therefore,
live vaccines (eg, varicella, MMR) should be delayed for 11 months after IVIG
administration as this therapy may decrease the child's ability to produce the appropriate
amount of antibodies to provide lifelong immunity (Options 3 and 5).
(Option 1) Hib vaccine is not a live vaccine, and final dose (fourth) is recommended
between age 12-15 months, according to the Centers for Disease Control and Prevention
(CDC).
(Option 2) Hep B vaccine is not a live vaccine; the CDC recommends that the final dose
(third) be administered between age 6-18 months.
(Option 4) PCV is also not a live vaccine, and the final dose (fourth) is recommended
between age 12-15 months, according to the CDC.
Educational objective:
Live vaccines (eg, varicella, MMR) should be delayed for up to 11 months after IVIG
administration as IVIG therapy may decrease the child's ability to produce the appropriate
amount of antibodies to provide lifelong immunity
A A A
Several clients check into the emergency department at the same time. Which client should
be seen first?
1. 6-year-old with blood-streaked stools [19%]
2. 10-year-old with epilepsy who had a short seizure at home and is asleep [26%]
3. 15-year-old with dental trauma and tooth avulsion [25%]
4. Newborn who spits up after every feed [28%]
Explanation: At age 15, clients should have their permanent teeth. If tooth avulsion occurs,
there is limited time (≤1 hour, longer if placed in cold milk) until death of the tooth. This is
a time-sensitive condition and the client should be seen first to avoid loss of a permanent
tooth.
(Option 1) This client needs to be assessed for the cause of blood in the stool. However,
this is not considered a medical emergency as long as only streaks and not large volumes of
blood are present. Large volumes can represent a gastrointestinal bleed, which is an
emergency.
(Option 2) A client who is not currently seizing is considered stable. It is normal for a child
to be sleepy following a seizure. The child should be assessed to ensure that air exchange is
appropriate.
(Option 4) It is normal for newborns to spit up after every feed as they are still adapting to
eating. The client should be assessed for hydration status and appropriate weight gain.
Educational objective:
In tooth avulsion, there is a limited amount of time (≤1 hour) before death of the affected
tooth. These clients need prompt treatment to save a permanent tooth.
A A A
The nurse in the emergency department is assessing a 12-month-old diagnosed with
intussusception. Which findings should the nurse expect? Select all that apply.
1. Palpable olive-shaped mass in epigastrium
2. Palpable sausage-shaped mass in upper right quadrant
3. Projectile vomiting containing blood
4. Screaming and drawing the knees up to the chest
5. Stool mixed with blood and mucus
Explanation: Intussusception is a common obstructive disorder in infancy that occurs when
one segment of the bowel telescopes into another. The classic clinical triad is intermittent,
severe, crampy abdominal pain; a palpable "sausage-shaped" mass on the right side of the
abdomen; and "currant jelly" stools. Other manifestations include inconsolable crying,
drawing the knees up to the chest during episodes of pain, and vomiting. The child may
appear normal and comfortable between episodes.
(Option 1) Infants with infantile hypertrophic pyloric stenosis often present with excessive
hunger (frequent feeder), a palpable olive-shaped mass in the epigastrium to the right of
the umbilicus, and projectile vomiting (can be up to 3 feet).
(Option 3) Projectile vomiting (without blood) is seen with pyloric stenosis and elevated
intracranial pressure. Bloody vomiting is seen with gastric ulcers and variceal bleed.
Intussusception causes non-projectile vomiting that is usually non-bloody, but stools mixed
with mucus and blood are seen.
Educational objective:
The classic clinical triad of intussusception is intermittent, severe, crampy abdominal pain;
a palpable sausage-shaped mass on the right side of the abdomen; and currant jelly stools.
A A A
The nurse is caring for a pediatric client with end-stage leukemia who is on comfort care
and is unresponsive. The child's parent asks, "How can you tell if my child is in pain?"
Which of these would the nurse describe as signs of discomfort? Select all that apply.
1. Blank facial expression
2. Facial grimacing
3. Groaning
4. Knees bent up near chest
5. Lying still
Explanation: FLACC scale (face, legs, activity, cry, consolability)
The nurse will provide teaching on signs that should prompt the parent to administer asneeded pain medication to the child.
(Option 1) A child who is comfortable will usually have a neutral facial expression. A child
in pain is likely to exhibit grimacing, frowning, or clenching of the jaw, based on the FLACC
face assessment.
(Option 5) A child who is comfortable will be lying quietly. A child who is squirming and
moving is more likely to be in pain, based on the FLACC activity assessment.
Educational objective:
It is difficult to assess for pain in the nonverbal client, particularly if the person is
unresponsive at the end of life. The FLACC scale is an accurate method of assessing pain in
the nonverbal child. This tool should be used to teach parents how to promote comfort for
their nonverbal child
A A A
A 2-month-old infant is brought to the pediatric emergency department due to vomiting
and diarrhea for 4 days. Assessment findings include lethargy, poor feeding, sunken
fontanel, temperature 100.4 F (38 C), heart rate 134/min, and respiratory rate 28/min.
Which prescription from the health care provider would be the priority?
1. Acetaminophen elixir 50 mg by mouth every 6 hours [1%]
2. Intravenous (IV) ampicillin 240 mg every 12 hours [2%]
3. IV normal saline bolus 20 mL/kg over 1 hour [92%]
4. Obtain a stool culture [4%]
Explanation: Infants and young children have a higher body water percentage than older
children and adults. As a result, they become dehydrated quickly with fluid losses caused
by vomiting and diarrhea. Signs of severe dehydration include lethargy, sunken fontanel,
poor feeding, increased heart rate, and increased respiratory rate.
When an infant's basic vital signs are intact and there is severe dehydration, the priority is
to rehydrate. Normal saline is the fluid of choice for a bolus in an infant. Electrolytes may
be added to the maintenance IV fluids if needed.
(Option 1) A temperature of 100.4 F (38 C) is a mild fever in an infant and may indicate the
need for acetaminophen. However, hydration of the infant takes priority over this action.
(Option 2) Antibiotics may be indicated due to the infant's increased temperature. The
fluid bolus is of higher priority due to the severe dehydration.
(Option 4) The history of vomiting and diarrhea for 4 days would indicate a stool culture to
determine a causative agent. This may be obtained after administration of the fluid bolus
Educational objective:
Severe dehydration occurs more rapidly in infants and young children than in adults due to
increased body water percentage. When severe dehydration occurs in an infant, the
priority is to rehydrate as appropriate.
A A A
A nurse is leading a discussion with a group of new parents. A parent asks about the first
food to introduce to a 5-month-old infant. What is the best response by the nurse?
1. "Finely mashed fruit, such as bananas, is given." [8%]
2. "Iron-fortified cereal, such as rice cereal, is offered." [82%]
3. "Mashed egg yolk is a good choice." [0%]
4. "Pureed carrots are well tolerated." [8%]
Explanation Before age 6 months, an infant should receive only breast milk or formula. The
infant is ready physiologically and developmentally for the addition of solid foods to the
diet at age 4-6 months as iron stores have declined. Iron-fortified cereals (rice, barley,
oatmeal, high protein) should be offered. Rice cereal is preferred due to the low risk of
allergy and ease of digestion (Option 2).
(Options 1, 3, and 4) Fruit juices and pureed fruit are typically offered next as a source of
vitamin C. Vitamin C increases iron absorption. These are followed by strained vegetables,
with yellow preferred due to the higher vitamin content. Foods are introduced one at a
time to identify any allergies. Foods known to commonly induce allergy (eg, peanuts, eggs,
seafood, whole milk) should not be introduced before age 1 year.
Educational objective:
Solid foods are introduced at age 4-6 months, with iron-fortified cereals (usually rice)
offered first due to their low allergy potential and ease of digestion. Fruit juices and pureed
fruits containing vitamin C are then offered, followed by strained vegetables. Egg yolks and
whites are introduced at age 1 year.
A A A
The health care provider (HCP) prescribes an oral iron suspension for 3 months for a 2-
year-old with iron deficiency anemia. Which instructions should be given to the parent?
Select all that apply.
1. Administer doses between meals
2. Administer doses with citrus juice
3. Obtain a full 3-month supply from the pharmacy
4. Place medicine at the back of the mouth
5. Report black, tarry stools to the HCP immediately
Explanation: Iron deficiency anemia, the most common chronic nutritional disorder, often
occurs in toddlers due to insufficient intake of dietary iron or excessive consumption of
milk. It is treated with increased consumption of iron-rich foods (eg, leafy green
vegetables, red meats, poultry, dried fruit, fortified cereal) and oral iron supplementation.
Key instructions for safe, effective administration of oral iron supplements include:
Administer between meals - Concentrations of stomach acid are higher between meals,
breaking down the iron to an easily absorbed state (Option 1)
Give with citrus juice - Absorption is enhanced when taken with a good source of vitamin C,
such as orange juice or other citrus fruit (Option 2)
Place medicine at the back of the mouth - Liquid iron can cause temporary staining of the
teeth. Using a dropper or straw to direct the iron toward the back of the mouth can reduce
this risk (Option 4).
Avoid giving with milk - Milk and other products with high amounts of calcium reduce
adequate absorption of iron supplements
Keep no more than a 1-month supply on hand - When ingested in extreme quantities, iron
can be toxic or even lethal. Only short-term amounts should be stored in the home, in a
child-proof location (Option 3).
(Option 5) Black or green tarry stools are an expected effect of oral iron supplements and
are considered an indicator of proper compliance.
Educational objective:
Oral iron supplements should be given between meals and consumed with citrus juice to
promote absorption, and administered to the back of the mouth to prevent tooth staining.
No more than a 1-month supply of supplements should be kept on hand to reduce the risk
of accidental poisoning. Oral iron should not be taken with milk.
A A A
The nurse cares for an 11-lb (5-kg) infant admitted with dehydration and prepares to
calculate intake and output over an 8-hour shift. Using the data in the exhibit, calculate the
total output in milliliters for the 8-hour shift. Record your answer as a whole number. Click
on the exhibit button for additional information. Intake and output record
Emesis 120 mL
Wet diaper 1 50 g
Wet diaper 2 52 g
Wet diaper 3 46 g
*Weight of a dry diaper = 30 g
Answer: 178 (mL)
Explanation: To measure the urinary output of an infant in diapers, subtract the weight of
the diaper when dry from its weight when wet. One (1) gram of weight is equal to one (1)
milliliter of fluid. Adequate urinary output for an infant is 2 mL/kg/hr.
Calculation:
Urine output in diapers:
Diaper 1: 50 − 30 = 20 g
Diaper 2: 52 − 30 = 22 g
Diaper 3: 46 − 30 = 16 g
Total mg of urine: 58 g = 58 mL
Total output
(Emesis) + (Urine) = 120 mL + 58 mL = 178 mL
Educational objective:
Urinary output for a child in diapers is calculated by subtracting the dry weight of the
diaper from its weight when wet. One (1) gram of weight is equal to one (1) milliliter of
fluid.
A A A
What is the best activity for a school-aged child hospitalized for vaso-occlusive sickle cell
crisis?
1. Finger painting [18%]
2. Playing a game of Chinese checkers in the activity room [16%]
3. Playing video games [12%]
4. Watching a favorite movie [52%]
Explanation: A child in vaso-occlusive sickle cell crisis will be experiencing a high level of
pain due to the occlusion of small blood vessels from increased red blood cell sickling.
Supportive and symptomatic treatment includes round-the-clock pain management with
opioids, intravenous fluids for hydration, and bed rest to decrease energy expenditure and
oxygen demand.
Age-specific nonpharmacologic strategies should also be implemented to manage pain and
help limit the amount of needed narcotic analgesia. For a school-aged child, such activities
include distraction (watching TV, listening to music, reading), relaxation, guided imagery,
warm soaks, positioning, and gentle massage.
(Option 1) Finger painting is messy and best done in the activity room; it is not appropriate
for a child confined to bed.
(Option 2) A child must be on bed rest when in vaso-occlusive sickle cell crisis. Playing a
game in the activity room does not maintain bed rest and would be too stimulating for the
child.
(Option 3) Playing video games may be too exciting and stimulating for the child; an
environment low in stimuli will promote rest.
Educational objective:
Supportive and symptomatic treatment for vaso-occlusive sickle cell crisis includes pain
management and bed rest. Nonpharmacologic measures to alleviate pain include
distraction (watching TV, listening to music, reading), relaxation, guided imagery, warm
soaks, positioning, and gentle massage.
A A A
A 2-year-old in the emergency department is suspected of having intussusception. Which
assessment finding should the nurse expect?
1. Black, sticky stools [2%]
2. Greasy, foul-smelling stools [6%]
3. Stools mixed with blood and mucus [56%]
4. Thin, "ribbon-like" stools [34%]
Explanation: Intussusception is an intestinal obstruction that occurs when a segment of the
bowel folds (ie, telescopes) into another segment. Pressure gradually increases within the
bowel, causing ischemia and leakage of blood and mucus into the lumen, which produces
the characteristic stool mixed with blood and mucus (ie, red, "currant jelly"). Initially, some
infants may have only general symptoms (eg, irritability, diarrhea, lethargy). Subsequently,
episodes of sudden abdominal pain (cramping), drawing the knees up to the chest, and
inconsolable crying are seen. After an episode, the infant may vomit and then appear
otherwise normal. Assessment may show a sausage-shaped abdominal mass.
(Option 1) Melena (dark red or black, sticky stool) is an indication of an upper
gastrointestinal (UGI) bleed. Gastritis is a common cause of UGI bleeding in infants and
toddlers.
(Option 2) Oily or bulky, foul-smelling stool is an indication of excess fat in the stool
(steatorrhea) from malabsorption. This is characteristic of pancreatic insufficiency, cystic
fibrosis, or celiac disease.
(Option 4) Thin, ribbon-like stool is characteristic of Hirschsprung disease (congenital
aganglionic megacolon). Bowel obstruction is caused by failure of the internal sphincter to
relax.
Educational objective:
The classic symptom triad of intussusception is abdominal pain, "currant jelly" stools, and a
sausage-shaped abdominal mass. However, it is more common for clients to have episodes
of sudden abdominal pain, inconsolable crying, and vomiting followed by periods of normal
behavior.
A A A
The registered nurse is performing triage at a pediatric emergency department. Which
client should be seen first?
1. Child with history of cystic fibrosis (CF) has new yellow sputum and cough today
[18%]
2. Crying infant with fiery redness and moist papules in the diaper region [6%]
3. Grade-school client with swollen ecchymotic ankle after playing basketball [2%]
4. Adolescent client with abdominal pain, heart rate 120/min, and respirations 26/min
[72%]
Explanation: The client with abdominal pain has abnormal vital signs, which is a sign of a
systemic condition. Adult criteria apply to adolescent clients in terms of physiological
signs/symptoms. A pulse of 120/min signals dehydration and this client's respirations are
above normal. This is the most serious acuity.
(Option 1) The client with a history of CF would be treated second as clients with CF have
chronic respiratory issues related to the thick mucus plugging the airways. This client will
probably need antibiotics but is stable and can wait. The severity of the situation is
considered when prioritizing client care based on airway, breathing, and circulation (ABC).
The seriousness of the adolescent client's condition related to "C" (dehydration) is a
priority over a relatively stable "B." There is nothing indicating that this client is in
respiratory distress.
(Option 2) The infant has diaper dermatitis from irritation of urine and stool on the skin. A
secondary infection with Candida albicans can occur. Diaper dermatitis is most common in
infants age 9-12 months. Ointment will be provided. Mild diaper dermatitis is treated with
a topical water-impermeable barrier (eg, zinc oxide). If the infant has an infection with
Candida albicans, an antifungal topical medication is also used. When care must be
prioritized, young children do not automatically go first. Prioritization is decided by the
client's acuity.
(Option 3) The grade-school client has a limited extremity injury and the priority principle
is always "life before limb." Therefore, the client with abdominal pain is more important.
Educational objective:
In prioritization, the severity of ABC is more important than absolute order. As a result, a
severe "C" client comes before a stable "B" client. The priority principle is to take "life
before limb" in this order. When care must be prioritized, young children do not
automatically go first.
A A A
The nurse is reviewing anticipatory guidance with the parents of a 6-month-old infant with
phenylketonuria. Which statements by the nurse are appropriate? Select all that apply.
1. "A low-phenylalanine diet is required."
2. "Meat and dairy products should not be introduced into the diet."
3. "Phenylketonuria is self-limiting and usually resolves by adulthood."
4. "Special infant formula is required."
5. "Tyrosine should be removed from the diet."
Explanation: Phenylketonuria (PKU) is one of a few genetic inborn errors of metabolism.
Individuals with PKU lack the enzyme (phenylalanine hydroxylase) required for converting
the amino acid phenylalanine into the amino acid tyrosine. As unconverted phenylalanine
accumulates, irreversible neurologic damage can occur.
A low-phenylalanine diet is essential in the treatment of PKU (Option 1). Phenylalanine
cannot be entirely eliminated from the diet as it is an essential amino acid and necessary
for normal development. The diet must meet nutritional needs while maintaining
phenylalanine levels within a safe range (2-6 mg/dL [120-360 µmol/L] for clients age <12).
There is no known age at which the diet can be discontinued safely, and lifetime dietary
restrictions are recommended for optimal health (Option 3).
Management of the client with PKU includes:
Monitoring serum levels of phenylalanine
Including synthetic proteins and special formulas (eg, Lofenalac, Phenyl-Free) in the diet
(Option 4)
Eliminating high-phenylalanine foods (eg, meats, eggs, milk) from the diet (Option 2)
Encouraging the consumption of natural foods low in phenylalanine (most fruits and
vegetables)
(Option 5) Restriction of dietary tyrosine is not necessary. Tyrosine levels in clients with
PKU may be normal or slightly decreased.
Educational objective:
Phenylketonuria requires lifetime dietary restrictions. Infants should be given special
formulas (eg, Lofenalac). For children and adults, high-phenylalanine foods (eg, meats,
eggs, milk) should be restricted and replaced with protein substitutes.
A A A
A nurse is assessing a 1-month-old infant with an atrial septal defect (ASD). Which
assessment finding does the nurse expect?
1. Muffled heart tones [19%]
2. Murmur [53%]
3. Cyanosis [19%]
4. Weak femoral pulses [6%]
Explanation: The nurse would expect to hear a murmur with an atrial septal defect. This
defect is an abnormal opening between the right and left atria, allowing blood from the
higher pressure left atrium to flow into the lower pressure right atrium. The back-andforth flow of blood between the 2 chambers causes a vibration that is heard as a murmur
on auscultation. ASD has a characteristic systolic murmur with a fixed split second heart
sound. Some clients may also have a diastolic murmur.
(Option 1) Muffled heart tones are not typical in ASD. Muffled heart tones that are heard
postsurgical intervention are concerning for cardiac tamponade.
(Option 3) Atrial and ventricular septal defects are acyanotic congenital heart defects
because the blood from the high pressure left side (oxygenated blood) goes to the low
pressure right side.
(Option 4) Weak lower and strong upper extremity pulses are present in coarctation of the
aorta.
Educational objective:
In a child with atrial septal defect, the nurse would expect to hear a heart murmur on
auscultation of heart sounds.
A A A
The nurse is caring for an infant diagnosed with Hirschsprung disease who is awaiting
surgery. Which assessment finding requires the nurse's immediate action?
1. Abdominal distension with no change in girth for 8 hours [6%]
2. Did not pass meconium or stool within 48 hours after birth [26%]
3. Episode of foul-smelling diarrhea and fever [26%]
4. Excessive crying and greenish vomiting [39%]
Explanation: Hirschsprung disease (HD) occurs when a child is born with some sections of
the distal large intestine missing nerve cells, rendering the internal anal sphincter unable to
relax. As a result, there is no peristalsis and stool is not passed. These newborns exhibit
symptoms of distal intestinal obstruction. They have a distended abdomen and will not
pass meconium within the expected 24-48 hours. They also have difficulty feeding and
often vomit green bile. Surgical removal of the defective section of bowel is necessary and
colostomy may be required.
A potentially fatal complication is Hirschsprung enterocolitis, an inflammation of the colon,
which can lead to sepsis and death. Enterocolitis will present with fever; lethargy;
explosive, foul-smelling diarrhea; and rapidly worsening abdominal distension.
(Option 1) Mild to moderate abdominal distension is an expected finding with a diagnosis
of HD; however, increasing abdominal girth is a serious finding that must be reported.
(Option 2) Failure to pass meconium or stool within 24-48 hours after birth is an expected
finding of HD.
(Option 4) Bilious vomiting and excessive crying are expected findings of HD. In
enterocolitis, vomiting can occur more frequently and the client appears more ill.
Educational objective:
Enterocolitis, a potentially fatal complication of Hirschsprung disease, is characterized by
explosive, foul-smelling diarrhea; fever; and worsening abdominal distension.
A A A
The clinic nurse interviews the parents of a 6-month-old about the child's diet and feeding
schedule. Which parent statement causes the nurse the most concern?
1. "Apples are a healthy food, so we often make apple pie for our child." [5%]
2. "Chopped pears are one of our child's favorite foods." [8%]
3. "Oatmeal with fresh honey is our child's favorite breakfast." [57%]
4. "We have found TV dinners to be convenient as they have both meat and vegetables."
[28%]
Explanation:
Although more than one of these parent comments are concerning, the most concerning is
feeding honey to a child under age 1 year. Honey (especially raw or wild) is not
recommended for children under age 1 due to the risk for infant botulism. An infant under
age 1 has an immature gut system that can allow Clostridium botulinum spores
contaminated in honey to colonize the gastrointestinal tract and release toxin that causes
botulism.
Botulinum toxin produces muscle paralysis by inhibiting the release of acetylcholine at the
neuromuscular junction. Infants often present with constipation, diminished deep tendon
reflexes, and generalized weakness. Additional symptoms are lack of head control,
difficulty in feeding, and decreased gag reflex, which can progress to respiratory failure.
Isolation of the organism from the child's stool can take several days; therefore, diagnosis is
usually made by history, and treatment with botulism immune globulin is started before
laboratory results are known.
(Option 1) Apple pie is not the best way to serve apples to a 6-month-old as the other
ingredients add too much fat and sugar. This would need to be addressed but is not a
priority over the use of honey.
(Option 2) Raw fruits are appropriate for a 6-month-old.
(Option 4) Although TV dinners contain meat and vegetables, they are not the best source
of food for an infant due to the high sodium content. This would need to be addressed after
the use of honey is addressed.
Educational objective:
Due to the risk of infant botulism, honey should not be given to children under age 1 year.
A A A
The home health nurse is visiting an infant who recently had surgery to repair tetralogy of
Fallot. The nurse should teach the parents to report which findings indicative of heart
failure to the health care provider (HCP)? Select all that apply.
1. Cool extremities
2. Increase in appetite
3. Puffiness around the eyes
4. Reduction in number of wet diapers
5. Weight loss
Explanation: Heart failure may develop after surgical repair of tetralogy of Fallot, and
infants and children can quickly decompensate hemodynamically when it occurs. Clinical
manifestations are grouped into 3 primary categories— impaired myocardial pumping,
pulmonary congestion, and systemic venous congestion.
(Option 2) The infant would have a decrease in appetite with heart failure symptoms.
(Option 5) The infant would more likely have experienced weight gain due to fluid
retention.
Educational objective:
The nurse should teach parents of an infant or child with a repaired congenital heart defect
to recognize and report signs and symptoms of heart failure to the HCP. These may include
rapid breathing rate; rapid heart rate at rest; dyspnea; activity intolerance (especially
during feeding in infants); pale, cool extremities; weight gain; reduction in wet diapers; a [Show Less]