Detailed Answer Key
Homework 8-10; Pediatrics
1. A nurse is collecting data from a 9-month-old infant. Which of the following findings would
require further intervention?
A. Positive Babinski reflex
Rationale: 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
Rationale: 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
Rationale: 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
Rationale: 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 is reinforcing teaching a parent of a child who has a fracture of the epiphyseal
plate. Which of the following is an appropriate statement by the nurse?
A. “The blood supply to the bone is disrupted.”
Rationale: Children heal fractures in less time than adults because of the generous
blood supply to the bone and the epiphyseal plate.
B. “Normal bone growth can be affected.”
Rationale: A fracture of the epiphyseal plate can affect growth in a child. Therefore,
it needs to be detected and treated rapidly.
C. “Bone marrow can be lost though the fracture.”
Rationale: The epiphyseal plate is the cartilage growth plate. Therefore, bone
marrow is not lost through this type of fracture.
D. “The healing process will take longer.”
Rationale: Children heal fractures in less time than adults because of the generous
blood supply to the bone and the epiphyseal plate.
CAA_DetailedAnswerKey created
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, Detailed Answer Key
Homework 8-10; Pediatrics
3. A nurse is planning to speak to a group of adolescents about toxic shock syndrome (TSS). The
nurse knows that TSS is commonly associated with which of the following?
A. High-absorbency tampons
Rationale: Toxic shock syndrome, a severe disease caused by a toxin made by
Staphylococcus aureus, is characterized by shock and multiple organ
dysfunction. It most often affects menstruating women who use highly
absorbent tampons.
B. Mosquito bites
Rationale: Mosquito bites are not associated with TSS.
C. International travel
Rationale: International travel is not associated with TSS.
D. Multiple sexual partners
Rationale: TSS is not associated with multiple sexual partners.
4. A nurse is collecting data from an infant. Which of the following is a clinical manifestation of
pyloric stenosis?
A. Absent bowel sounds
Rationale: Visible gastric peristaltic waves moving from the left to the right are a
clinical manifestation of pyloric stenosis.
B. Increased sodium level
Rationale: Vomiting causes a depletion of fluid and electrolytes, therefore a
decrease in serum sodium levels is a clinical manifestation of pyloric
stenosis.
C. Projectile vomiting after feedings
Rationale: Pyloric stenosis is a narrowing and thickening of the pyloric canal
between the stomach and the duodenum resulting in projectile vomiting.
D. Golf ball-sized mass over the left quadrant
Rationale: An olive-shaped mass is palpable right of the umbilicus is a clinical
manifestation of pyloric stenosis.
CAA_DetailedAnswerKey created
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, Detailed Answer Key
Homework 8-10; Pediatrics
5. A nurse is planning care for a child who has juvenile rheumatoid arthritis. Which of the
following is an appropriate action for the nurse to take?
A. Administer opioids on a schedule.
Rationale: NSAIDs are used to control pain. Therefore, administering opioids on a
schedule is not an appropriate action for the nurse to take.
B. Schedule prolonged periods of complete joint immobilization daily.
Rationale: Physical mobility will assist in preserving function and maintaining mobility.
Therefore, prolonged periods of complete joint immobilization is not an
appropriate action for the nurse to take.
C. Apply cool compresses for 20 minutes every hour.
Rationale: Heat is beneficial for relieving pain and stiffness. Therefore, applying cool
compresses for 20 minutes every hour is not an appropriate action for
the nurse to take.
D. Maintain night splints to the affected joint.
Rationale: Maintaining night splints to the affected joints will assist in range of motion.
Therefore, this is an appropriate action for the nurse to take.
CAA_DetailedAnswerKey created
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, Detailed Answer Key
Homework 8-10; Pediatrics
6. A nurse is caring for a school-age child who has mild persistent asthma. Which of the following
is an expected finding? (Select all that apply.)
A. Symptoms are continuous throughout the day.
B. Daytime symptoms occur more than twice a week.
C. Nighttime symptoms occur approximately twice a month.
D. Minor limitations occur with normal activity.
E. Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value.
Rationale: Symptoms are continuous throughout the day is incorrect. Continual
asthma symptoms throughout the day are seen with severe
persistent asthma.
Daytime symptoms occur more than twice a week is correct. A child
with mild persistent asthma will typically have daytime symptoms
more than twice a week, but not daily.
Nighttime symptoms occur approximately twice a month is incorrect.
Nighttime symptoms occurring approximately twice a month are
seen with intermittent asthma.
Minor limitations occur with normal activity is correct. A child with mild
persistent asthma will have some minor limitations with normal daily
activities.
Peak expiratory flow (PEF) is greater than or equal to 80% of the
predicted value is correct. A child with mild persistent asthma will have a
PEF greater than or equal to 80% of the predicted value.
CAA_DetailedAnswerKey created
10/05/2012 page 4 of
Homework 8-10; Pediatrics
1. A nurse is collecting data from a 9-month-old infant. Which of the following findings would
require further intervention?
A. Positive Babinski reflex
Rationale: 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
Rationale: 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
Rationale: 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
Rationale: 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 is reinforcing teaching a parent of a child who has a fracture of the epiphyseal
plate. Which of the following is an appropriate statement by the nurse?
A. “The blood supply to the bone is disrupted.”
Rationale: Children heal fractures in less time than adults because of the generous
blood supply to the bone and the epiphyseal plate.
B. “Normal bone growth can be affected.”
Rationale: A fracture of the epiphyseal plate can affect growth in a child. Therefore,
it needs to be detected and treated rapidly.
C. “Bone marrow can be lost though the fracture.”
Rationale: The epiphyseal plate is the cartilage growth plate. Therefore, bone
marrow is not lost through this type of fracture.
D. “The healing process will take longer.”
Rationale: Children heal fractures in less time than adults because of the generous
blood supply to the bone and the epiphyseal plate.
CAA_DetailedAnswerKey created
10/05/2012 page 1 of
, Detailed Answer Key
Homework 8-10; Pediatrics
3. A nurse is planning to speak to a group of adolescents about toxic shock syndrome (TSS). The
nurse knows that TSS is commonly associated with which of the following?
A. High-absorbency tampons
Rationale: Toxic shock syndrome, a severe disease caused by a toxin made by
Staphylococcus aureus, is characterized by shock and multiple organ
dysfunction. It most often affects menstruating women who use highly
absorbent tampons.
B. Mosquito bites
Rationale: Mosquito bites are not associated with TSS.
C. International travel
Rationale: International travel is not associated with TSS.
D. Multiple sexual partners
Rationale: TSS is not associated with multiple sexual partners.
4. A nurse is collecting data from an infant. Which of the following is a clinical manifestation of
pyloric stenosis?
A. Absent bowel sounds
Rationale: Visible gastric peristaltic waves moving from the left to the right are a
clinical manifestation of pyloric stenosis.
B. Increased sodium level
Rationale: Vomiting causes a depletion of fluid and electrolytes, therefore a
decrease in serum sodium levels is a clinical manifestation of pyloric
stenosis.
C. Projectile vomiting after feedings
Rationale: Pyloric stenosis is a narrowing and thickening of the pyloric canal
between the stomach and the duodenum resulting in projectile vomiting.
D. Golf ball-sized mass over the left quadrant
Rationale: An olive-shaped mass is palpable right of the umbilicus is a clinical
manifestation of pyloric stenosis.
CAA_DetailedAnswerKey created
10/05/2012 page 2 of
, Detailed Answer Key
Homework 8-10; Pediatrics
5. A nurse is planning care for a child who has juvenile rheumatoid arthritis. Which of the
following is an appropriate action for the nurse to take?
A. Administer opioids on a schedule.
Rationale: NSAIDs are used to control pain. Therefore, administering opioids on a
schedule is not an appropriate action for the nurse to take.
B. Schedule prolonged periods of complete joint immobilization daily.
Rationale: Physical mobility will assist in preserving function and maintaining mobility.
Therefore, prolonged periods of complete joint immobilization is not an
appropriate action for the nurse to take.
C. Apply cool compresses for 20 minutes every hour.
Rationale: Heat is beneficial for relieving pain and stiffness. Therefore, applying cool
compresses for 20 minutes every hour is not an appropriate action for
the nurse to take.
D. Maintain night splints to the affected joint.
Rationale: Maintaining night splints to the affected joints will assist in range of motion.
Therefore, this is an appropriate action for the nurse to take.
CAA_DetailedAnswerKey created
10/05/2012 page 3 of
, Detailed Answer Key
Homework 8-10; Pediatrics
6. A nurse is caring for a school-age child who has mild persistent asthma. Which of the following
is an expected finding? (Select all that apply.)
A. Symptoms are continuous throughout the day.
B. Daytime symptoms occur more than twice a week.
C. Nighttime symptoms occur approximately twice a month.
D. Minor limitations occur with normal activity.
E. Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value.
Rationale: Symptoms are continuous throughout the day is incorrect. Continual
asthma symptoms throughout the day are seen with severe
persistent asthma.
Daytime symptoms occur more than twice a week is correct. A child
with mild persistent asthma will typically have daytime symptoms
more than twice a week, but not daily.
Nighttime symptoms occur approximately twice a month is incorrect.
Nighttime symptoms occurring approximately twice a month are
seen with intermittent asthma.
Minor limitations occur with normal activity is correct. A child with mild
persistent asthma will have some minor limitations with normal daily
activities.
Peak expiratory flow (PEF) is greater than or equal to 80% of the
predicted value is correct. A child with mild persistent asthma will have a
PEF greater than or equal to 80% of the predicted value.
CAA_DetailedAnswerKey created
10/05/2012 page 4 of
