HESI RN PEDS V2 50 Questions & Answers with Rationales 2024

1.The nurse is planning postoperative care for a child who has had a cleft lip repair. What is the most important reason to minimize this child's crying during the recovery period? A. Tear formation increases salivation. B. This behavior increases respirations. C. Excessive hysteria can lead to vomiting. D. Crying stresses the suture line - Rationale: choice D Prevention of stress on the lip suture line is essential for optimum healing and the cosmetic appearance of a cleft lip repair. Although crying also causes options A, B, and C, these conditions do not create a problem for the child with a cleft lip repair. An infant is receiving digoxin for congestive heart failure. The apical heart rate is assessed at 80 beats/min. What intervention should the nurse implement? A. Call for a portable chest radiograph. B. Obtain a therapeutic drug level. C. Reassess the heart rate in 30 minutes. D. Administer digoxin immune Fab stat. - Rationale: Answer: D. Sinus bradycardia (heart rate 90 to 110 beats/min in an infant) is an indication of digoxin toxicity, so assessment of the client's digoxin level has the highest priority. Option A is not indicated at this time. Option C provides helpful assessment data but does not address the cause of the problem and delays needed intervention. Option D is indicated for a serious, life-threatening overdose with digoxin. The nurse admits a child to the intensive care unit with a possible diagnosis of Wilms tumor - What is the most safety precaution for child? A. maintain NPO status B. Limit visitors to the immediate family C. Place a do not palpate abdomen sign on head of bed D. encourage ambulatory in pre operative period - C. Protect child from injury; place a sign on bed stating "no abdominal palpation" (to prevent accidental fragmentation and dislodging into the abdominal cavity). The other option choices are not relevant at this time. The nurse is preparing a teaching plan for the mother of a child who has been diagnosed with celiac disease. Choosing which lunch will be within the therapeutic management of a child with celiac disease? A. Turkey salad, milk, and oatmeal cookies B. Baked chicken, coleslaw, soda, and frozen fruit dessert C. Tuna salad sandwich on whole wheat bread, milk, and ice cream D. Turkey sandwich on rye bread, orange juice, and fresh fruit - Correct Answer: B Rationale: A child with celiac disease is managed on a gluten-free diet, which eliminates food products containing oats, wheat, rye, or barley. A 6-month-old male infant is admitted to the postanesthesia care unit with elbow restraints in place. He has an endotracheal tube and is ventilator-dependent but will be extubated soon following recovery from anaesthesia. Which nursing intervention should be included in this child's plan of care? A. Keep restraints on at all times to prevent unplanned extubation. B. Remove restraints one at a time and provide range-of-motion exercises. C. Remove all restraints simultaneously and provide play activities D. Document the reason for application of the restraints every 72 hours. - Remove restraints one at a time and provide range-of-motion exercises. Removing restraints one at a time is safer than option C. The infant should have the restrained extremities assessed frequently for signs of neurologic or vascular impairment, and range-of-motion exercises should be performed with these assessments. Under no circumstances should restraints be applied to the client continuously. Documentation of assessment findings regarding the restrained extremities must occur much more frequently than every 72 hours; however, the reason for using restraints must be justified and should be stated in the medical record. The nurse assigns an unlicensed assistive personnel (UP) to provide morning care to a newly admitted child with bacterial meningitis. What is the most important instruction for the nurse to review with the UP? A.Use designated isolation precautions. B. Keep the lighting in the room dim. C. Allow the parents to assist with care D. Report any pain that the child experiences - A. Rationale: All these are important measures to review with the UP, but the most important is option A. Improper use of isolation precautions can place other staff and clients at risk for infection. Options B. C, and D promote client comfort and reduce anxiety but are of a lower priority than option A. The nurse is caring for a child with intussusception who is scheduled for a barium enema prior to a surgical procedure. Which action should the nurse take first? A. Evacuate the bowel of impacted feces B. Admnister magnesium sulfate C. Place the child on a clear liquid diet D. Assess the stool for white color - C Rationale: Intussusception, an invagination or telescoping of one portion of the intestine into another, causes intestinal obstruction in children (usually occurs between 3 months and 5 years of age). Nonsurgical treatment is attempted with hydrostatic pressure created by barium instillation, which often reduces the area of bowel intussusception. In preparation for a barium enema, the client should first be placed on a clear liquid diet for the entire day: then magnesium sulfate is administered for bowel evacuation. A barium enema is likely to cause option A. After the enema, white stool may be seen as the body naturally removes any remaining barium. A3-week-old infant is referred to an orthopedic clinic because the pediatrician heard a click when flexing the child's right hip during a routine physical examination. The orthopedic physician suspects that the child might have developmental dysplasia of the hip (DDH). The parents ask the nurse to identify risk factors commonly associated with DDH. Which response is accurate? A. Vertex delivery B. Male gender C. Breech presentation D. Second-born child - C. Rationale: Developmental dysplasia of the hip (DDH) occurs more often in infants who present in the breech position, not the vertex (head-first) position. Twice as many females as males present in the breech pasition; thus, 80% of children with DDH are females, not males. Of breech presentations, 60% occur with first-born children, not subsequent siblings, possibly because of the unstretched uterus and compaction of the surrounding abdominal contents, which tend to increase compression on the uterus in the nulliparous woman. The nurse is teaching the parents of a 2-year-old child with a congenital heart defect about signs and symptoms of congestive heart failure. Which information about the child is most important for the parents to report to the health care provider? A. sits or squats frequently when playing outdoors B. Exhibits a sudden and unexplained weight gain C. Is not completely toilet- trained and has some accidents D. Demonstrates irritation and fatigue 1 hour before bedtime - B Rationale: Sudden and unexplained weight gain can indicate fluid retention and is a sign of congestive heart failure. Option A is used by the child to reduce chronic hypoxia, especially during exercise. Option C is common; 2-year-olds are not expected to be toilet-trained. Option D is normal. A newborn female whose mother is HIV-positive is scheduled for the first follow- up assessment with the nurse. If the child is HIV-positive, which initial symptom is she most likely to exhibit? A. Shortness of breath B. Joint pain C. Persistent cold D. Organomegaly - C Rationale: Respiratory tract infections commonly occur in the pediatric population, but the child with AIDS has a decreased ability to defend the body against these common infections. Thus, the most typical presenting symptom of a child who contracted AIDS through vertical transmission (i.e., from the mother during delivery) is a persistent cold or respiratory infection. Options A, B, and D are symptoms of AIDS complications that may occur later as the disease progresses. Following the administration of immunizations to a 6-month-old girl, the nurse provides the family with home care instructions, Which statement by the mother indicates that further teaching is needed? A. "I will give her a baby aspirin every 4 hours as needed for fever." B. "I will call the clinic if her cry becomes highpitched or unusual." C. "I know I can expect her to be irritable over the next 2 days. D. "I will exercise her legs regularly to decrease the soreness." - Rationale: Although fever may occur, non-aspirin-containing medications should be used because of the risk of Reye syndrome. Option B indicates a severe reaction, whereas option C is a common side effect. Option D decreases soreness in the thigh injection site. A child breaks out with varicella infection (chickenpox) while hospitalized for a minor surgical procedure. Which intervention should the nurse implement first? A. Place a mask on the child before transporting the child outside the room. B. Immunize exposed family members with the varicella vaccine. C. Place the child in strict isolation to prevent an outbreak on the unit. D. Determine which staff have had varicella before making assignments. - Rationale: The period of communicability of varicella is 2 days before the rash appears until all lesions are crusted; varicella is spread by direct or indirect contact of saliva or vesicles. Strict isolation is indicated to prevent further exposure to staff and others. Staff who have had varicella or the vaccine are not susceptible to contracting or spreading the virus and should be the only personnel assigned to care for this client. Option A is not sufficient to prevent exposure to others. Option B must be done prior to exposure. The nurse observes a 4-year-old boy in a day care setting. Which behavior should the nurse expect this Child to exhibit? A. Throws a temper tantrum when told he must share the toys. B. Plays by himself for most of the day. C. Boasts aggressively when telling a story. D. Cries and is fearful when separated from his parents. - Rationale: Four-year-old children are aggressive in their behavior and enjoy telling tales. Options A and D are typical toddler behaviors. A preschooler's play is usually cooperative, so playing alone is not typical. Which preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis? A. Monitor for signs of metabolic acidosis. B. Estimate the quantity of diarrhea stools. C. Place in a supine position after feeding. D. Observe for projectile vomiting. - D Rationale: Projectile vomiting, the classic sign of pyloric stenosis, contributes to metabolic alkalosis. Metabolic acidosis is the opposite imbalance from alkalosis and is not an expected finding. An antidiarrheal agent is not indicated. Option C is dangerous because of the potential for aspiration with frequent vomiting. During routine screening at a school clinic, an otoscope examination of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. Based on these findings, what action should the nurse take? A. No action is required because this is an expected finding for a school-aged child. B. Ask if the child has had a cold, runny nose, or any ear pain lately. C. Send a note home advising parents to have the child evaluated by a health care provider. D. Call the parents and have them take the child home from school for the rest of the day. - B Rationale: More information is needed to interpret these findings. The tympanic membrane is normally pearly gray, not bulging, and moves when a client blows against resistance or when a small puff of air is blown into the ear canal. Because these findings are not completely normal, further assessment of history and related signs and symptoms are needed to interpret the findings accurately. Based on the data obtained from the otoscope examination, options A, C, and D are not indicated. When caring for a child with congenital heart disease and polycythemia, which nursing intervention has the highest priority? A. Administering oxygen therapy continuously B. Restricting fluids as ordered C. Maintaining adequate hydration D. Maintaining digoxin levels - Maintaining adequate hydration The key word in this question is polycythemia. Hydration decreases blood viscosity and the risk for thrombus formation, the most common complication of polycythemia. Options A and D are nursing interventions for the cardiac client but do not treat polycythemia. Fluid intake should be increased, not restricted. The nurse is conducting an initial admission assessment of a 12-month-old child in celiac crisis. Which intervention is most important for the nurse to implement? A. Assess the child's mucous membranes and skin turgor. B. Contact food services about needed menu restrictions. C. Determine the child's food likes and dislikes. D. Ask the parents about the child's recent dietary intake. - A Rationale: An infant having a celiac crisis has severe diarrhea and is at high risk for fluid volume deficit. The nurse should first assess for indications of fluid volume deficit and then implement options B, C, and D. When inserting a nasogastric tube into the stomach of a 3-month-old infant, which nursing intervention is most important to Implement? A. Use a blanket as a mummy restraint. B. Monitor the infant's heart rate. C. Lubricate the catheter with saline, D. Explain the procedure to the parents. - B Rationale: All interventions may be implemented during nasogastric tube insertion, but the most important nursing action is to monitor the infant's heart rate, which may decrease because of vagal nerve stimulation and can occur when the tube is inserted. Options A, C, and D are of lower priority than option B. In making the initial assessment of a 2-hour-old infant, which finding should lead the nurse to suspect a congenital heart defect? A. Irregular respiration and heart rate B. Gagging C. Blue feet and hands D. Diminished femoral pulses - D. Diminished femoral pulses At which point during the physical examination should a child with asthma be assessed for the presence or absence of intercostal retractions? A. Inspiration B. Coughing C. Apneic episodes D. Expiration - A Rationale: Intercostal retractions result from respiratory effort to draw air into restricted airways. The retractions will not be noticeable when air is expelled from the lungs, such as when the client is coughing or expiring. During apnea, the client is not attempting to draw air into the airways. Apnea indicates that the respiratory effort is absent. Which interventions should the nurse include in the teaching plan for the mother of a 6-year-old who is experiencing encopresis secondary to a fecal impaction? (Select all that apply.) A. Provide a low-fiber diet. J5. Administer mineral oil dally. C. Decrease the daily fluids. D. Eliminate dairy products. E. Initiate consistent tolleting routine. - Encopresis is fecal incontinence, usually as the result of recurring fecal impaction and an enlarged rectum caused by chronic constipation. Encopresis is managed through bowel retraining with mineral oil, eliminating dairy products, and initiating a regular toileting routine. A high-fiber diet, not option A, and increased daily fluids, not option C, are components of care for a child with encopresis. The nurse is examining a male child experiencing an exacerbation of juvenile rheumatoid arthritis (JRA) and notes that his mobility is greatly reduced. What is the most likely cause of the child's impaired mobility? A. Pathologic fractures B. Poor alignment of joints C. Dyspnea on exertion D. Joint inflammation - D Rationale: Joint inflammation and pain are the typical manifestations of an exacerbation of JRA. Options A, B, and C are not specifically related to JRA. A 3-month-old infant returns from surgery with elbow restraints and a Logan bow over a cleft lip suture line. Which intervention should the nurse implement to maintain suture line integrity during the initial postoperative period? A. Place the infant upright in an infant seat position. B. Provide mittens with the use of elbow restraints. C. Use soft rubber catheters for nasal suctioning. D. Apply water-soluble lubricant to the suture line - A Rationale: The use of an infant seat simulates a supine position with the head elevated and also prevents aspiration. Prone positioning should be avoided to prevent disruption of the protective Logan bow and prevent the infant from rubbing the face on the bed surface. Mittens are not necessary and decrease the ability to provide sensory comfort, such as hand holding. Nasal suctioning should be avoided to prevent trauma or dislodging clots at the surgical site. Water-soluble lubricant will dry the suture line and cause crusting, which predisposes the suture line to poor healing and scarring. A 7-month-old infant with a rotavirus causing severe diarrhea is admitted for treatment. Which intervention should the nurse implement first? A. Obtain a scale to weigh the infant's diapers. B. Instruct the mother to offer Pedialyte regularly. C. Insert an intravenous (IV) line and begin IV fluids. D. Obtain a stool specimen for analysis. - C Rationale: An infant with severe diarrhea is at high risk for dehydration, so the nurse's priority is to initiate IV fluids to rehydrate the infant. Options A, B, and D can then be implemented as needed.