BSNC 5000: Module
2 Pediatrics
A nurse is teaching an adolescent client who has type 1 diabetes mellitus about
managing hypoglycemia. Which of the following statements should the nurse include in
the teaching?
A. "You should drink 8 oz of a regular soft drink if you experience hypoglycemia."
B. "You should drink 4 oz of orange juice if you experience hypoglycemia."
C. "You should take 2 glucose tablets if you experience hypoglycemia."
D. "You should take 3 tsp of sugar if you experience hypoglycemia." - answersCorrect
Answer: B. "You should drink 4 oz of orange juice if you experience hypoglycemia."
The nurse should tell the client to drink 4 oz of orange juice if hypoglycemia occurs.
Incorrect Answers:
A. The nurse should tell the client to drink 6 oz (NOT 8 oz) of a regular soft drink if
hypoglycemia occurs.
C. The nurse should tell the client to take 4 glucose tablets (NOT 2) if hypoglycemia
occurs.
D. The nurse should tell the client to take 2 tsp (NOT 3) of sugar if hypoglycemia occurs
A nurse is assessing a 6-year-old client at a well-child visit. Which of the following
findings requires further assessment by the nurse?
A. Presence of sparse, fine pubic hair
B. Decreased head circumference compared to full height
C. Increased leg length in relation to height
D. Presence of a loose central incisor - answersCorrect Answer: A. Presence of sparse,
fine pubic hair
The development of sexual characteristics prior to the age of 9 years in boys and 8
years in girls is an indication of precocious puberty and requires further evaluation.
Incorrect Answers:
B. The head circumference of a school-age child decreases when compared to full
height due to skeletal lengthening.
C. Body proportion varies with a slimmer appearance and longer legs in a school-age
child. Leg length increases and waist circumference decreases related to height in this
age group.
,D. The deciduous teeth start shedding at this age, beginning with the lower central
incisors
RBC Range: - answersMale: 4.3-5.9 million/mm3
Female 3.5 -5.5 million/mm3
A nurse is assessing an infant who develops respiratory distress, absence of breath
sounds on one side, and deviation of the trachea away from the affected side. Based on
these manifestations, which of the following conditions is the infant experiencing?
A. Tension pneumothorax
B. Flail chest
C. Pulmonary contusion
D. Fractured rib - answersCorrect Answer: A. Tension pneumothorax
The nurse should identify these manifestations as an indication the infant is developing
a tension pneumothorax. The infant might also become cyanotic and show asymmetry
of the thorax.
Incorrect Answers:
B. Manifestations of flail chest include a pulling of the traumatized rib area inward during
inspiration and outward during expiration.
C. Manifestations of pulmonary contusion include decreased breath sounds,
tachycardia, tachypnea, and blood-tinged secretions.
D. Manifestations of a rib fracture include pain and ecchymosis in the area of trauma,
swelling, and muscle spasms.
TSH Range: - answers(0.5-5.0 µU/mL
A nurse is assessing a toddler who has measles (rubeola). Which of the following
findings should the nurse expect?
A. Koplik spots
B. Parotitis
C. Strawberry tongue
D. Paroxysmal coughing - answersCorrect Answer: A. Koplik spots
Koplik spots are small, irregular oral lesions with a bluish-white center. They are
characteristic of measles (rubeola). Koplik spots appear about 2 days before the
maculopapular rash and are accompanied by fevers, malaise, conjunctivitis, and other
cold manifestations.
Incorrect Answers:
B. Swollen parotid glands are an expected finding in a child who has MUMPS.
C. Strawberry tongue is an expected finding in a child who has SCARLET FEVER.
D. Paroxysmal coughing is an expected finding in a child who has PERTUSSIS
Nevus simplex or Stork bite - answersDiscoloration that typically blanches with pressure
and becomes more prominent with crying. This finding does not require notification of
the provider.
, A nurse is assessing a preschooler who has HIV. Which of the following manifestations
should the nurse expect?
A. Generalized petechiae
B. Jaundice
C. Obesity
D. Chronic diarrhea - answersD. Small bowel bacterial overgrowth is possible in people
with HIV. Intestinal problems may make a person with HIV more likely to have an
overgrowth of bacteria. This may lead to diarrhea and other digestive issues
Incorrect Answers:
A. Generalized petechiae are not a manifestation of HIV in a preschooler.
B. Jaundice is not a manifestation of HIV in a preschooler.
C. Failure to thrive and weight loss are expected findings for a preschooler who has
HIV.
A nurse is assessing a child who has a ventricular septal defect. Which of the following
findings should the nurse expect?
A. Diastolic murmur
B. Murmur at the left sternal border
C. Cyanosis that increases with crying
D. Widened pulse pressure - answersCorrect Answer: B. Murmur at the left sternal
border
A ventricular septal defect (a hole in the septal wall between the ventricles) is an
acyanotic heart defect. A systolic murmur can be heard best at the lower left sternal
border. The sound is transmitted in the direction of blood flow, so any backflow of blood
from the left to the right ventricle through the septal defect is best heard in this area.
Incorrect Answers:
A. A diastolic murmur is an expected finding in a child who has an ATRIAL SEPTAL
DEFECT.
C. Cyanosis that increases with crying is an expected finding in a child who has an AV
CANAL DEFECT.
D. Widened pulse pressure is an expected finding in a child who has PDA
A nurse is preparing to administer an enema to a 10-month-old infant. Which of the
following actions should the nurse plan to take?
A. Administer the enema using room-temperature tap water
B. Insert the tubing 7.5 cm (3 in) into the rectum
C. Position the infant sitting upright on a bedpan while administering the enema
D. Hold the infant's buttocks together after administering the fluid Check Answer -
answersCorrect Answer: D. Hold the infant's buttocks together after administering the
fluid
Because the infant is incontinent, the nurse should hold the buttocks together for a short
time to maintain retention of the enema.
Incorrect Answers:
A. Tap water is hypotonic and can cause a rapid fluid shift and fluid overload. An
isotonic solution of 0.9% sodium chloride should be used.
2 Pediatrics
A nurse is teaching an adolescent client who has type 1 diabetes mellitus about
managing hypoglycemia. Which of the following statements should the nurse include in
the teaching?
A. "You should drink 8 oz of a regular soft drink if you experience hypoglycemia."
B. "You should drink 4 oz of orange juice if you experience hypoglycemia."
C. "You should take 2 glucose tablets if you experience hypoglycemia."
D. "You should take 3 tsp of sugar if you experience hypoglycemia." - answersCorrect
Answer: B. "You should drink 4 oz of orange juice if you experience hypoglycemia."
The nurse should tell the client to drink 4 oz of orange juice if hypoglycemia occurs.
Incorrect Answers:
A. The nurse should tell the client to drink 6 oz (NOT 8 oz) of a regular soft drink if
hypoglycemia occurs.
C. The nurse should tell the client to take 4 glucose tablets (NOT 2) if hypoglycemia
occurs.
D. The nurse should tell the client to take 2 tsp (NOT 3) of sugar if hypoglycemia occurs
A nurse is assessing a 6-year-old client at a well-child visit. Which of the following
findings requires further assessment by the nurse?
A. Presence of sparse, fine pubic hair
B. Decreased head circumference compared to full height
C. Increased leg length in relation to height
D. Presence of a loose central incisor - answersCorrect Answer: A. Presence of sparse,
fine pubic hair
The development of sexual characteristics prior to the age of 9 years in boys and 8
years in girls is an indication of precocious puberty and requires further evaluation.
Incorrect Answers:
B. The head circumference of a school-age child decreases when compared to full
height due to skeletal lengthening.
C. Body proportion varies with a slimmer appearance and longer legs in a school-age
child. Leg length increases and waist circumference decreases related to height in this
age group.
,D. The deciduous teeth start shedding at this age, beginning with the lower central
incisors
RBC Range: - answersMale: 4.3-5.9 million/mm3
Female 3.5 -5.5 million/mm3
A nurse is assessing an infant who develops respiratory distress, absence of breath
sounds on one side, and deviation of the trachea away from the affected side. Based on
these manifestations, which of the following conditions is the infant experiencing?
A. Tension pneumothorax
B. Flail chest
C. Pulmonary contusion
D. Fractured rib - answersCorrect Answer: A. Tension pneumothorax
The nurse should identify these manifestations as an indication the infant is developing
a tension pneumothorax. The infant might also become cyanotic and show asymmetry
of the thorax.
Incorrect Answers:
B. Manifestations of flail chest include a pulling of the traumatized rib area inward during
inspiration and outward during expiration.
C. Manifestations of pulmonary contusion include decreased breath sounds,
tachycardia, tachypnea, and blood-tinged secretions.
D. Manifestations of a rib fracture include pain and ecchymosis in the area of trauma,
swelling, and muscle spasms.
TSH Range: - answers(0.5-5.0 µU/mL
A nurse is assessing a toddler who has measles (rubeola). Which of the following
findings should the nurse expect?
A. Koplik spots
B. Parotitis
C. Strawberry tongue
D. Paroxysmal coughing - answersCorrect Answer: A. Koplik spots
Koplik spots are small, irregular oral lesions with a bluish-white center. They are
characteristic of measles (rubeola). Koplik spots appear about 2 days before the
maculopapular rash and are accompanied by fevers, malaise, conjunctivitis, and other
cold manifestations.
Incorrect Answers:
B. Swollen parotid glands are an expected finding in a child who has MUMPS.
C. Strawberry tongue is an expected finding in a child who has SCARLET FEVER.
D. Paroxysmal coughing is an expected finding in a child who has PERTUSSIS
Nevus simplex or Stork bite - answersDiscoloration that typically blanches with pressure
and becomes more prominent with crying. This finding does not require notification of
the provider.
, A nurse is assessing a preschooler who has HIV. Which of the following manifestations
should the nurse expect?
A. Generalized petechiae
B. Jaundice
C. Obesity
D. Chronic diarrhea - answersD. Small bowel bacterial overgrowth is possible in people
with HIV. Intestinal problems may make a person with HIV more likely to have an
overgrowth of bacteria. This may lead to diarrhea and other digestive issues
Incorrect Answers:
A. Generalized petechiae are not a manifestation of HIV in a preschooler.
B. Jaundice is not a manifestation of HIV in a preschooler.
C. Failure to thrive and weight loss are expected findings for a preschooler who has
HIV.
A nurse is assessing a child who has a ventricular septal defect. Which of the following
findings should the nurse expect?
A. Diastolic murmur
B. Murmur at the left sternal border
C. Cyanosis that increases with crying
D. Widened pulse pressure - answersCorrect Answer: B. Murmur at the left sternal
border
A ventricular septal defect (a hole in the septal wall between the ventricles) is an
acyanotic heart defect. A systolic murmur can be heard best at the lower left sternal
border. The sound is transmitted in the direction of blood flow, so any backflow of blood
from the left to the right ventricle through the septal defect is best heard in this area.
Incorrect Answers:
A. A diastolic murmur is an expected finding in a child who has an ATRIAL SEPTAL
DEFECT.
C. Cyanosis that increases with crying is an expected finding in a child who has an AV
CANAL DEFECT.
D. Widened pulse pressure is an expected finding in a child who has PDA
A nurse is preparing to administer an enema to a 10-month-old infant. Which of the
following actions should the nurse plan to take?
A. Administer the enema using room-temperature tap water
B. Insert the tubing 7.5 cm (3 in) into the rectum
C. Position the infant sitting upright on a bedpan while administering the enema
D. Hold the infant's buttocks together after administering the fluid Check Answer -
answersCorrect Answer: D. Hold the infant's buttocks together after administering the
fluid
Because the infant is incontinent, the nurse should hold the buttocks together for a short
time to maintain retention of the enema.
Incorrect Answers:
A. Tap water is hypotonic and can cause a rapid fluid shift and fluid overload. An
isotonic solution of 0.9% sodium chloride should be used.
