The nurse is caring for a 3 year old child who is 2 hours postop from a cardiac catheritization via the right
femoral artery. Which assessment finding is an indication of arterial obstruction? - Answers Right foot is
cool to the touch and appears pale and blanched
During fundal massage, place one hand at the fundus, what is the second hand used for - Answers to
anchor fundus
Following a motor vehicle collision, a 3 year old girl has a spica cast applied. Which toy is best for the
nurse for this 3 year old child? - Answers Set of cloth and hand puppets
There is a question that has to be put in order - Answers *isolate the baby, move mom to private room,
collect u/a, start iv*
An infant with tetralogy of fallot becomes acutely cyanotic and hyperpneic. Which action should the
nurse implement first? - Answers Place the infant in a knee-chest position
How do you measure the frequency of contractions - Answers from the beginning of one to the
beginning of the next
A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respirations. The nurse
determines that the increased respiratory rate is a compensatory mechanism for which acid base
alteration? - Answers Metabolic Acidoses
Mothers Hemoglobin A1C - Answers give her a consultation to a nutritionist
A 7 year old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low
intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare
provider? - Answers Serum potassium of 3.0 mg/dL
Baby shows cyanosis in hands and feet and has elevated respirations - Answers gradually warm the baby
Cyanotic 3 hour old infant temperature 96.5, 40 breaths/min, 165 beats/minute. Intervention best to
implement? - Answers gradually warm under heat source
The nurse is evaluating diet teaching for a client who has nontropical sprue (celiac disease). Choosing
which food indicates that the teaching has been effective? - Answers *Creamed corn*
Baby is showing signs of mottling - Answers check temperature
During a well-baby check, the nurse hides a block under the baby's blanket, and the baby looks for the
block. Which normal growth and development milestone is the baby developing? - Answers Object
Permanence
Mom is at 20 week gestation and has gained 20 lbs, what is of most concern out of the data of mom -
Answers increased weight gain
, The nurse is measuring he frontal occipital circumference (FOC) of a 3 month old infant, and notes that
the FOC has increased 5 inches since birth and the child's head appears large in relation to body size.
Which action is most important for the nurse to take next? - Answers Palpate the anterior fontanel for
tension and bulging
Mom asks why her baby is being screened for T4 and TSH levels - Answers it is state protocol to monitor
for metabolic abnormalities
The nurse is preparing a 10 year old with a lacerated forehead for suturing. Both parents and 12 years
old sibling are at the child's bedside. Which instruction best supports family? - Answers Please decide
who will stay when the healthcare provider begins suturing
Patient is having labor back pain - Answers counter pressure on lower back (sacrum)
The nurse is planning for a 5 month old with gastroesophageal reflux disease whose weight has
decreased by 3 ounces since the last clinic visit one month ago. To increase caloric intake and decrease
vomiting, what instructions should the nurse provide this mother? - Answers Thicken formula with
cereal for each feeding
Woman had cleft lip, dads uncle had cleft lip - Answers send them for genetic testing
While teaching a parenting class to new parents the nurse describes the needs of infants and toddlers
regarding discipline and limit setting. What is the most important reason for implementing such
parenting behaviors? - Answers They provide the child with a sense of security
Woman in labor and they look at vagina and see cord - Answers put woman in Trendelenburg position
The parents of a newborn infant with hypospadia are concerned about when the surgical correction
should occur. What information should the nurse provide? - Answers Repairs typically should be done
before the child is potty trained
Pregnant woman has a diaphragm - Answers she needs to have it refitted for another diaphragm
Which drink choice on a hot day indicates to the nurse that a teenager with sickle cell anemia
understands dietary considerations related to the disease? - Answers Lemonade
Baby starts showing signs of respiratory difficulty (nasal flaring, expiratory grunt, cyanosis) - Answers
check O2 saturation levels
The nurse is assessing an infant with diarrhea and lethargy. Which finding should the nurse identify that
is consistent with early dehydration? - Answers Tachycardia
Baby progressing in extrauterine life would show what signs - Answers good vigorous cry with
stimulation