An infant client is diagnosed with a cyanotic congenital heart defect (CCHD). The
nurse knows a cyanotic congenital heart defect is associated with which
symptom as reported by the parent?
Poor feeding with no or very poor weight gain.
Reports of poor feeding, difficulty feeding, and poor weight gain or no weight gain are
symptoms that occur in infants with congenial heart defects.
The nurse performs a home care visit for a young adult diagnosed with cystic
fibrosis. The nurse intervenes if which finding is disscussed?
She takes pancreatic enzymes one hour after eating.
Enzymes should be taken at the beginning of a meal, with a snack, or within 30 mins. of
eating.
A client delivers a healthy 8-lb, 2 oz. newborn. The client mentions to the nurse
that the newborn's "soft spot" bulges out when the newborn cries. Which
statement made by the nurse is most appropriate?
Anterior fontanel will normally bulge out when the newborn coughs/cries.
Fontanels should feel flat, firm, and well-demarcated when the newborn is at rest.
Coughing/crying may cause the anterior fontanel to bulge.
A school-age client is admitted to the hospital with a diagnosis of idiopathic
hypopituitarism. Which clinical manifestation is the nurse most likely to observe?
Short stature
Pediatric clients with idiopathic hypopituitarism characteristically have short stature and
slow growth.
The newborn nursery nurse provides care for a client diagnosed with hip
dysplasia. The nurse anticipated which treatment to be prescribed for the client?
Pavlik harness
,Pavlik harness is used to treat hip dysplasia in newborn clients to stabilize and keep the
hip joint in proper alignment.
The nurse performs assessments on infants at the health department. The nurse
identifies which finding as an early indication of cerebral palsy (CP)?
The 4-month-old infant lacks head control.
The earliest indicator of CP is delayed gross motor development. Signs include stiff/rigid
arms/legs, arching back, and floppy/limp body posture.
The nurse in a pediatric clinic is completing health record audits and noticed that
a preschool client is on a delayed immunization schedule per the parents request.
The client is five years old and it has been three weeks since the initial
administration of the measles, mumps, and rubella (MMR) vaccine, which is the
best response by the nurse?
Call the parents and explained that the child will need to be seen in the next week
to receive the second dose of the MMR vaccine.
According to the CDC, the MMR vaccine requires a 4 week time period between the first
and second doses.
An adolescent client diagnosed with attention deficit hyperactive disorder (ADHD)
asked why methylphenidate was prescribed. The nurse educates the client and
parents that methylphenidate is prescribed for which desired effect?
Central nervous system stimulant
Central nervous system stimulants improve concentration and adaptive behavior.
Pharmacological therapy is useful in the management of attention deficit hyperactive
disorder.
The nurse cares for a toddler, client with nausea, vomiting, and diarrhea. Which
intervention is best for the nurse to perform to maintain an adequate fluid intake?
Offer oral rehydration solutions (ORS) to rehydrate.
If the child is vomiting, the nurse gives a small amount of oral rehydration solution at
frequent intervals. Oral rehydration solution contain sodium potassium chloride, citrate,
and glucose, which are necessary for homeostasis.
, During a well child, check up for a six month old client. The parent reports the
client received the first DTaP at two months of age and has received no other
vaccinations. Which action by the nurse is most appropriate?
Give second DTaP.
By the age of six months, the child should be ready for the third immunization when the
schedule has been interrupted it is appropriate to simply continue with the schedule.
The nurse instructs the parents of a school-age client about how to collect a 24
hour urine specimen at home using a clean, empty container. Which size
container does the nurse recommend that the client use for the collection?
A 48 ounce (1440 ml) collection container.
The expected amount of urine output in a 24 hour period for school age child is about
1200 mL. A 48 ounce collection container would be best to hold the expected 40 ounces
of urine .
The clinic nurse teaches a parent how to care for a child with impetigo. Which
information does the nurse include in the teaching plan?
Soften and remove crust and debris.
Care of the affected skin is important to prevent worsening wounds The parent should
remove crust in debris by softening then with solution compresses, then apply topical
bactericidal ointment to the affected areas.
The nurse observes a child client walk up and down steps the nurse notes. The
child has a steady gait and can use short sentences. The nurse estimates the
child's age to be how many months?
24 months
The 24 month old child goes up and downstairs alone runs well with a wide stance,
build a tower of 67 blocks and has a vocabulary of about 300 words.
A parent brings a newborn to the healthcare providers office. The newborn is
vomiting, has a domino distention, and is diagnosed with pyloric stenosis. Which
characteristic of the newborns emesis does the nurse expect?
Projectile and forceful
nurse knows a cyanotic congenital heart defect is associated with which
symptom as reported by the parent?
Poor feeding with no or very poor weight gain.
Reports of poor feeding, difficulty feeding, and poor weight gain or no weight gain are
symptoms that occur in infants with congenial heart defects.
The nurse performs a home care visit for a young adult diagnosed with cystic
fibrosis. The nurse intervenes if which finding is disscussed?
She takes pancreatic enzymes one hour after eating.
Enzymes should be taken at the beginning of a meal, with a snack, or within 30 mins. of
eating.
A client delivers a healthy 8-lb, 2 oz. newborn. The client mentions to the nurse
that the newborn's "soft spot" bulges out when the newborn cries. Which
statement made by the nurse is most appropriate?
Anterior fontanel will normally bulge out when the newborn coughs/cries.
Fontanels should feel flat, firm, and well-demarcated when the newborn is at rest.
Coughing/crying may cause the anterior fontanel to bulge.
A school-age client is admitted to the hospital with a diagnosis of idiopathic
hypopituitarism. Which clinical manifestation is the nurse most likely to observe?
Short stature
Pediatric clients with idiopathic hypopituitarism characteristically have short stature and
slow growth.
The newborn nursery nurse provides care for a client diagnosed with hip
dysplasia. The nurse anticipated which treatment to be prescribed for the client?
Pavlik harness
,Pavlik harness is used to treat hip dysplasia in newborn clients to stabilize and keep the
hip joint in proper alignment.
The nurse performs assessments on infants at the health department. The nurse
identifies which finding as an early indication of cerebral palsy (CP)?
The 4-month-old infant lacks head control.
The earliest indicator of CP is delayed gross motor development. Signs include stiff/rigid
arms/legs, arching back, and floppy/limp body posture.
The nurse in a pediatric clinic is completing health record audits and noticed that
a preschool client is on a delayed immunization schedule per the parents request.
The client is five years old and it has been three weeks since the initial
administration of the measles, mumps, and rubella (MMR) vaccine, which is the
best response by the nurse?
Call the parents and explained that the child will need to be seen in the next week
to receive the second dose of the MMR vaccine.
According to the CDC, the MMR vaccine requires a 4 week time period between the first
and second doses.
An adolescent client diagnosed with attention deficit hyperactive disorder (ADHD)
asked why methylphenidate was prescribed. The nurse educates the client and
parents that methylphenidate is prescribed for which desired effect?
Central nervous system stimulant
Central nervous system stimulants improve concentration and adaptive behavior.
Pharmacological therapy is useful in the management of attention deficit hyperactive
disorder.
The nurse cares for a toddler, client with nausea, vomiting, and diarrhea. Which
intervention is best for the nurse to perform to maintain an adequate fluid intake?
Offer oral rehydration solutions (ORS) to rehydrate.
If the child is vomiting, the nurse gives a small amount of oral rehydration solution at
frequent intervals. Oral rehydration solution contain sodium potassium chloride, citrate,
and glucose, which are necessary for homeostasis.
, During a well child, check up for a six month old client. The parent reports the
client received the first DTaP at two months of age and has received no other
vaccinations. Which action by the nurse is most appropriate?
Give second DTaP.
By the age of six months, the child should be ready for the third immunization when the
schedule has been interrupted it is appropriate to simply continue with the schedule.
The nurse instructs the parents of a school-age client about how to collect a 24
hour urine specimen at home using a clean, empty container. Which size
container does the nurse recommend that the client use for the collection?
A 48 ounce (1440 ml) collection container.
The expected amount of urine output in a 24 hour period for school age child is about
1200 mL. A 48 ounce collection container would be best to hold the expected 40 ounces
of urine .
The clinic nurse teaches a parent how to care for a child with impetigo. Which
information does the nurse include in the teaching plan?
Soften and remove crust and debris.
Care of the affected skin is important to prevent worsening wounds The parent should
remove crust in debris by softening then with solution compresses, then apply topical
bactericidal ointment to the affected areas.
The nurse observes a child client walk up and down steps the nurse notes. The
child has a steady gait and can use short sentences. The nurse estimates the
child's age to be how many months?
24 months
The 24 month old child goes up and downstairs alone runs well with a wide stance,
build a tower of 67 blocks and has a vocabulary of about 300 words.
A parent brings a newborn to the healthcare providers office. The newborn is
vomiting, has a domino distention, and is diagnosed with pyloric stenosis. Which
characteristic of the newborns emesis does the nurse expect?
Projectile and forceful
