MATERNAL FINAL EXAM REVIEW, complete 100% Updated 2026 - Rasmussen College.

MATERNAL FINAL EXAM REVIEW – • The nurse is caring for a 5-year-old child with a central venous access device (CAD) for chemotherapy administration. Which action by the nurse is most appropriate? o Allow the child to play freely without restrictions. o Change the occlusive dressing every two weeks. o Allow the child to hold the medication filled syringes. o Flush the line with heparin or saline as per protocol. • The nurse is caring for a child with growth hormone deficiency who is receiving recombinant human growth hormone (rhGH) therapy. The child's parent expresses concern about the child's recent reports of hip pain and limping. Based on this information, which action would the nurse take? o Reassure the parent that hip pain is a common side effect of rhGH therapy o Observe the child's ambulation for signs of slipped capital femoral epiphysis o Suggest the parent apply a warm compress to the child's hip o Advise the parent to increase the child's physical activity to strengthen the hip muscles • The nurse is planning care for a 6-year-old child admitted with dehydration secondary to influenza. The child has a congenital hearing impairment and uses a hearing aid. The child is also learning to read lips. Which nursing intervention ensures effective communication with the child? Select all that apply. o Provide written communication for all interactions. o Communicate only through the child's parents. o Incorporate visual aids when communicating. o Use a sign language interpreter for all communications o Ensure the child's hearing aid is functioning. • The nurse cares for a G4P4 postpartum client who delivered a macrocosmic term infant 2 hours ago via cesarean section. The client's pregnancy was complicated by gestational diabetes controlled with diet. What initial assessment does the nurse prioritize? o Blood glucose levels. o Fundal height and tone. o Comfort and pain level. o Skin integrity and incision. • A child with a neurological disorder is undergoing a lumbar puncture. Which action would the nurse take to minimize the risk of a post-procedure headache? o Encourage the child to ambulate after the procedure o Encourage the child to lie flat for at least 30 minutes o Apply a cold compress to the puncture site o Allow the child to drink a caffeinated drink after the procedure • A nurse working in a homeless shelter provides care to a child who was a victim of emotional neglect. Which assessment findings would the nurse anticipate in this child? o Multiple fractures at various stages of healing. o Antisocial or withdrawing from social interaction.o Bruises and burns on the buttocks. o Pain on urination and itching of the genital area. • A nurse is providing discharge teaching to a postpartum client. What does the nurse educate the client to report to their provider immediately? o Feeling tired and needing frequent naps o Mild cramping and light bleeding. o Moderate breast tenderness and fullness. o Increased lochia flow with larger clots. • A nurse is educating parents on preventing child maltreatment. Which recommendation should the nurse prioritize? o Enroll the child in multiple extracurricular activities. o Avoid discussing stressful topics in front of the child. o Use physical discipline sparingly and only when necessary. o Establish a strong support network of family and friends. • A child with Cushing syndrome presents with a moon-faced appearance, low serum protein levels due to muscle wasting, and consistent blood pressures averaging between 160-180/90-95 mmHg. The healthcare provider has written several orders. As the nurse is planning care for this child, which intervention would be prioritized to address the underlying cause of these symptoms? o Schedule the child for surgical removal of the adrenal tumor o Encourage the child to engage in muscle-strengthening exercises o Provide a low-sodium diet to manage hypertension o Administer an antihypertensive medication • A nurse is evaluating a postpartum client's understanding of self-care after discharge. Which statement by the client indicates a need for further teaching? o "I will monitor the color and amount of my lochia." o "I can use tampons to manage my lochia flow." o "I will call my healthcare provider if I develop a fever." o "I will wash my hands before and after perineal hygiene." • During a well-child visit, a nurse is discussing anticipatory guidance with the caregivers of a 9-month-old infant. Which advice should the nurse prioritize to prevent unintentional injuries as the infant begins to crawl? o Encourage the purchase of soft toys only o Schedule regular developmental screenings o Install stairway gates and cabinet locks o Ensure the infant's diet includes sufficient iron • A nurse is planning care for a child with a chronic illness and their family. Which outcome is most realistic and supportive of the family's adjustment to the illness? o The family will relocate to be closer to a specialized treatment center. o The parents will avoid discussing the illness to protect the child's emotional well-being. o The family will plan for the child to be cured of the illness within sixmonths. o The family will develop a daily routine that incorporates the child's care needs. • A 7-year-old child undergoing chemotherapy for leukemia is experiencing severe nausea and vomiting. The parents are concerned about the child's nutritional intake. Which nursing intervention is most appropriate to address this issue? o Suggest small, frequent, high-calorie meals throughout the day. o Advise the parents to give the child their favorite foods regardless of nutritional value. o Encourage the child to eat large meals three times a day. o Administer intramuscular antiemetics when the child starts vomiting. • A 10-year-old child is brought to the emergency department with a head injury after falling from a bicycle. The child is conscious but has a headache and nausea. The nurse notes that the child's left pupil is more dilated than the right and reacts sluggishly to light. Which action would the nurse prioritize in this situation? o Providing reassurance to the child and parents. o Administering pain medication for the headache. o Giving intravenous dexamethasone to decrease inflammation. o Preparing the child for a CT scan of the head. • A client with a history of severe dysmenorrhea is considering a non-hormonal intrauterine device (IUD) for contraception. Which statement by the nurse is most appropriate? o This type of IUD may be spontaneously expelled at a higher rate due to the heaving bleeding associated with dysmenorrhea." o This type of IUD may cause uterine cramping for a few weeks but will help to improve the symptoms associated with dysmenorrhea over time." o This type of IUD will not have a positive or negative impact on symptoms associated with dysmenorrhea." o This type of IUD may not be the best choice because it may worsen the symptoms associated with dysmenorrhea." • During a home visit, a nurse observes that a 4-month-old infant is frequently placed in a semi-reclined position in a swing for naps. Which instruction by the nurse is most appropriate? o Allow the infant to sleep in the parent's bed for better supervision. o Place the infant on their back in a crib for naps and nighttime sleep. o Use a car seat for naps as it provides a safer semi-reclined position. o Continue using the swing as it helps the infant sleep longer. • A 10-month-old infant is brought to the clinic for a well-baby visit. The parent states that the infant is not yet creeping or crawling. Which action by the nurse is most appropriate? o Refer the infant to a neurologist for further evaluation. o Assess the infant's overall development and motor skills. o Advise the parent to use a baby walker to encourage movement. o Suggest the parent enroll the infant in a physical therapy program. • A nurse is assessing a 3-year-old child who presents with multiple bruises in variousstages of healing and a spiral fracture of the arm. The parent reports the child fell off the couch. What should the nurse's next step be? o Advise the parent to be more careful in supervising the child. o Interview the child in the presence of the parent to verify the story. o Accept the parent's explanation and document the findings. o Report the findings to the child protection team for further investigation. • A client in labor is experiencing intense pain and is unable to relax for a vaginal examination. Which action should the nurse perform first? o Administer an oral analgesic as quickly as possible. o Perform the vaginal examination quickly to minimize discomfort. o Encourage the client to use controlled breathing techniques. o Ask the client to rate their pain on a scale of 1 to 10. • A 4-year-old child is brought to the emergency department after sustaining a burn injury from hot water. The child is crying and appears to be in pain. The burn covers the child's chest and is blistered and weeping fluid. Which action would the nurse perform first? o Administer oral pain medication. o Cover the burn with a dry, sterile dressing. o Gently place a topical antibiotic on the burn area. o Apply cool water to the burn area. • A 5-year-old child with cerebral palsy (CP) is having trouble with self-care activities. Which intervention would be most appropriate for the nurse to implement? o Limit the child's participation in self-care to prevent frustration o Perform all self-care activities for the child o Encourage the use of adaptive devices for feeding and dressing o Promote rest periods in between activities. • A child is brought to the emergency department after ingesting a caustic substance. The child has immediate pain in the mouth and throat and is drooling saliva. Which action would the nurse take? o Provide strong analgesics for pain relief. o Administer activated charcoal. o Perform an endoscopy to assess the extent of the injury. o Induce vomiting to remove the substance • An adolescent returns to the clinic for a 6-month follow-up after beginning insulin pump therapy for type 1 diabetes mellitus. Which finding most strongly indicates that the therapy is effective? o The adolescent reports less frequent episodes of hypoglycemia o The adolescent has gained weight since starting the therapy o The adolescent's blood glucose levels fluctuate widely throughout the day o The adolescent's HbA1C level is within the target range • The nurse is planning care for a child with severe atopic dermatitis who is experiencing intense pruritus and secondary infections. Which interventions would the nurse include? Select all that apply.o Administer antihistamines to control the itching. o Recommend daily baths with hot water to cleanse the skin thoroughly. o Suggest the use of tight clothing to prevent scratching. o Frequent application of fragrance-/dye-free moisturizer. o Encourage the use of scented lotions to keep the skin moisturized. • A client in the transition phase of labor is experiencing intense discomfort and expresses a feeling of loss of control. What is the most appropriate nursing intervention? o Perform a quick vaginal examination to assess progress. o Encourage the client to use focused breathing techniques. o Provide a detailed explanation of the labor process. o Increase the dose on the epidural anesthesia immediately. • A nurse is educating a parent who is concerned about their newborn's frequent loose stools. The newborn is exclusively breastfed. Which statement by the nurse is most appropriate? o "Loose stools suggest the infant is not getting enough milk and needs supplementation." o "Loose stools are a sign of milk intolerance and may require a change in diet." o "Loose stools are a sign of a possible infection and requires immediate medical attention." o "Loose stools are expected for breastfed infants and indicate proper digestion." • A client who had a cesarean birth is having trouble voiding after the removal of the indwelling urinary catheter. Which action by the nurse is most appropriate? o Reinsert the indwelling urinary catheter immediately. * o Administer a diuretic to stimulate urine production Encourage the client to drink more fluids and attempt to void every 2 hours. o Perform a bladder scan and notify the healthcare provider if the bladder is distended. • A 10-year-old child with a history of asthma is brought to the clinic with reports of increased wheezing and shortness of breath. The child's peak flow meter reading is in the red zone. Based on these findings, which action would the nurse take first? o Schedule a follow-up appointment for the next day o Teach the child breathing exercises to reduce anxiety o Instruct the child to use their rescue inhaler immediately o Advise the child to avoid physical activity • What is the teaching for a child with a newly applied cast on their leg. Which instruction would the nurse provide to prevent complications? o Encourage the child to walk as soon as possible to maintain mobility. o Allow the child to scratch inside the cast if it becomes itchy. o Keep the cast elevated on a pillow to prevent edema. o Avoid moving the casted leg to prevent discomfort. • A nurse is providing education to the parents of a child with juvenile idiopathicarthritis (JIA) about managing the condition at home. Which statement made by the parents indicates a need for further teaching? o We will ensure our child gets plenty of rest and avoids excessive strain on joints. o "We will give our child NSAIDs when their pain level is above 8/10. o "We will encourage our child to do range-of-motion exercises daily. o "We will apply heat to the affected joints to reduce pain and inflammation." • During a prenatal visit, a client reports persistent vomiting beyond the 12th week of pregnancy. What should the nurse analyze as the most likely cause and the most appropriate action? o Expected morning sickness; no further action needed. o Gastroenteritis; recommend over-the-counter antiemetics. o Hyperemesis gravidarum; requires further evaluation and possible hospitalization o Food poisoning; suggest dietary modifications. • The nurse is caring for a child admitted with severe dehydration due to gastroenteritis. Which laboratory finding would the nurse expect to find? Select all that apply. o Elevated hematocrit and hemoglobin levels. o Diminished platelet count o Increased serum sodium levels. o Low urine specific gravity. o Decreased serum potassium levels. • A 7-year-old child is brought to the emergency department after a near-drowning incident in a swimming pool. The child is conscious but lethargic and has a persistent cough. What is the priority nursing action? o Provide warm blankets to prevent hypothermia. o Perform chest physiotherapy to clear the lungs. o Assess breath sounds and Sp02. o Administer fresh frozen plasma. • The nurse is caring for a child who presents with increased intracranial pressure (IC) due to a fall. Which intervention would the nurse prioritize to reduce ICP? o Administer corticosteroids as prescribed o Place the child in a Trendelenburg position o Apply pressure to the jugular veins o Encourage the child to cough frequently • A client with a history of spinal cord injury is concerned about their ability to engage in sexual activities. Which nursing intervention is most appropriate to address this concern? o Suggest the client avoid sexual activities to prevent further injury. o Advise the client to focus on non-sexual forms of intimacy. o Refer the client to a psychologist for counseling on sexual health. o Educate the client on the use of assistive devices to facilitate sexual activities. • A nurse is caring for a child with muscular dystrophy, and the parents express feelings of powerlessness and frustration due to the progressive nature of the disease. Which nursing intervention is most appropriate to help the family cope withthese feelings? o Suggest that the parents focus on the positive aspects of their child's condition. o Recommend that the parents seek a second opinion from another healthcare provider. o Advise the parents to avoid discussing the disease progression with their child to limit related anxiety. o Encourage the parents to join a support group for families with children who have muscular dystrophy. • A client with a history of a previous cesarean section presents to the emergency department in labor and is experiencing signs of uterine rupture. What is the nurse's priority action? o Initiate oxytocin infusion. o Monitor contraction frequency and intensity. o Prepare for an emergency cesarean section. o Administer pain medication. • A 3-year-old child with bronchiolitis is being discharged home. Which instruction would the nurse provide the parents to manage the child's care safely at home? o Administer antibiotics as prescribed o Use a cool mist vaporizer in the child's room o Keep the child in a lying flat position to ease breathing o Restrict the child's fluid intake to prevent overhydration • During a health assessment, the nurse observes that a 3-year-old child exhibits egocentric behavior and has difficulty sharing toys with other children. Which instructions would the nurse provide the parents to address the child's behavior? Select all that apply. o Provide strategies that encourage the child to share. o Avoid playdates until the child learns to share. o Explain this is a normal developmental stage for preschoolers. o Give the child more toys to reduce conflicts over-sharing. o Discipline the child more strictly to enforce sharing. • A nurse is evaluating a newborn's Apgar score at 1 minute of life and notes the following: heart rate 90 bpm, weak cry, some flexion of extremities, grimaces when stimulated, and body pink with blue extremities. What APGAR score does the nurse document? o 6 o 5 o 0 3 o 4 • A client who weighs 66 pounds is prescribed ceftriaxone IV 50 mg/kg/day, to be administered in two equal doses. The medication available is labeled as 100 mg/mL. How many milliliters (mL) will the nurse administer per dose? Round to the nearest tenth. o 7.5 mL • A 5-year-old child is brought to the emergency department by their parents with severe nausea, vomiting, and diarrhea. The child is diagnosed with influenza. Which findings would provide the most information about the child's hydrationstatus? Select all that apply. o Decreased urine output o Frequency of bowel movements o Pale mucous membranes o Increased urine specific gravity o Elastic skin turgor • A 12-year-old child is experiencing anxiety about starting middle school and has developed tics such as throat clearing and finger tapping. Which nursing intervention would the nurse implement? o Instruct the parents to discipline the child for displaying these behaviors. o Ignore the behaviors as they will resolve on their own. o Refer the child to a neurologist for further evaluation. o Inform the parents these behaviors are often stress-related and suggest strategies to reduce anxiety. • During a prenatal visit, a nurse measures the fundal height of a client at 28 weeks gestation and finds it to be 24 cm. What does the nurse suspect is the most likely cause of this finding? o The client is likely experiencing polyhydramnios. o The client is pregnant with twins. o The client was diagnosed with gestational diabetes. o The pregnancy length was previously miscalculated. • A 4-year-old child with a history of asthma is brought to the emergency department with difficulty breathing. The nurse needs to administer a bronchodilator via a nebulizer and the child is anxious and uncooperative. Which actions would the nurse take to ensure effective medication administration? Select all that apply. o Give the medication orally instead of using the nebulizer. o Restrain the child and administer the medication quickly. o Ask the parents to help calm and relax the child. o Explain the procedure to the child using age-appropriate language o Administer the medication while the child is sleeping. • A nurse is reviewing the Healthy People 2030 goals related to maternal and child health. Which research topic is most relevant to explore to advance evidence-based practice in this area? o The effectiveness of prenatal care in reducing maternal mortality rates. o The role of diet in managing chronic illnesses in adults. o The impact of social media on adolescent mental health. o The influence of workplace stress on employee productivity. • A nurse is assessing a child with suspected intellectual disability. Which action should the nurse take to ensure a comprehensive assessment? o Obtain a detailed history including developmental milestones and family history. o Use a standardized IQ test without considering cultural differences. o Focus primarily on the child's academic performance. o Rely on the parents' description of the child's behavior without further evaluation.• The nurse is preparing discharge instructions for the parents of a school-age child who has been hospitalized for an acute illness. Which information would the nurse include in the discharge plan? Select all that apply. o A list of the child's favorite activities. o A summary of the child's hospital stay. o When to follow up with their healthcare provider. o Information on the child's school performance. o Detailed instructions on the child's medication regimen. • A newborn is placed under phototherapy treatment for jaundice. Which action by the nurse is most appropriate? o Applying lotion to the newborn's skin to prevent dryness o Ensuring the newborn's eyes are covered to protect from light. o Turning off the phototherapy lights during feedings. o Keawing the newborn clothed to maintain body temperature. • A child with a brain tumor is scheduled for radiation therapy. The parents ask about the potential long-term side effects. What does the nurse include in the discussion? o Potential for learning disabilities and cognitive challenges. o Minimal impact on pediatric bone growth. o Immediate hair regrowth after therapy. o Long-term psychological depression. • The nurse is assessing a child with suspected infective endocarditis. Which findings would the nurse anticipate finding during the assessment? Select all that apply. o Petechiae o Heart murmur o Wheezing o Rash o Abdominal pain o High fever • A nurse completes closed tracheal suctioning of the endotracheal tube in a client on a ventilator. Which would be the best measure indicating this procedure was effective? o The pressure alarm is not sounding on the ventilator indicating patency. o The client's breath sounds are clear to auscultation throughout lung fields. o There is no visible water in the endotracheal tube or ventilator tubing. o The client is not coughing up secretions and is not using accessory muscles. • The nurse is aware of the special needs of children related to pain assessment. What is the priority for the nurse to consider when completing a pain assessment? o Reason for the pain o Chronological age of child o Pain medication used and last dose administered o Developmental age of child • The nurse is preparing to administer IV fluid to a 2-year-old child admitted to thehospital with a second-degree burn to the chest. Which assessment would the nurse perform prior to administering IV fluids with potassium? o Blood pressure o Urine output. o Respiratory rate. o Pain level. • The nurse is caring for a child diagnosed with varicella who has lesions at multiple stages. Which nursing action would the nurse take to manage the child's symptoms and prevent transmission? o Isolate the child until all lesions have crusted over. o Apply topical antibiotics to all lesions. o Encourage the child to take frequent baths with oatmeal-based products. o Administer acetaminophen for fever and pruritus. • A nurse is caring for a child with a chronic illness who is experiencing frequent hospitalizations. What strategy should the nurse implement to improve the child's quality of life? o Limit the child's interactions with peers to prevent infections and complications. o Encourage the child to participate in normal daily activities as much as possible. o Advise the family to avoid discussing the illness with the child or in front of the child. o Focus on managing the child's physical symptoms and minimizing complications. • The parents of a 4-year-old child bring their child to Urgent Care due to wheezing and shortness of breath. The child has a history of asthma and is exhibiting a peak expiratory flow rate (PER) that is significantly lower than their personal best. Which action would the nurse take first? o Prepare for emergency intubation. o Give a short-acting beta-agonist. o Instruct on use of incentive spirometry. o Administer an antihistamine. • The nurse is conducting a prenatal assessment and notes that the client has a history of gestational diabetes. What is the most appropriate nursing action? o Advise the client to avoid all sugary foods and drinks. o Schedule the client for an early glucose tolerance test. o Suggest the client monitor her blood sugar levels at home. o Reassure the client that gestational diabetes will not recur. • The nurse cares for an infant with fluid overload secondary to heart failure. The nurse assesses the client's respiratory status. Which findings would the nurse anticipate? o Nasal flaring and bradypnea. o Rhonchi and intercostal retractions o Diminished breath sounds and good aeration. o Increased work of breathing and tachypnea. • A child with hemophilia A is admitted with a swollen, painful knee after a minor fall.Which action would the nurse take first? o Apply a warm compress to the knee. o Administer factor VII replacement therapy. o Encourage the child to perform range-of-motion exercises. o Elevate the affected leg and apply ice. • During a home visit, a nurse observes that the parents of a child with Type 1 diabetes mellitus are struggling to manage the child's blood glucose levels. What is the most appropriate nursing action to support the family? o Provide the parents with additional printed educational materials on diabetes management. o Arrange for a follow-up visit with a diabetes educator to review and reinforce management techniques. o Suggest that the parents take turns managing the child's care to reduce individual stress. o Recommend that the parents consider using complementary therapies to manage the child's condition. • A client in their second trimester is experiencing increased vaginal discharge and is concerned about its significance. Which question is most important for the nurse to ask to gather further cues? o "What is the color and consistency of the discharge?" o "What kind of personal hygiene products do you use?" o "What would you estimate your daily water intake as?" o "How often have you been sexually active in the past week?" • The nurse is caring for a 7-year-old child who is scheduled for surgery. The child is visibly anxious and has been asking many questions about the procedure. Which approach would the nurse take to help reduce the child's anxiety? o Provide the child with a detailed, technical explanation of the surgery. o Avoid discussing the surgery to prevent further anxiety. o Use age-appropriate language and visual aids to explain the procedure. o Tell the child not to worry and that everything will be fine. • A child diagnosed with a brain tumor is experiencing increased intracranial pressure (IC). Which assessment cue is most concerning to the nurse? o Diplopia. o Projectile vomiting o Morning headache. o Mild irritability. • A 6-year-old child is seen in the emergency department after a head injury. The child is conscious but has no memory of the event and is vomiting. The parents ask if the vomiting is due to a gastrointestinal infection they had last week. Which actions would the nurse take to determine the cause of the vomiting? Select all that apply. o Monitor for signs of increased intracranial pressure. o Assess the child's temperature and abdominal pain.o Review the child's recent dietary intake. o Perform a neurological assessment. o Administer antiemetic medication and observe the response. • A couple is developing a birth plan and wants to include their older child in the birth experience. What should the nurse analyze to ensure this is a positive experience for the family? o The child's developmental level and ability to handle the birth experience. o The couple's available support from extended family members. o TR couple's preference for use of medications to assist the birth. o The hospital's policy on children being present in the delivery room • A client who had a cesarean birth is experiencing constipation. Which actions by the nurse are most appropriate? Select all that apply. o Encourage increased fluid intake. o Administer a suppository. o Administer an oral laxative. o Request an oral stool softener. o Recommend a high-fiber diet. • After a cesarean birth, a client is reluctant to ambulate due to pain. Which action by the nurse is most appropriate? o Explain the importance of ambulation and provide adequate pain relief. o Allow the client to remain in bed until they feel ready to walk. o Use a wheelchair to transport the client around the unit. o Schedule physical therapy sessions to assist with ambulation. • A nurse observes several toddlers playing in the hospital playroom. Which play behaviors should the nurse anticipate in children of this age group? o The children are cooperating and playing school with an assigned teacher and students. o The toddlers are playing with different toys in their own spots around the playroom and not aware of each other. o The children are eagerly sharing toys and are happily giving toys to one another. o The children are playing with the same toys but largely playing independently next to each other. • A nurse observes several toddlers playing in the hospital playroom. Which play behaviors should the nurse anticipate in children of this age group? o The children are cooperating and playing school with an assigned teacher and students. o The toddlers are playing with different toys in their own spots around the playroom and not aware of each other. o The children are eagerly sharing toys and are happily giving toys to one another. o The children are playing with the same toys but largely playing independently next to each other. • A pediatric nurse is caring for children on a surgical unit. When would the nurse advocate for the use of a patient-controlled analgesia (PCA)?o If the child is interested in administering their own medication o If the child's pain is constant or frequent o If the child is 5 years old or older o If the child has intermittent pain • The nurse is assessing a 10-year-old child who has been hospitalized for 10 days following a nephrectomy. The child is having trouble sleeping due to being hospitalized. Which parameter would the nurse assess to improve the child's sleep? o Social interactions with peers. o Diet and fluid intake. o Bedtime routine and environment. o Academic performance. • The nurse is educating the parents of a child with diabetes insipidus about the importance of medication compliance. Which statement made by the parent indicates a need for further teaching? o "I will ensure my child drinks plenty of fluids throughout the day." o "I will monitor my child's urine output and notify the healthcare provider if it increases." o "I will give the desmopressin nasal spray as prescribed, even if my child seems better." o "I will reduce the desmopressin dose if my child is drinking less water." • A child with a history of seizures is being evaluated for medication management, Which statement made by the parent indicates a need for further education? o "I will monitor for signs of bruising or bleeding and report them." o "I will give the medication with food to minimize stomach upset." o "I will shake the liquid medication thoroughly before each dose." o "I will stop the medication if my child has no seizures for a week." • A child with a history of seizures is being evaluated for medication management. Which statement made by the parent indicates a need for further education? o "I will monitor for signs of bruising or bleeding and report them." o "I will give the medication with food to minimize stomach upset." o "I will shake the liquid medication thoroughly before each dose." o "I will stop the medication if my child has no seizures for a week.. • A nurse is preparing a preschool aged child for a radiologic procedure. The child is visibly anxious and refuses to listen to explanations. Which action would the nurse implement to help the child? o Force the child to listen to the explanation. o Tell the child that the procedure will not hurt. o Use a toy or game to distract the child and explain the procedure in simple terms. o Schedule the procedure without the child's knowledge to avoid anxiety. • A 6-year-old child with a history of cystic fibrosis is admitted with pneumonia. The child has a productive cough with thick, tenacious sputum. Which intervention would the nurse prioritize to improve the child's respiratory status?o Performing percussion and postural drainage o Providing a high-calorie, high-protein diet o Administering intravenous antibiotics o Encouraging the child to rest in bed • The nurse is assessing a client who is considering using a diaphragm for contraception. Which client cue is most concerning to the nurse? o The client experiences irregular menstrual cycles and moderate dysmenorrhea. o The client reports feeling confident in the steps of diaphragm insertion and removal. o The client reports dissatisfaction with condoms and reports they do not use them. o The client has a history of frequent and recurrent urinary tract infections (UTIs). • A 10-year-old child with a suspected neurologic disorder is scheduled for a computed tomography (CT) scan. Which nursing actions would the nurse take to ensure the child's safety during the procedure? Select all that apply. o Watch a video with the child showing how a CT scan works o Administer a sedative to the child before the scan o I Encourage the child to drink plenty of fluids before the scan o Explain the procedure in detail to the child o Ensure the child remains still during the scan • A 5-vear-old child with sickle cell anemia is experiencing an acute pain crisis and requires intravenous (IV) fluids. When preparing to insert an IV catheter, which site would be appropriate for this child? o Antecubital fossa o Scalp vein o Temporal vein o Dorsal surface of the hand • The nurse is educating a client in their first trimester about the importance of folic acid intake. Which teaching point does the nurse emphasize? o Folic acid supports the maternal immune system. o Folic acid prevents neural tube defects in the fetus. o Folic acid helps minimize morning sickness. o Folic acid reduces the risk of gestational diabetes. • The healthcare provider has prescribed a body brace for a child with scoliosis that is to be worn for 23 hours a day. The child reports discomfort so they choose not to wear the brace as prescribed. Which action would the nurse take? o Refer the child to a physical therapist for alternative treatments. o Explain the importance of wearing the brace to prevent worsening of the condition. o Suggest the child wear the brace only during the day. o Reprimand the child for not following the treatment plan. • A child with leukemia is experiencing neutropenia. Which action by the nurse is priority? o Administer live-virus vaccines to boost immunity.o Allow the child to play with similarly aged children o Encourage frequent handwashing and limit visitors. o Avoid any procedure involving a needle stick. • A 12-year-old client is discovered to have moderate hypertension on several subsequent blood pressure readings. The nurse provides instructions to reinforce the health care provider's recommendations. What does the nurse include in this teaching as part of the client's recommended treatment? Select all that apply. o Smoking cessation, if indicated. o Early and aggressive use of antihypertensive medications. o Emphasize the importance of weight loss. o Stress management and stress-reducing play. o A low-salt, low-sugar diet. o Prepare the child's meals separately from the family's meals. o Increasing vegetables and eliminating fruit. o Exercise that meets the client's interests and activities. o Use of low-fat dairy products in the diet. • A child with congenital hypothyroidism is being treated with synthetic thyroid hormone. During a follow-up visit, the nurse notes that the child has dry skin, fatigue, and little growth. Which parameter would the nurse assess to determine the effectiveness of the current treatment? o Dietary intake and physical activity levels o Immunization history o Family history of thyroid disorders o Serum T4 and T3 levels • The nurse is reviewing the laboratory results of a client who is pregnant and notes a positive rubella titer. What is the most appropriate nursing action? o Refer the client for further evaluation and possible treatment. o Schedule the client for a rubella vaccination immediately. o Advise the client to avoid contact with individuals who have rubella. o Reassure the client that they are immune to rubella. • A patient weighing 70 kg is prescribed vancomycin 10 mg/kg every 12 hours. The medication is available as 500 mg/10 mL. How many milliliters (mL) will the nurse administer per dose? Round to the whole number. o 14 mL CASE STUDY (6 Questions) • Nursing Notes --– Date: 4/6. --- Time: 1130 A 2-year-old client brought to a pediatric urgent clinic by parent. Parent reports client had a viral illness about 6 weeks ago and has not fully recovered. Parent reports client has become more and more fatigued since the illness. Parents also report fussiness outside of client’s normal behavior. On assessment client has lost 7 pounds since last well-child visit 3 months ago. Client skin pale with poor skin turgor, warm to the touch. Client afebrile. Breathing somewhat deep and rapid, lung sounds clear. Sweet odor notes to breath. Mucusmembranes dry and pink. Thin, green nasal secretions noted with some dried around nares, Mild diaper rash to bilateral buttock, skin intact. Parent states, “It seems like her diaper is always wet, even when I just changed it.” Bowel sounds active in all quadrants. Client sits on parent’s lap and buries head into parent’s chest and does not answer questions during assessment. o #1: Which clues are most concerning to the nurse? Select all that apply. ▪ Nasal secretions ▪ Hydration status ▪ Bowel assessment ▪ Respirations ▪ Reported energy level ▪ Mucous membranes ▪ Weight loss ▪ Diaper rash ▪ Breath odor ▪ Observed client behavior o #2: For each question by the nurse to the patient, specify if the question is indicated or not indicated for this client. ▪ “Did your child run a high fever during the recent illness?” • Not indicated ▪ “How many wet diapers per day is your child producing?” • Indicated ▪ “What makes the child become fussy?” • Indicated ▪ “What time is your child’s typical bedtime? • Not Indicated ▪ “How has your child’s appetite been since the recent illness?” • Indicated ▪ “What does your child typically drink throughout the day?” • Indicated • Nursing Notes --- Time: 1200 Client’s parent answers RN question. Parent reports client has “good” appetite stating, “He wants to eat all day. I figured it was a growing spurt.” Parent also reports client has good fluid intake and states, “He is always drinking. I have to fill his sippy cup multiple times throughout the day.” Parent also reports client is urinating frequently and reports many episodes of the client peeing through the diaper. • Lab Results Glucose Serum: 408 (Normal Range = 70-140) Glucose Urine: Positive (Normal = Negative)Ketones, Urine: Positive (Normal Range = Positive) o #3: The nurse documents additional assessment data at 1200. Complete the following sentences by choosing from the list of options. ▪ Based on the client assessment and parent reports, the nurse suspects the client may have developed new onset Type 1 Diabetes. The nurse also suspects the client is most likely suffering from a related complication of Diabetic Ketoacidosis. o #4: The nurse documents additional assessment data at 1200. Which immediate actions should the nurse anticipate to treat the client’s condition? Select all that apply. ▪ Continuous cardiac monitoring ▪ Electrolyte replacement and monitoring ▪ Intravenous insulin infusion ▪ Aggressive fluid replacement ▪ Frequent respiratory assessment ▪ Arterial blood gas monitoring ▪ Diabetes sick-day management education ▪ Admission to intensive care unit ▪ Antibiotic therapy ▪ Blood glucose monitoring every 4 hours • Nursing Notes --- Time: 1330 Client admitted to pediatric intensive care unit after diagnosis of DKA related to likely new onset of Type 1 diabetes. Client is alert, but lethargic. Rapid and deep respirations continue. Vital signs are not concerning at this time. Client accompanied by parents. RN started 2 peripheral IV sites. Fluid bolus administered and maintenance fluid infusing in the first PIV site. Newly graduated perception nurse prepares IV insulin for administration and is observed by nurse preceptors. o #5: Select/highlight the correct answer. ▪ Precepting RN verifies medication right and insulin sent from pharmacy. ▪ Blood glucose checked. ▪ Initial bolus and beginning rate calculated and verified by 2 RNs. ▪ Second PIV site flushed, and normal saline carrier flushed and connected to IV site. ▪ Insulin tubing primed and immediately attached to primary tubing ▪ At port closest to client PIV site. ▪ IV pump programmed and verified by 2 RNs. Insulin administration started. • Nursing Notes --- Date: 4/10 --- Time: 0800 A client remains admitted to pediatric ICU for management of DKA as a result of new onset of Type 1 diabetes. The patient remains on IV insulin infusion. The patient’s condition is improving. The patient is alert, and behavior is appropriate for age. The patient has goodappetite, eating well on a diabetic diet. The patient’s blood glucose levels have remained within expected limits for the past 24 hours. DKA is resolved. Anticipate patient transfer to pediatric unit later today. o #6: The client remains admitted to the inpatient pediatric unit. The nurse reviews the most recent notes from 4/10. Complete the following sentences by choosing from the list of options. ▪ The nurse expects the provider to discontinue the regular insulin infusion. The nurse also anticipates a prescription for subcutaneous insulin. Case Study (6 Questions) • Nursing Notes --- Date: 12/3 --- Time: 1330 Client involved in motor vehicle accident. Was in car seat at the time of accident. Car seat was ejected, and infant found strapped in car seat on floor of vehicle back seat. Infant accompanied by parent, not involved in accident. Child is restless and crying, unable to console. Infant laid on exam table for assessment. Infant freely moving bilateral upper extremities and left lower extremity. Minimal free movement noted in right lower extremity. Right lower extremity notes for edema and bruising. On light palpation of right lower extremity, infant withdraws the extremity from RN. Palmar sweating notes bilaterally. The parent states, “I have never heard her cry like this. I am sure she is in a lot of pain.” Neurovascular assessment WNL in all extremities. • Vital Signs --- Date: 12/3 --- Time: 1300 BP: 110/74. --- HR: 174. --- RR: 42. --- Temp: 98.8F (37.1C). --- SPO2: 96% RA. • Time: 1400 Provider notifies of infant assessment. Right lower extremity immobilized. Prescription for opioid pain medication obtained. RN prepares to insert peripheral IV. • Orders --- Date: 12/3 --- Time: 1405 Morphine sulfate 1mg IV push every 4 hours as needed for moderate or severe pain. Give first dose now. Right lower extremity x-ray. • Time: 1500 X-ray confirmed simple, closed, and moderately displaced right femur fracture. Othropedics consulted. Sedation for closed manipulation and casting is scheduled. Infant admitted to pediatric unit for preoperative preparation. Mother of infant, involved in car accident, cleared in emergency department. Both parents accompany infant to pediatric unit. o #1: Review the information in the EHR. For the documented client date, specify if the data is relevant or irrelevant to the parent’s concerns. ▪ Palmar sweating → Relevant ▪ Heart Rate → Relevant ▪ Blood Pressure → Irrelevant ▪ Withdrawal Response → Relevant ▪ Extremity Assessment → Relevant▪ Client’s age → Irrelevant ▪ Temperature → Irrelevant o #2: Review the information in the EHR. Which actions should the nurse include in the plan of care for this procedure? Select all that apply. ▪ Wrap the infant to contain other extremities and promote comfort. ▪ Select an appropriate site in the infant’s hands or unaffected foot. ▪ Place a transparent dressing over the insertion site for consistent monitoring. ▪ Provide comfort measures such as a pacifier during the procedure. ▪ Stop the procedure if the infant cries extensively. ▪ Allow the parent to remain in the room to comfort the infant. ▪ Encourage the parent to hold the infant during the procedure. ▪ Secure the peripheral IV with surgical-grade tape to prevent accidental removal ▪ Apply security device to limb of peripheral IV site to protect and maintain the IV. ▪ Provide analgesic sedation prior to performing the procedure. o #3: The nurse cares for the client in the pediatric unit. Which interventions should the nurse implement to promote safe and developmentally appropriate care for the client? Select all that apply. ▪ Assess the infant with gentle and smooth movements. ▪ Ask the parents to leave the room when the nurse performs cares. ▪ Smile and talk to infant in a calm tone during assessments and cares. ▪ Ensure crib siderails are up at all times when the infant is in the crib. ▪ Complete procedures as quickly as possible to minimize anxiety. ▪ Instruct the parents to leave the infant in the crib at all times. ▪ Provide a pacifier to promote non-nutritive sucking and comfort. ▪ Educate the parents to keep one hand on infant if crib siderail is down. ▪ Demonstrate how to hold infant to prevent further injury. ▪ Place the infant in a room closer to the nurses station. o #4: The nurse prepares to administer medication to the infant. Complete the sentences by choosing from the lists of options. ▪ The nurse verifies the prescribed dose or morphine is appropriate. The nurse’s most appropriate action is to administer the medication. o #5: Select whether the following requires intervention or does not require intervention. ▪ Neurovascular assessment at 1830 • Does not require intervention ▪ Output assessment at 2245 • Requires intervention ▪ IV assessment at 2245 • Requires intervention ▪ Level of consciousness at 1830• Does not require intervention ▪ Pain assessment at 2245 • Requires intervention ▪ Temperature at 1800 • Does not require intervention ▪ Hunger cues at 2245 • Requires intervention o #6: Swelling resolved and neurovascular assessment WNL. Infant pain well controlled on acetaminophen and rest. Parents providing care for infant in hospital. Provider prescribed discharge today. Discharge education provided to parents. Parents asked to repeat education related to cast care. ▪ If I notice the right foot and toes are more swollen, pale, or blue, I need to call the provider immediately. ▪ “I will regularly check the skin around the cast for any areas or irritation or sores.” ▪ “I will ensure the cast does not get wet. We will give a sponge bath and cover the cast with a plastic bag.” ▪ “I will keep my infant lying flat on her back at all times to avoid further injury to the right leg.” ▪ “If I notice any foul smell from under the cast, I will call the provider for further assessment.” ▪ “I will continue to give my infant acetaminophen as needed to control their pain.” Suspect Bacterial meningitis findings? SATA -elevate WBC, arched back, Positive brudzinski/kernig sign Suspect DKA, priority nursing action? Assess the child’s glucose level, assess for ketones in the urine