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The nurse is planning postoperative care
for a child who has had a cleft lip repair.
What is the most important reason to D. Crying stresses the suture line
minimize this child's crying during the
recovery period? Rationale:
A. Tear formation increases salivation. Prevention of stress on the lip suture line
B. This behavior increases respirations. is essential for optimum healing and the
C. Excessive hysteria can lead to vomit- cosmetic appearance of a cleft lip repair.
ing.
D. Crying stresses the suture line
An infant is receiving digoxin for conges- B. Obtain a therapeutic drug level.
tive heart failure. The apical heart rate
is assessed at 80 beats/min. What inter- Rationale:
vention should the nurse implement? Sinus bradycardia (heart rate <90 to 110
A. Call for a portable chest radiograph. beats/min in an infant) is an indication
B. Obtain a therapeutic drug level. of digoxin toxicity, so assessment of the
C. Reassess the heart rate in 30 minutes. client's digoxin level has the highest pri-
D. Administer digoxin immune Fab stat. ority
The nurse admits a child to the intensive
care unit with a possible diagnosis of C. Place a do not palpate abdomen sign
Wilms tumor - What is the most safety on head of bed
precaution for child?
A. maintain NPO status Rationale:
B. Limit visitors to the immediate family Protect child from injury; place a sign
C. Place a do not palpate abdomen sign on bed stating "no abdominal palpation"
on head of bed (to prevent accidental fragmentation and
D. Encourage ambulation in the pre-op- dislodging into the abdominal cavity).
erative period
The nurse is preparing a teaching plan
for the mother of a child who has been
B. Baked chicken, coleslaw, soda, and
diagnosed with celiac disease. Choosing
frozen fruit dessert
which lunch will be within the therapeutic
management of a child with celiac dis-
Rationale:
ease?
A. Turkey salad, milk, and oatmeal cook-
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ies
B. Baked chicken, coleslaw, soda, and
A child with celiac disease is managed
frozen fruit dessert
on a gluten-free diet, which eliminates
C. Tuna salad sandwich on whole wheat
food products containing oats, wheat,
bread, milk, and ice cream
rye, or barley.
D. Turkey sandwich on rye bread, orange
juice, and fresh fruit
B. Remove restraints one at a time and
provide range-of-motion
A 6-month-old male infant is admitted to
the postanesthesia care unit with elbow
Rationale:
restraints in place. He has an endotra-
Removing restraints one at a time is safer
cheal tube and is ventilator-dependent
than option C. The infant should have
but will be extubated soon following re-
the restrained extremities assessed fre-
covery from anesthesia. Which nursing
quently for signs of neurologic or vascu-
intervention should be included in this
lar impairment, and range-of-motion ex-
child's plan of care?
ercises should be performed with these
A. Keep restraints on at all times to pre-
assessments. Under no circumstances
vent unplanned extubation.
should restraints be applied to the client
B. Remove restraints one at a time
continuously. Documentation of assess-
and provide range-of-motion exercises.
ment findings regarding the restrained
C. Remove all restraints simultaneously
extremities must occur much more fre-
and provide play activities.
quently than every 72 hours; however,
D. Document the reason for application
the reason for using restraints must be
of the restraints every 72 hours.
justified and should be stated in the med-
ical record
The nurse assigns an unlicensed assis-
A. Use designated isolation precautions.
tive personnel (UAP) to provide morning
care to a newly admitted child with bac-
Rationale:
terial meningitis. What is the most impor-
All these are important measures to re-
tant instruction for the nurse to review
view with the UAP, but the most important
with the UAP?
is option A. Improper use of isolation pre-
A. Use designated isolation precautions.
cautions can place other staff and clients
B. Keep the lighting in the room dim.
at risk for infection.
C. Allow the parents to assist with care.
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D. Report any pain that the child experi-
ences.
C. Place the child on a clear liquid diet
Rationale:
Intussusception, an invagination or tele-
The nurse is caring for a child with intus- scoping of one portion of the intestine
susception who is scheduled for a bari- into another, causes intestinal obstruc-
um enema prior to a surgical procedure. tion in children (usually occurs between 3
Which action should the nurse take first? months and 5 years of age). Nonsurgical
A. Evacuate the bowel of impacted feces treatment is attempted with hydrostatic
B. Administer magnesium sulfate pressure created by barium instillation,
C. Place the child on a clear liquid diet which often reduces the area of bow-
D. Assess the stool for white color el 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 adminis-
tered for bowel evacuation.
C. Breech presentation
A 3-week-old infant is referred to an or-
Rationale:
thopedic clinic because the pediatrician
Developmental dysplasia of the hip
heard a click when flexing the child's right
(DDH) occurs more often in infants
hip during a routine physical examina-
who present in the breech position, not
tion. The orthopedic physician suspects
the vertex (head-first) position. Twice
that the child might have developmental
as many females as males present in
dysplasia of the hip (DDH). The parents
the breech position; thus, 80% of chil-
ask the nurse to identify risk factors com-
dren with DDH are females, not males.
monly associated with DDH. Which re-
Of breech presentations, 60% occur
sponse is accurate?
with first-born children, not subsequent
A. Vertex delivery
siblings, possibly because of the un-
B. Male gender
stretched uterus and compaction of the
C. Breech presentation
surrounding abdominal contents, which
D. Second-born child
tend to increase compression on the
uterus in the nulliparous woman.