To take the vital signs of a 4-month old child, which order will give the most accurate results?
A. Respiratory rate, heart rate, then rectal temperature
B. Heart rate, rectal temperature, then respiratory rate.
C. Rectal temperature, heart rate, then respiratory rate
D. Rectal temperature, respiratory rate, then heart rate - ANS A. Respiratory rate, heart rate,
then rectal temperature
The respiratory rate should be taken first in infants, since touching them or performing
unpleasant procedures usually makes them cry, elevating the heart rate and making respirations
difficult to count. Rectal temperature is the most invasive procedure, and is mot likely to
precipitate crying, so should be done last.
When planning the care for a child who has had a cleft lip repair, the nurse knows that crying
should be minimized because it
A. increases salivation
B. increases the respiratory rate
C. leads to vomiting
D. stresses the suture line - ANS D. stresses the suture line
Prevention of stress on the lip suture line is essential for optimum healing and the cosmetic
appearance of a cleft lip repair. Although crying also causes increased salivation, increased
respiratory rate and may lead to vomiting, these conditions do not create a problem for the child
with a cleft lip repair.
A full-term infant is admitted to the newborn nursery. After careful assessment, the nurse
suspects that the infant may have an esophageal atresia. Which symptoms is this newborn
likely to have exhibited?
A. choking, coughing, and cyanosis
B. projectile vomiting and cyanosis
C. apneic spells and grunting
D. scaphoid abdomen and anorexia - ANS A. choking, coughing, and cyanosis
(A) includes the "3 C's" of esophageal atresia caused by the overflow of secretions into the
trachea. (B) is characteristic of pyloric stenosis in the infant. (C) could be due to prematurity or
sepsis, and grunting is a sign of respiratory distress. (D) is characteristic of a diaphragmatic
hernia.
Which behavior would the nurse expect a two-year-old child to exhibit?
A. build a house with blocks
B. ride a tricycle
, C. display possessiveness of toys
D. look at a picture book for 15 minutes - ANS C. display possessiveness of toys
Two-year old children are egocentric and unable to share with other children. (A, B, and D) are
behaviors of a preschooler.
A 5-month-old is admitted to the hospital with vomiting and diarrhea. The pediatrician prescribed
dextrose 5% and 0.25% normal saline with 2 mEq KCI/100 mL to be infused at 25mL/hr. Prior to
initiating the infusion, the nurse should obtain which assessment finding?
A. frequency of emesis is the last 8 hours
B. serum BUN and creatinine levels
C. current blood sugar level
D. appearance of the stool - ANS B. serum BUN and creatinine levels
Regardless of a client's age, adequate renal function must be present before adding potassium
to IV fluids. (A) is important in determining the need for fluid replacement. (C) is not indicated.
(D) is useful information, but will not impact administration of the prescribed IV solution.
A preschool-age child who is hospitalized for hypospadias repair is most strongly influenced by
which behavior?
A. ability to communicate verbally
B. response to separation from family
C. concern for body integrity
D. socialization with other children - ANS C. concern for body integrity
The preschooler's major stressor is concern for his body integrity. He fears that his "insides will
leak out". A child undergoing surgery to his genitalia is even more concerned about body
integrity. the preschooler is quite verbal so comprehension of the words he uses or hears may
be inaccurate, while his imagination and fears may fantasize the reality. (B) is a concern for all
children, but of most concern to the toddler. (D) is not a prime concern in this situation.
The nurse is teaching a 12-year old male adolescent and his family about taking injections of
growth hormone for idiopathic hypopituitarism. Which adverse symptoms, commonly associated
with growth hormone therapy should the nurse plan to describe to the child and his family?
A. polyuria and polydipsia
B. lethargy and fatigue
C. increased facial hair
D. facial bone structure changes - ANS A. polyuria and polydipsia
Signs and symptoms of diabetes or hyperglycemia need to be reported. those receiving growth
hormone should be monitored to detect elevated blood sugars and glucose intolerance.
Lethargy and fatigue are associated with any number of health alterations, but is not associated
with the growth hormone therapy. Increased facial hair and facial bone structure changes are
normal changes that occur with 12-year old males.
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