LACHARITY 19 - Pediatric Problems

Question 1

A 3-month-old infant arrives at the health center for a scheduled well-child
visit. The parents ask the nurse why the infant extends the arms and legs in
response to a loud sound. Which response by the nurse is best?
1. Inform the parents that this is a normal reflex that generally disappears by
4 to 6 months of age.
2. Tell the parents that if the behavior does not change by 6 months, the infant
will need further evaluation.
3. Remind the parents that this is a normal response that indicates the infant’s
hearing is intact.
4. Reassure the parents that the behavior is normal and not an indicator of
any problem such as cerebral palsy.

Answer 1

Ans: 1 The infant’s behavior is consistent with the Moro and startle reflexes.
The Moro reflex usually disappears by 6 months of age. The startle reflex
usually disappears by 4 months of age. A hearing test is not based on
response to loud sounds alone. Although it is true that further evaluation
may be needed if the reflexes do not disappear, there is no need for the nurse
to discuss this with the parents at this time. The infant’s behavior is not
consistent with cerebral palsy. Focus: Prioritization; Test Taking Tip: In
studying pediatrics, pay attention to developmental milestones. Moro, startle,
and Babinski reflexes are three classic examples of what the nurse observes
during physical assessment. Can you name others?

Question 2

Which pediatric pain patient should be assigned to a newly graduated RN?
1. An adolescent who has sickle cell disease and was recently weaned from
morphine delivered via a patient-controlled analgesia device to an oral
analgesic; he has been continually asking for an increased dose
2. A child who needs premedication before reduction of a fracture; the child
has been crying and is resistant to any touch to the arm or other procedures
3. A child who is receiving palliative end-of-life care; the child is receiving
opioids around the clock to relieve suffering, but there is a progressive
decrease in alertness and responsiveness
4. A child who has chronic pain and whose medication and
nonpharmacologic regimen has recently been changed; the mother is
anxious to see if the new regimen is successful

Answer 2

Ans: 2 The set of circumstances is least complicated for the child with the
fracture, and this would be the best patient for a new and relatively
inexperienced nurse. The child is likely to have a good response to pain
medication, and with gentle encouragement and pain management, the
anxiety will resolve. The other three children have more complex social and
psychological issues related to pain management. Focus: Assignment.

Question 3

The nurse caring for a 3-year-old child plans to assess the child’s pain using
the Wong-Baker FACES® Pain Rating Scale. Which accompanying
assessment question would be the most useful?
3561. “If number 0 (smiling face) were no pain and number 10 (crying face) were
a big pain, what number would your pain be?”
2. “Can you point to the face picture with one finger and tell me what that
pain feels like inside of you?”
3. “The smiling face has ‘no hurting’; the crying face has a ‘really big hurting.’
Which face is most like your hurting?”
4. “If you look at these faces and I give you a paper and pencil, can you draw
for me the face that looks most like your pain?”

Answer 3

Ans: 3 Pain rating scales using faces (depicting smiling, neutral, frowning,
crying, and so on) are appropriate for young children who may have
difficulty describing pain or understanding the correlation of pain to
numerical or verbal descriptors. The other questions require abstract
reasoning abilities to make analogies and the use of advanced vocabulary.
Focus: Prioritization; Test Taking Tip: When caring for children, you must
use the principles of growth and development to choose the best assessment
tools and to differentiate normal from abnormal findings.

Question 4

The nurse is caring for several children with cancer who are receiving
chemotherapy. The nurse is reviewing the morning laboratory results for
each of the patients. Which patient condition combined with the indicated
357laboratory result would cause the nurse the greatest concern?
1. Nausea and vomiting with a potassium level of 3.3 mEq/L (3.3 mmol/L)
2. Epistaxis with a platelet count of 100,000/mm 3 (100 × 10 9 /L)
3. Fever with an absolute neutrophil count of 450/mm 3 (450 × 10 9 /L)
4. Fatigue with a hemoglobin level of 8 g/dL (80 g/L)

Answer 4

Ans: 3 National guidelines indicate that rapid treatment of infection in
neutropenic patients is essential to prevent complications such as
overwhelming sepsis and secondary infections; therefore, the child with fever
and a low neutrophil count is the priority. A potassium level of 3.3 mEq/L
(3.3 mmol/L) is borderline low and should be monitored. Nosebleeds are
common, and the patient and parents should be taught to apply direct
pressure to the nose, have the child sit upright, and not disturb the clot.
Severe spontaneous hemorrhage is not expected until the platelet count drops
below 20,000 mm 3 (20 × 10 9 /L). Children can withstand low hemoglobin
levels. The nurse should help the patient and parents regulate activity to
prevent excessive fatigue. Focus: Prioritization.

Question 5

A 7-month-old infant arrives at the health center for a scheduled well-child
visit. When the nurse approaches the infant to obtain vital signs, the infant
cries vigorously and clings fearfully to the mother. Which of the following
phenomena provides the best explanation for the infant’s behavior?
1. Separation anxiety
2. Disassociation disorder
3. Stranger anxiety
4. Autism spectrum

Answer 5

Ans: 3 This infant is displaying stranger anxiety; the child becomes anxious
when exposed to unfamiliar people (strangers). Separation anxiety occurs
when the child is separated from the primary caregiver; anxiety and crying
are also common behaviors. Stranger anxiety and separation anxiety are
concurrent and generally begin at 7 to 8 months of age. Disassociation
disorder is characterized by disconnected thoughts and is not a disorder of
370infancy. Autism spectrum is characterized by poor social interaction. The age
of the child is significant because autism is not usually detected at 7 months
of age. Focus: Prioritization.

Question 6

A 6-year-old child who received chemotherapy and had anorexia is now
cheerfully eating peanut butter, yogurt, and applesauce. When the mother
arrives, the child refuses to eat and throws the dish on the floor. What is the
nurse’s best response to this behavior?
1. Remind the child that foods tasted good today and will help her or his
body to get strong.
2. Allow the mother and child time alone to review and control the behavior.
3. Ask the mother to leave until the child can finish eating and then invite her
back.
4. Explain to the mother that the behavior could be a normal expression of
anger.

Answer 6

Ans: 4 Help the mother to understand that the child may be angry about
being left in the hospital or about her inability to prevent the illness and
protect the child. Reminding the child about the food and the purpose of the
food does not address the strong emotions underlying the outburst. Allowing
the mother and child time alone is a possibility, but the assumption would be
that the mother understands the child’s behavior and is prepared to deal with
the behavior in a constructive manner. Asking the mother to leave the child
suggests that the mother is a source of stress. Focus: Prioritization.

Question 7

An 18-month-old child has oral mucositis secondary to chemotherapy. Which
task should the nurse delegate to the unlicensed assistive personnel (UAP)?
1. Reporting evidence of severe mucosal ulceration
2. Assisting the child in swishing and spitting mouthwash
3. Assessing the child’s ability and willingness to drink through a straw
4. Feeding the child a bland, moist, soft diet

Answer 7

Ans: 4 Helping the child to eat is within the scope of responsibilities for a
UAP. Assessing ability and willingness to drink and checking for extent of
mucosal ulceration is the responsibility of an RN. An 18-month-old child is
not able to swish and spit, which could result in swallowing the mouthwash.
Mouthwash is not intended for swallowing because it can contain alcohol and
other ingredients not safe for ingestion. Focus: Delegation

Question 8

The pediatric unit charge nurse is making patient assignments for the evening
shift. Which patient is most appropriate to assign to an experienced
LPN/LVN?
1. A 1-year-old patient with severe combined immunodeficiency disease who
is scheduled to receive chemotherapy in preparation for a stem cell
transplant
2. A 2-year-old patient with Wiskott-Aldrich syndrome who has orders for a
platelet transfusion
3. A 3-year-old patient who has chronic graft-versus-host disease and is
incontinent of loose stools
3584. A 6-year-old patient who received chemotherapy 1 week ago and is
admitted with increasing lethargy and a temperature of 101°F (38.3°C)

Answer 8

Ans: 3 LPN/LVN scope of practice includes care of patients with chronic and
stable health problems, such as the patient with chronic graft-versus-host
disease. Chemotherapy medications are considered high-alert medications
and should be given by RNs who have received additional education in
chemotherapy administration. Platelets and other blood products should be
given by RNs. The 6-year-old patient has a history and clinical manifestations
consistent with neutropenia and sepsis and should be assessed by an RN as
quickly as possible. Focus: Assignment.

Question 9

The pediatric unit charge nurse is working with a new RN. Which action by
the new RN requires the most immediate action on the part of the pediatric
unit charge nurse?
1. Wearing gloves, gowns, and a mask for a neutropenic child who is
receiving chemotherapy
2. Placing a newly admitted child with respiratory syncytial virus (RSV)
infection in a room with another child who has RSV
3. Wearing a N95 respirator mask when caring for a child with tuberculosis
4. Performing hand hygiene with soap and water after caring for a child with
diarrhea caused by Clostridium difficile

Answer 9

Ans: 1 Protective isolation (wearing gloves, gowns, and mask) revealed no
significant differences in infection rates for children who are neutropenic.
General standard precautions are advised with routine patient care. Although
private rooms are preferred for patients who need droplet precautions, such
as patients with RSV infection, they can be placed in rooms with other
patients with exactly the same microorganism. An N95 respirator is
recommended for tuberculosis. Washing hands with soap and water after
caring for a patient with C. difficile is also recommended. Focus: Prioritization.

Question 10

The nurse is preparing to care for a 6-year-old child who has just undergone
allogenic stem cell transplantation. Which nursing tasks should the nurse
delegate to the unlicensed assistive personnel (UAP)? Select all that apply.
1. Stocking the child’s room with standard personal protective equipment
items
2. Teaching the child to perform thorough hand washing after using the
bathroom
3. Reminding the child to wear a face mask outside of the hospital room
4. Assessing the child’s oral cavity for signs and symptoms of infection
5. Talking to the family members about the methods to reduce risk of
infection

Answer 10

Ans: 1, 3 Because all patient care staff members should be familiar with
standard personal protective equipment, a UAP will be able to stock the
room. Reminding the child to wear a face mask is also a task that can be done
by a UAP, although the RN is responsible for the initial teaching. Initially
teaching the child hand-washing technique, nursing assessments, and family
education is within the scope of the registered nurse and not a UAP. Focus:
Delegation.

Question 11

A 4-month-old infant boy is brought to the emergency department by his
parents. He has been vomiting and fussy for the past 24 hours. On exam,
there are circular bruises on his back. What priority assessment does the
nurse anticipate?
1. Chest x-ray examination
2. Ultrasonography of the head
3. Electroencephalography
4. Ophthalmologic examination

Answer 11

Ans: 4 The history and physical examination suggests shaken baby
syndrome. An ophthalmologic examination is indicated to determine if the
infant has retinal hemorrhages characteristic of shaken baby syndrome.
371Electroencephalography may be indicated if there is evidence of seizures.
Magnetic resonance imaging or computed tomography of the head (not
ultrasonography) can detect subdural hematomas. There is no evidence that
would support the need for a chest x-ray examination. Focus: Prioritization;
Test Taking Tip: To answer this type of question, analyze key information:
age, symptoms, and injury. Vomiting and fussiness accompany many
disorders, but how would a 4-month old infant sustain circular bruises? After
you have identified the problem (probable abuse), use knowledge of
disorders related to age groups to narrow the field (shaken baby syndrome
common among young infants), and identify common manifestations of the
disorder (retinal hemorrhage), then you can select the appropriate assessment
technique.

Question 12

Which action will the public health nurse take to have the most impact on
the incidence of infectious diseases in the school?
1. Make soap and water readily available in the classrooms.
2. Ensure that students are immunized according to national
recommendations.
3. Provide written information about infection control to all parents.
4. Teach students how to cover their mouths when they cough or sneeze.

Answer 12

Ans: 2 The incidence of once-common infectious diseases such as measles,
chickenpox, and mumps has been most effectively reduced by the
immunization of all school-age children. The other actions are also helpful
but will not have as great an impact as immunization. Focus: Prioritization.

Question 13

While working in the pediatric clinic, the nurse receives a telephone call
from the parent of a 13-year-old child who is receiving chemotherapy for
359leukemia. The patient’s sibling has chickenpox (varicella). Which action will
the nurse anticipate taking next?
1. Administer varicella-zoster immune globulin to the patient.
2. Teach the parent about the correct use of acyclovir.
3. Educate the parent about contact and airborne precautions.
4. Prepare to admit the patient to a private room in the hospital.

Answer 13

Ans: 1 The administration of varicella-zoster immune globulin can prevent
the development of varicella in immunosuppressed patients and will
typically be prescribed. Acyclovir therapy and hospitalization may be
required if the child develops a varicella-zoster virus infection. Contact and
airborne precautions will be implemented to prevent the spread of infection
to other children if the child is hospitalized with varicella. Focus:
Prioritization.

Question 14

An unimmunized 7-year-old child who attends a local elementary school
contracts rubeola (measles). The child has two siblings, ages 9 and 11 years,
who also attend the elementary school. Which action by the school nurse is a
priority?
1. Exclude the child and siblings from attending school for 21 days.
2. Notify all parents of children attending the school of the exposure.
3. Recommend that siblings receive the measles vaccine.
4. Recommend that siblings receive measles immunoglobulin.

Answer 14

Ans: 1 Rubeola is a highly contagious infectious disease with severe
consequences that include death. The Centers for Disease Control and
Prevention reports that 9 of 10 susceptible persons with close contact to a
person with measles will contract the disease. The incubation period is 7 to 21
days. Excluding the infected and exposed children during this period of time
is a priority to prevent exposure of healthy children enrolled in the
elementary school. Although it is important to notify the parents of the other
children in the school of the exposure, limiting exposure of other children is
the priority. Mumps, measles, and rubella vaccine administered within 72
hours of initial measles exposure and immunoglobulin administered within 6
days of exposure may provide some protection or modify the clinical course
of the disease in unimmunized children; however, the priority is to prevent
an epidemic by limiting exposure. Focus: Prioritization.

Question 15

The school nurse is performing developmental screenings for children who
will be entering preschool. A 4-year-old girl excitedly tells the nurse about
her recent birthday party. As she relates the details of the event, she
frequently stutters. Which action by the nurse is most appropriate at this
time?
1. Refer the child to an audiologist.
2. Obtain a detailed birth history from the parents.
3. Document the findings on the child’s school record.
4. Refer the child to a speech pathologist.

Answer 15

Ans: 3 Stuttering during the preschool years is a normal variation,
particularly when excited or upset. The cause is attributed to preschool
children’s increased cognitive abilities and imagination such that their speech
cannot keep up with their thoughts. Documenting this on the child’s record is
important for continued observation to determine if it extends beyond the
preschool years. Focus: Prioritization.

Question 16

An adolescent with cystic fibrosis (CF) is admitted to the pediatric unit with
increased shortness of breath and pneumonia. Which nursing activity is most
important to include in the patient’s care?
1. Allowing the adolescent to decide if aerosolized medications are needed
2. Scheduling postural drainage and chest physiotherapy every 4 hours
3. Placing the adolescent in a room with another adolescent with CF
4. Encouraging oral fluid intake of 2400 mL/day

Answer 16

Ans: 2 National guidelines indicate that airway clearance techniques are
critical for patients with CF; hence, postural drainage and chest
372physiotherapy are a priority. National guidelines also indicate that children
and adolescents with CF who are hospitalized with respiratory illnesses
should be placed on contact precautions. Furthermore, people with CF
should be separated from others with CF to reduce droplet transmission of
CF pathogens. There is no evidence that increased fluid intake adequately
thins respiratory secretions, and chest physiotherapy is the priority. Focus:
Prioritization.

Question 17

The nurse has obtained this assessment information about a 3-year-old
patient who has just returned to the pediatric unit after having a
tonsillectomy. Which finding requires the most immediate follow-up?
1. Frequent swallowing
2. Hypotonic bowel sounds
3. Reports of a sore throat
4. Heart rate of 112 beats/min

Answer 17

Ans: 1 Frequent swallowing after tonsillectomy may indicate bleeding. The
nurse should inspect the back of the throat for evidence of bleeding. The
other assessment results are expected in a 3-year-old child after surgery.
Focus: Prioritization; Test Taking Tip: Be aware of expected findings so that
unexpected findings are noticed. In this case, frequent swallowing can
indicate bleeding, which should be assessed often and reported to the health
care provider if necessary.

Question 18

The nurse is providing nursing care for a newborn infant with respiratory
distress syndrome (RDS) who is receiving nasal continuous positive airway
pressure ventilation. Which assessment finding is most important to report to
360the health care provider?
1. Apical pulse rate of 156 beats/min
2. Crackles audible in both lungs
3. Tracheal deviation to the right
4. Oxygen saturation of 93%

Answer 18

Ans: 3 Tracheal deviation suggests tension pneumothorax, a possible
complication of positive-pressure ventilation. The nurse will need to
communicate rapidly with the health care provider and assist with actions
such as chest tube insertion. The heart rate, crackles, and oxygen saturation
will be reported to the health care provider but are expected in RDS and do
not require immediate intervention. Focus: Prioritization.

Question 19

The nurse is assisting with the delivery of a 31-week gestational age
premature newborn who requires intubation for respiratory distress
syndrome (RDS). Which medication does the nurse anticipate will be needed
first for this infant?
1. Theophylline
2. Surfactant
3. Dexamethasone
4. Albuterol

Answer 19

Ans: 2 Research indicates that the administration of synthetic surfactant
improves respiratory status and decreases the incidence of pneumothorax in
premature infants with RDS. The other medications may be used if
respiratory distress persists, but the first medication administered will be the
surfactant. Focus: Prioritization.

Question 20

The nurse obtains this information when assessing a 3-year-old patient with
uncorrected tetralogy of Fallot who is crying. Which finding requires
immediate action?
1. The apical pulse rate is 118 beats/min.
2. A loud systolic murmur is heard in the pulmonic area.
3. There is marked clubbing of the child’s nail beds.
4. The lips and oral mucosa are dusky in color.

Answer 20

Ans: 4 Circumoral cyanosis indicates a drop in the partial pressure of
oxygen that may precipitate seizures and loss of consciousness. The nurse
should rapidly place the child in a knee–chest position, administer oxygen,
and take steps to calm the child. The other assessment data are expected in a
child with congenital heart defects such as tetralogy of Fallot. Focus:
Prioritization.

Question 21

The nurse is observing a preschool classroom of children between the ages of
3 to 4 years of age. When planning actions to ensure that each child meets
normal developmental goals, which child will require the most immediate
intervention?
1. A 3-year-old boy who needs help dressing
2. A 4-year-old girl who has an imaginary friend
3. A 4-year-old girl who engages only in parallel play
4. A 3-year-old boy who draws stick figures

Answer 21

Ans: 3 At 4 years of age, children engage in pretend play. Parallel play is
seen in younger children between the ages of 2 and 3 years when they play
side by side with limited interaction. The other behaviors are
developmentally appropriate. The nurse will plan interventions to ensure
that all the children meet developmental goals, but the 4-year-old child
engaging only in parallel play will require the most immediate intervention.
Focus: Prioritization; Test Taking Tip: Consider predominant modes of play
based on age.

Question 22

After receiving the change-of-shift report, which patient should the nurse
assess first?
1. An 18-month-old patient with coarctation of the aorta who has decreased
pedal pulses
2. A 3-year-old patient with rheumatic fever who reports severe knee pain
3. A 5-year-old patient with endocarditis who has crackles audible
throughout both lungs
4. An 8-year-old patient with Kawasaki disease who has a temperature of
102.2°F (38.9°C)

Answer 22

Ans: 3 Crackles throughout both lungs indicate that the child has severe left
ventricular failure as a complication of endocarditis. Hypoxemia is likely, so
the child needs rapid assessment of oxygen saturation, initiation of
supplemental oxygen delivery, and administration of medications such as
373diuretics. The other children should also be assessed as quickly as possible,
but they are not experiencing life-threatening complications of their medical
diagnoses. Focus: Prioritization

Question 23

The pediatric unit charge nurse is working with a newly graduated RN who
has been on orientation in the unit for 2 months. Which patient should the
charge nurse assign to the new RN?
3611. A 2-year-old patient with a ventricular septal defect for whom digoxin 90
mcg by mouth has been prescribed
2. A 4-year-old patient who had a pulmonary artery banding and has just
been transferred in from the intensive care unit
3. A 9-year-old patient with mitral valve endocarditis whose parents need
teaching about IV antibiotic administration
4. A 16-year-old patient with a heart transplant who was admitted with a
low-grade fever and tachycardia

Answer 23

Ans: 1 This patient requires the least complex assessments and interventions
of the four patients. Safe administration of oral medications such as digoxin
would have been included in the orientation of the new RN graduate. The
conditions of the other patients are more complex, and they require
assessments or interventions (e.g., teaching) that should be carried out by an
RN with more experience. Focus: Assignment.

Question 24

The nurse is obtaining the history and physical information for a child who
is recovering from Kawasaki disease and receives aspirin therapy. Which
information concerns the nurse the most?
1. The child attends a day-care center 5 days a week.
2. The child’s fingers have areas of peeling skin.
3. The child is very irritable and cries frequently.
4. The child has not received any immunizations.

Answer 24

Ans: 4 Children who receive aspirin therapy are at risk for the development
of Reye syndrome if they contract viral illnesses such as varicella or
influenza, so the lack of immunization is the greatest concern for this child.
Peeling skin on the fingers and toes and irritability are consistent with
Kawasaki disease but do not require any change in therapy. Because
Kawasaki disease is not a communicable disease, there is no risk for
transmission to other children in the day care (although assuring that
immunizations are up to date before returning to day care is important).
Focus: Prioritization.

Question 25

The RN is working with an LPN/LVN to provide care for a 10-year-old
patient with severe abdominal, hip, and knee pain caused by a sickle cell
crisis. Which action taken by the LPN/LVN requires the RN to intervene
immediately?
1. Administering oral pain medication as needed
2. Positioning cold packs on the child’s knees
3. Encouraging increased fluid intake
4. Monitoring vital signs every 2 hours

Answer 25

Ans: 2 Sickle cell crisis may include vaso-occlusive crisis, splenic
sequestration, and aplastic crisis. The symptoms experienced by this child are
indicative of both vaso-occlusive crisis and splenic sequestration. Placing cold
packs on the knees of a child with vaso-occlusive crisis results in
vasoconstriction, placing the child at risk for thrombosis formation.
Encouraging increased fluid intake is advised to prevent thrombosis
formation. Monitoring vital signs is a method to assess for life-threatening
complications associated with both vaso-occlusive crisis and splenic
sequestration. Vaso-occlusive crisis is associated with severe pain and pain
medication is recommended. Focus: Prioritization.

Question 26

The nurse has just received a change-of-shift report about these pediatric
patients. Which patient will the nurse assess first?
1. A 1-year-old patient with hemophilia B who was admitted because of
decreased responsiveness
2. A 3-year-old patient with von Willebrand disease who has a dose of
desmopressin (DDAVP) scheduled
3. A 7-year-old patient with acute lymphocytic leukemia who has
chemotherapy-induced thrombocytopenia
4. A 16-year-old patient with sickle cell disease who reports acute right lower
quadrant abdominal pain

Answer 26

Ans: 1 Because decreased responsiveness in a 1-year-old patient with a
clotting disorder may indicate intracerebral bleeding, this patient should be
assessed immediately. The other patients also require assessments or
interventions but are not at immediate risk for life-threatening or disabling
complications. Focus: Prioritization.

Question 27

The nurse is reviewing a complete blood count for a 3-year-old patient with
idiopathic thrombocytopenic purpura (ITP). Which information should the
nurse report immediately to the health care provider (HCP)?
1. Prothrombin time (PT) of 12 seconds
2. Hemoglobin level of 6.1 g/dL (61 g/L)
3. Platelet count of 40,000/mm 3 (40 × 10 9 /L)
4. Leukocyte count of 5600/mm 3 (5.6 × 10 9 /L)

Answer 27

Ans: 2 The low hemoglobin count may signify bleeding; therefore, alerting
the HCP is recommended. ITP is an autoimmune disorder by which
circulating platelets are destroyed by autoantibodies. Platelet production
from the bone marrow, however, is not affected. Laboratory findings
characteristic of ITP include a low platelet count generally less than
20,000/mm 3 (20 × 10 9 /L). However, all other indices of the complete blood
count are normal. Additionally, the PT and partial thromboplastin time are
normal with ITP. In this 3-year-old child, the leukocytes and PT are normal.
The platelet count is low but consistent with this disease. Focus:
Prioritization.

Question 28

A 4-year-old patient with acute lymphocytic leukemia has these medications
ordered. Which one is most important to double-check with another licensed
nurse?
1. Prednisone 1 mg PO
2. Amoxicillin 250 mg PO
3. Methotrexate 10 mg PO
4. Filgrastim 5 mcg subcutaneously

Answer 28

Ans: 3 Methotrexate is a high-alert drug, and extra precautions, such as
double checking with another nurse, should be taken when administering
this medication. Although many pediatric units have a policy requiring that
all medication administration to children be double-checked, the other
medications listed are not on the high-alert list published by the Institute for
Safe Medication Practices. Focus: Prioritization; Test Taking Tip: For test
taking purposes and for safety in the clinical setting, it is worthwhile to
memorize medications that are considered “high-alert” drugs.

Question 29

A 6-year-old child arrives in the emergency department with active seizures.
Which assessment is a priority for the nurse to obtain?
1. Heart rate
2. Body mass index (BMI)
3. Blood pressure
4. Weight

Answer 29

Ans: 4 The child will need medication to control the seizures. Medications
for children are based on weight in kilograms. Although heart rate and blood
pressure may be obtained, the priority is to stop the seizures with medication.
There is no clinical indication for BMI for a child with active seizures. Focus:
Prioritization.

Question 30

The nurse is caring for a 3-year-old patient who has returned to the pediatric
intensive care unit after insertion of a ventriculoperitoneal shunt to correct
hydrocephalus. Which assessment finding is most important to communicate
to the surgeon?
1. The child is crying and says, “It hurts!”
2. The right pupil is 1 mm larger than the left pupil.
3. The cardiac monitor shows a heart rate of 130 beats/min.
4. The head dressing has a 2-cm area of bloody drainage.

Answer 30

Ans: 2 Pupil dilation may indicate increased intracranial pressure and
should be reported immediately to the surgeon. The other data are not
unusual in a 3-year-old patient after surgery, although they indicate the need
for ongoing assessments or interventions. Focus: Prioritization.

Question 31

The nurse is caring for a newborn with a myelomeningocele who is awaiting
surgical closure of the defect. Which assessment finding is of most concern?
1. Bulging of the sac when the infant cries
2. Oozing of stool from the anal sphincter
3. Flaccid paralysis of both legs
4. Temperature of 101.8°F (38.8°C)

Answer 31

Ans: 4 The elevated temperature indicates possible infection and should be
reported immediately to the surgeon so that treatment can be started. The
other data are typical in an infant with myelomeningocele. Focus:
Prioritization.

Question 32

An excited mother calls the nurse for advice. “My child got cleaning solution
in her eyes, and I rinsed her eyes with water for a few minutes. What should I
do? She is still screaming!” What does the nurse instruct the caller to do first?
1. Comfort the child and check her vision.
2. Continue to irrigate the eyes with water.
3. Call the Poison Control Center.
4. Call 911 to request an ambulance.

Answer 32

Ans: 2 Even though the child is screaming, the mother must continue to
irrigate the eyes for at least 20 minutes. Another adult, if present, should call
the Poison Control Center and 911. Focus: Prioritization.

Question 33

The nurse is caring for a child with a foreign body in the ear canal who has
not been evaluated by the health care provider. Which actions should the
nurse implement? Select all that apply.
1. Inspect the pinna for trauma.
2. Irrigate the auditory canal with warm water.
3633. Obtain a history for the type of object.
4. Attempt to remove the object with forceps.
5. Use an otoscope to check for perforation.

Answer 33

Ans: 1, 3 The nurse should assess the pinna for trauma and obtain history for
the type of object as a component of a complete assessment which could
determine the course of action by the health care provider. Some foreign
bodies may swell when water is used for irrigation, further lodging the object
in the auditory canal. Removing the object with forceps could traumatize the
tympanic membrane and auditory canal further. Placing an otoscope in the
auditory canal could wedge the object further into the canal. Focus:
Prioritization.

Question 34

An adolescent who was hospitalized for anorexia nervosa is following the
prescribed treatment plan. Her self-esteem and weight have gradually
improved, but she continues to refer to herself as “fatty.” She is able to
verbalize an appropriate diet and exercise plan. At this point, what is the
priority concern?
1. Patient needs to continue to gain weight.
2. Patient has an unrealistic body image.
3. Patient needs more information about nutrition.
4. Patient lacks motivation to adhere to therapy

Answer 34

Ans: 2 The patient continues to refer to herself as “fatty” and still has a
disturbed body image; however, she has appropriate knowledge, and her
self-esteem has improved. The patient has demonstrated ability to follow the
therapeutic plan while in the hospital. Interventions should be designed to
help her to continue after discharge. Focus: Prioritization.

Question 35

A 6-year-old girl arrives in the emergency department with her parents. She
hit her head when she fell from the jungle gym in the school playground.
Which questions are appropriate for the nurse to ask to assess the child’s
neurologic status? Select all that apply.
1. What is your home address?
2. What time does your family eat dinner?
3. What grade are you in?
4. What is your teacher’s name?
5. What time did you fall?
6. What is the name of your school?

Answer 35

Ans: 1, 3, 4, 6 This child is in Piaget’s stage of concrete operations. Children
in this stage can organize experiences and understand some complex
information. However, children in this age group have difficulty
conceptualizing time; therefore, asking questions about the time that
incidents occur will not be helpful in determining the child’s orientation.
Focus: Prioritization.

Question 36

A 2-year-old child who has abdominal pain is diagnosed with
intussusception. A hydrostatic reduction has been performed. Which finding
should be reported immediately before surgery proceeds?
1. Palpable sausage-shaped abdominal mass
2. Passage of normal brown stool
3. Passage of currant jelly–like stools
4. Frequent nausea and vomiting

Answer 36

Ans: 2 Passage of brown stool indicates resolution of the intussusception, so
surgery may not be necessary. The other findings are part of the clinical
presentation of this disorder. Focus: Prioritization.

Question 37

A parent calls the emergency department, saying, “I think my toddler might
have swallowed a little toy. He is breathing okay, but I don’t know what to
do.” What is the most essential question to ask the caller?
1. “Has he vomited?”
2. “Have you been checking his stools?”
3. “What do you think he swallowed?”
4. “Has he been coughing?”

Answer 37

Ans: 4 Even though the caller reports that the child is “breathing okay,”
additional questions about possible airway obstruction are the priority (e.g.,
coughing, gagging, choking, drooling, refusing to eat or drink).
Gastrointestinal symptoms should be assessed but are less urgent. The type
of foreign body, in the absence of symptoms, may dictate a wait-and-see
approach, in which case the parent would be directed to check the stools for
passage of the foreign body. Focus: Prioritization; Test Taking Tip: In
emergency situations, apply the ABCs (airway, breathing, and circulation)
before proceeding to other actions.

Question 38

The nurse is teaching a group of day-care workers about how to avoid
transmission of hepatitis A in day-care settings. What is the single most
effective measure to emphasize?
3641. Hand hygiene should be performed often to prevent and control the spread
of infection.
2. Children in whom hepatitis has been diagnosed should not share toys with
others.
3. Children with episodes of fecal incontinence should be isolated from
others.
4. Immunizations are recommended before children are admitted into day-
care settings.

Answer 38

Ans: 1 Hand washing is the most important aspect to emphasize.
Addressing fecal incontinence and sharing of personal items may be
recommended when the disease is in an infectious stage. Immunizations are
recommended, but this would be emphasized to parents rather than day-care
workers. Focus: Prioritization.

Question 39

These medications have been prescribed for a 9-year-old patient with deep
partial- and full-thickness burns. Which medication is most important to
double-check with another licensed nurse before administration?
1. Silver sulfadiazine ointment
2. Famotidine 20 mg IV
3. Lorazepam 0.5 mg PO
4. Multivitamin 1 tablet PO

Answer 39

Ans: 3 Oral sedation agents such as the benzodiazepines are considered
high-alert medications when ordered for children, and extra precautions
should be taken before administration. Many facilities require that all
medications administered to pediatric patients be double-checked before
administration, but the lorazepam is the most important to double-check with
another nurse. Focus: Prioritization.

Question 40

The nurse is caring for a 5-year-old whose mother asks why he still wets the

bed. What is the best response?
1. “He is old enough that he should no longer be wetting the bed.”
2. “Most children outgrow bed-wetting by the time they start school.”
3. “His bed-wetting may be due to an immature bladder or deep sleep
pattern. ”
4. “He will probably stop once he realizes how embarrassing it is to wet the
bed. ”

Answer 40

Ans: 3 Theories about bed-wetting relate it to immature bladder and deep
sleep patterns. Although it is true that most children stop bed-wetting by the
time they start school, this does not answer the mother’s question. Many boys
wet the bed until after the age of 5 years. The fourth response is not accurate
because often bed-wetting is not within the control of a 5-year-old child.
Focus: Prioritization.

Question 41

Which intervention for a 5-year-old child who still wets the bed would be
best assigned to the unlicensed assistive personnel (UAP)?
1. Reminding the child to use the bathroom before going to bed
2. Teaching the mother about moisture alarm devices
3. Administering the prescribed dose of imipramine
4. Discussing research related to the use of hypnosis with the mother

Answer 41

Ans: 1 Reminding the child about something that has already been taught is
within the scope of practice for a UAP. An LPN/LVN could administer the
oral medication. Teaching and discussion of other strategies for dealing with
bed-wetting require additional education and are more appropriate to the
scope of practice of the professional RN. Focus: Delegation.

Question 42

Parents of a 13-year-old adolescent girl expressed concern because she
spends “quite a bit of time in her room alone in front of the mirror.” The girl’s
height and weight are in the 50th percentile. In the exam room, the girl is
quiet but does answer questions appropriately. What advice should the nurse
provide to the parents?
1. “Further evaluation by a psychologist is needed because your daughter
spends a lot of time alone in her room.”
2. “Limit the amount of time that your daughter is allowed to spend alone in
her room.”
3. “This behavior is normal. Your daughter is adjusting to the physical
changes she is experiencing.”
3654. “This behavior may be associated with depression, and further evaluation
by a counselor is advised.”

Answer 42

Ans: 3 This is normal behavior in early adolescence. During this time period,
adolescents are conscious of their rapid physical changes. As a result, they
spend more time in front of the mirror inspecting their bodies. Consider that
the height and weight are normal; therefore, an eating disorder is not likely.
Also, the girl does answer questions appropriately, so mental health issues
are not likely. Focus: Prioritization; Test Taking Tip: It will be helpful to
know what types of physical and mental health disorders are common at
various developmental stages because these issues are likely to be on the
NCLEX® Examination and will occur commonly in a pediatric nursing
376practice setting.

Question 43

A 16-year-old female adolescent arrives at the health center. She tells the
nurse that she’s been sexually active for 6 months “but only with my
boyfriend.” Her immunizations are up to date. Screening for which sexually
transmitted disease (STD) will be most important for this patient?
1. Syphilis
2. Genital herpes simplex
3. Human papillomavirus
4. Chlamydia

Answer 43

Ans: 4 Recommendations by the Centers for Disease Control and Prevention
recommend annual screening for chlamydia (and gonorrhea) for all sexually
active women younger than the age of 25 years. Chlamydia is the most
prevalent STD in the United States. Screening for syphilis and genital herpes
simplex is recommended only if other risk factors or evidence of disease are
present. The patient is fully immunized, which would include the human
papillomavirus vaccine. Focus: Prioritization.

Question 44

The health care provider has ordered cooling measures for a child with fever
who is likely to be discharged when the temperature comes down. Which
task will the nurse delegate to the unlicensed assistive personnel (UAP)?
1. Providing explanations of nursing actions to the family
2. Assisting the child to remove the outer clothing
3. Advising the parent to use acetaminophen instead of aspirin
4. Monitoring the child’s level of consciousness and orientation level

Answer 44

Ans: 2 The UAP can help with the removal of outer clothing, which allows
the heat to dissipate from the child’s skin. Assessments, advising, and
explaining require RN-level education and scope of practice. Focus:
Delegation.

Question 45

A tearful parent brings a child to the emergency department after the child
takes an unknown amount of children’s chewable vitamins at an unknown
time. The child is currently alert and asymptomatic. What information should
be immediately reported to the health care provider?
1. The ingested children’s chewable vitamins contain iron.
2. The child has been treated previously for ingestion of toxic substances.
3. The child has been treated several times before for accidental injuries.
4. The child was nauseated and vomited once at home.

Answer 45

Ans: 1 Iron is a toxic substance that can lead to massive hemorrhage, coma,
shock, and hepatic failure. Deferoxamine is an antidote that can be used for
severe cases of iron poisoning. The other information needs additional
investigation but will not change the immediate diagnostic testing or
treatment plan. Focus: Prioritization.

Question 46

The nurse is preparing a child for IV moderate (conscious) sedation before
repair of a facial laceration. What information should the nurse immediately
report to the health care provider?
1. The parent is unsure about the child’s tetanus immunization status.
2. The child is upset and pulls out the IV.
3. The parent declines the IV moderate (conscious) sedation.
4. The parent wants information about the IV moderate (conscious) sedation.

Answer 46

Ans: 3 Parental refusal is an absolute contraindication; therefore, the
provider must be notified. Tetanus status can be addressed later. The RN can
reestablish the IV access and provide information about moderate (conscious)
sedation; if the parent is still not satisfied, the provider can give more
information. Focus: Prioritization.

Question 47

A teenager arrives in the triage area alert and ambulatory, but his clothes are
covered with blood. His friends are yelling, “We were goofing around, and
he got poked in the abdomen with a stick!” Which comment would be of
most concern?
1. “There was a lot of blood, and we used three bandages.”
2. “He pulled the stick out, just now, because it was hurting him.”
3. “The stick was really dirty and covered with mud.”
4. “He has diabetes, so he needs attention right away.”

Answer 47

Ans: 2 An impaled object may be providing a tamponade effect, and
removal can precipitate sudden hemodynamic decompensation. Additional
history, including a more definitive description of the blood loss, depth of
penetration, and medical history, should be obtained. Other information,
such as the dirt on the stick or history of diabetes, is important in the overall
treatment plan but can be addressed later. Focus: Prioritization.

Question 48

The emergency department receives multiple individuals, mostly children,
who were injured when the roof of a day-care center collapsed because of a
heavy snowfall. Based on physiologic differences in children compared with
adults, for which injuries and complications will the nurse assess first? Select
all that apply.
1. Head injuries
2. Bradycardia or junctional arrhythmias
3. Hypoxemia
4. Liver and spleen contusions
5. Hypothermia
6. Fractures of the long bones
7. Lumbar spines injuries

Answer 48

Ans: 1, 3, 4, 5 Children have proportionately larger heads that predispose
them to head injuries. Hypoxemia is more likely because of their higher
oxygen demand. Liver and spleen injuries are more likely because the
thoracic cages of children offer less protection. Hypothermia is more likely
because of children’s thinner skin and proportionately larger body surface
area. They have strong hearts; therefore, pulse rate will increase to
compensate, but other arrhythmias are less likely to occur. Children have
relatively flexible bones compared with those of adults. The most likely
spinal injury in children is injury to the cervical area. Focus: Prioritization.

Question 49

A 16-year-old patient arrived at the cystic fibrosis (CF) clinic for a routine 3-
month visit. The most recent respiratory culture results are negative. Which
action is best for the nurse to take?
1. Place the patient in an exam room immediately upon arrival to the clinic.
2. Allow the patient to wait in the reception area until the provider is
available to see the patient.
3. Allow the patient to wait in the reception area with a mask until the
provider is available to see the patient.
4. Place the patient in a waiting area with other patients who also have
negative respiratory cultures.

Answer 49

Ans: 1 This is a CF clinic, so this patient may be exposed to others with CF if
he or she remains in the reception area. The CF Foundation recommends all
individuals with CF, regardless of respiratory culture results, be separated
from others with CF to reduce risk of droplet transmission of CF pathogens.
National guidelines indicate that the best solution is that patients with CF not
wait in common areas but be placed in a private exam room. However, when
377patients are in common waiting areas, a minimum distance of 3 feet (1 meter)
between patients should be maintained if patients have CF. Focus:
Prioritization.

Question 50

A child with Hirschsprung disease arrives on the pediatric unit from the
operating room with a temporary colostomy. Which task should the nurse
delegate to unlicensed assistive personnel (UAP)?
1. Assess the frequency and consistency of stool.
2. Instruct the parents on skin care.
3. Stock the room with ostomy supplies.
4. Assess the patient for pain.

Answer 50

Ans: 3 Assessment and patient teaching is the responsibility of the RN. The
UAP may stock the room with ostomy supplies but the nurse would give
instructions or validate the UAP’s knowledge of supplies. Focus: Delegation.

Question 51

A newborn infant is diagnosed with tracheoesophageal fistula. Which
nursing interventions should be implemented in the preoperative period?
Select all that apply.
1. Provide small frequent feedings.
2. Elevate the head of the bed.
3. Prepare a tracheostomy tray.
4. Set up suctioning.
5. Administer IV antibiotics.

Answer 51

Ans: 2, 4, 5 A tracheoesophageal fistula is a congenital malformation in
which the esophagus ends in a blind pouch and there is a fistula (opening)
between the esophagus and the trachea. The infant is a high risk for
aspiration of esophageal contents into the trachea; hence, the infant is NPO in
the preoperative period. IV fluids are administered to maintain hydration. A
tracheostomy is not indicated for tracheoesophageal fistula. Surgical
intervention for tracheoesophageal fistula include ligation of the fistula and
reanastomosis of the esophagus. Suction should be on hand to remove
secretions from the blind pouch. IV antibiotics are initiated in the
preoperative period. Focus: Prioritization.

Question 52

A 2-year-old child arrives at the health center for a routine well-child visit. A
complete blood count and lead level are obtained. The lead level is less than
10 mcg/dL (0.483 μmol/L). The hemoglobin is 8 g/dL (80 g/L). The hematocrit
367is 24% (0.24 volume fraction), and the mean corpuscular volume (MCV) is
65 μm 3 (65 fL). What questions should the nurse ask the parent to obtain a
more thorough history? Select all that apply.
1. Does your child eat nonfood substances?
2. Is your child more prone to infections?
3. Has your child experienced hair loss?
4. Does your child frequently have nosebleeds?
5. How much milk does your child drink?

Answer 52

Ans: 1, 5 Iron deficiency anemia is a microcytic anemia. Laboratory findings
consistent with iron deficiency anemia include low hemoglobin, hematocrit,
and MCV. Additionally, the patient may have thrombocytosis, which is an
increase in the number of platelets; so the child will not be more likely to
have nosebleeds. The white blood cell count (WBC) and WBC differential are
not affected by anemia; therefore, the child will not be more prone to
infections. Children with iron deficiency anemia experience pica, which is a
consumption of nonfood items. Excessive cow’s milk intake has been found
to cause anemia by irritating the intestine and resulting in microscopic blood
loss from the gastrointestinal tract. Focus: Prioritization.

Question 53

Liquid supplemental iron is prescribed for a 10-month-old child with iron
deficiency anemia. The parents tell the nurse that their child hates the taste of
medicine. Which of the following instructions should the nurse provide to the
parents? Select all that apply.
1. Give the iron orally with a syringe.
2. Mix the iron in a little bit of chocolate syrup.
3. Give the iron with food or milk.
4. Let the child drink the iron through a straw.
5. Give the iron with orange juice.

Answer 53

Ans: 1, 5 Iron supplementation can stain the teeth and has an unpleasant
taste. By administering the iron with a syringe to the back of the throat, it will
mask the taste and prevent staining of the teeth. The vitamin C in orange
juice increases iron absorption and may mask the unpleasant taste. Chocolate
contains caffeine, which interferes with the absorption of iron. Milk and food
also interfere with the absorption of iron. Although allowing a child to drink
the iron through a straw is feasible for an older child, a 10-month-old child
cannot developmentally perform this task. Focus: Prioritization.

Question 54

Parents of a 6-month-old girl bring the infant to the emergency department
because “she has not held anything down for the entire day.” The nurse
obtains a fingerstick blood glucose of 94 (5.22 mmol/L). The infant’s rectal
temperature is 101°F (38.3°C), heart rate is 198 beats/min, respiratory rate is
40 breaths/min, and blood pressure 60/38 mm Hg in the left arm. Which
nursing action is a priority?
1. Administer an antiemetic rectally.
2. Administer a bolus of D10W.
3. Administer a bolus of normal saline.
4. Administer an antipyretic rectally.

Answer 54

Ans: 3 This infant is experiencing severe dehydration, which is evidenced by
tachycardia and hypotension. The child is at risk for hypovolemic shock,
which is a life-threatening event. A bolus of normal saline or lactated Ringer’s
solution of 20 mL/kg is the standard of care to establish hemodynamic
stability. The blood glucose is normal. The safety profile for antiemetics have
not been established with infants, and the priority for this patient is to
establish hemodynamic stability. Fever can cause increased fluid loss;
however, the priority in this life-threatening situation is to establish
hemodynamic stability. Focus: Prioritization.

Question 55

A 10-year-old girl has completed a course of amoxicillin for a urinary tract
infection (UTI). This is the second UTI the child has had this year. The child is
in the 95th percentile for weight and has a history of constipation. Her
parents ask the nurse for preventive strategies for UTIs. Which of the
following preventive strategies is best for the nurse to recommend?
1. Increase fiber in the diet.
2. Drink cranberry juice.
3. Increased vitamin C in a diet.
4. Limit fluids at bedtime.

Answer 55

Ans: 1 Based on the history, this child’s constipation is the most likely
etiology of the UTI, and increasing dietary fiber is the best intervention.
Urinary stasis from constipation is the primary cause of UTIs in children.
Stool in the intestine prevents complete emptying of the bladder. There is no
conclusive evidence to support that cranberry juice and vitamin C prevent
UTIs. Limiting fluids at bedtime has not been shown to decrease UTI.
Increasing fluids however, helps to flush bacteria out of the bladder. Focus:
Prioritization.

Question 56

A 16-year-old boy comes into the office of the school nurse complaining of
left hip pain that began when playing basketball in gym class. The boy is in
the 85th percentile for height and weight. He complains of increased pain
with weight bearing. The nurse observes out-toeing of the left leg with
368ambulation. Which nursing action is a priority?
1. Administer ibuprofen and instruct the boy to rest.
2. Apply heat to the hip and elevate the left leg.
3. Refer the boy to the emergency department.
4. Apply ice to the hip and immobilize it with a splint.

Answer 56

Ans: 3 This boy is presenting with classic symptoms of slipped capital
femoral epiphysis (SCFE), which is a slippage of the femoral head at the
proximal epiphyseal plate. SCFE is an emergency. A delay in treatment can
result in necrosis and death of the femoral head. Although the exact cause of
SCFE is unknown, there is an increased incidence in boys. Additionally,
obesity is a risk factor for SCFE. Focus: Prioritization.

Question 57

A toddler is brought to the health center for a fever of 102°F (39°C) and a
sore throat. As the nurse places a toddler and his parents in the exam room,
the child experiences a tonic-clonic seizure. Which nursing action is a
priority?
1. Assess the child’s level of consciousness.
2. Obtain an oxygen saturation.
3. Loosen the child’s clothing.
4. Position the child in side-lying position.

Answer 57

Ans: 4 To ensure safety and prevent aspiration the first action by the nurse
should be to position the child in side-lying position. Other assessment and
actions will follow this initial step. Focus: Prioritization.