Midterm Flashcards
(126 cards)
1
Q
What does the surgical closure of the ductus arteriosus do?
a. Stop the loss of unoxygenated blood to the systemic circulation
b. Decrease the edema in legs and feet
c. Increase the oxygenation of blood
d. Prevent the return of oxygenated blood to the lungs
A
d. Prevent the return of oxygenated blood to the lungs
2
Q
Which defect results in increased pulmonary blood flow?
a. Pulmonic stenosis
b. Tricuspid atresia
c. Atrial septal defect
d. Transposition of the great arteries
A
c. Atrial septal defect
3
Q
What does a ventricular septal defect cause?
A
causes blood flow from left ventricle to right ventricle
extra workload for lungs and heart = CHF
4
Q
What can be heard from a ventricular septal defect? Where?
A
murmur @ lower left sternal border
5
Q
A nurse is assessing a child with an unrepaired ventricular septal defect. Which heart sound does the nurse expect to assess?
a. S3
b. S4
c. Murmur
d. Physiologic splitting
A
c. Murmur
6
Q
What should you do (action) and monitor for a child who went to sx to repair coarctation of the aorta?
A
action:
- inotropic meds
- mechanical ventilation
monitor:
- monitor lung sounds
- monitor BP for systemic hypertension
7
Q
A nurse is assessing a 3-year-old child who has aortic stenosis. WHich of the following findings should the nurse expect? (Select all that apply)
Hypotension
Bradycardia
Clubbing of the nail beds
Weak pulses
Murmur
A
Hypotension
Weak pulses
Murmur
8
Q
What position should a 7 year old assume who is experiencing TOF?
A
squatting
9
Q
What is tetralogy of fallot?
A
pulmonic stenosis
ventricular septal defect
overriding aorta
right ventricular hypertrophy
10
Q
The nurse is conducting a staff in-service on congenital heart defects. Which structural defect constitutes tetralogy of Fallot?
a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular
hypertrophy
b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular
hypertrophy
c. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy
d. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular
hypertrophy
A
a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular
hypertrophy
11
Q
A nurse is teaching nursing students the physiology of congenital heart defects. Which defect results in decreased pulmonary blood flow?
a. Atrial septal defect
b. Tetralogy of Fallot
c. Ventricular septal defect
d. Patent ductus arteriosus
A
b. Tetralogy of Fallot
12
Q
The nurse is conducting discharge teaching about signs and symptoms of heart failure to parents of an infant with a repaired tetralogy of Fallot. Which signs and symptoms should the nurse include? (Select all that apply.)
a. Warm flushed extremities
b. Weight loss
c. Decreased urinary output
d. Sweating (inappropriate)
e. Fatigue
A
c. Decreased urinary output
d. Sweating (inappropriate)
e. Fatigue
13
Q
An infant with an unrepaired tetralogy of Fallot defect is becoming extremely cyanotic during a routine blood draw. Which interventions should the nurse implement? Place in order from the highest-priority intervention to the lowest-priority intervention.
a. Administer 100% oxygen by blow-by.
b. Place the infant in knee-chest position.
c. Remain calm.
d. Give morphine subcutaneously or by an existing intravenous line.
A
b. Place the infant in knee-chest position.
a. Administer 100% oxygen by blow-by.
d. Give morphine subcutaneously or by an existing intravenous line.
c. Remain calm.
14
Q
What is an Epstein anomaly?
A
rare abnormality of the tricuspid valve
15
Q
Which cardiac lesion causes a decrease in pulmonary flow?
A
tricuspid atresia valve
16
Q
What is a TET spell? What can be done for tx?
A
AKA hypercyanotic spell
tx:
- oxygen supplementation
- knees to chest (squatting)
- give morphine
17
Q
An 8-month-old infant has a hypercyanotic spell while blood is being drawn. What is the priority nursing action?
a. Assess for neurologic defects
b. Place the child in the knee-chest position
c. Begin cardiopulmonary resuscitation
d. Prepare family for imminent death
A
b. Place the child in the knee-chest position
18
Q
What are examples of mixed cardiac defects? What happens?
A
- transposition of the great vessels
- total anomalous pulmonary venous return
- hypoplastic left heart syndrome
oxygenated and deoxygenated blood mix
19
Q
What are s/s of transposition of the great vessels? What is the tx?
A
cyanosis
low oxygen
tachypnea
death if untx
tx: prostaglandin E until sx
20
Q
A nurse is assisting in the care of a 6-week-old infant who has a ventricular septal defect (VSD). What should be done for digoxin toxicity?
A
- monitor apical HR
- look at EKG strip for prolonged PR interval
- monitor digoxin levels in blood
- signs of toxicity: vomiting
21
Q
The nurse is preparing to administer a dose of digoxin (Lanoxin) to a child in heart failure (HF). Which is a beneficial effect of administering digoxin (Lanoxin)?
a. It decreases edema.
b. It decreases cardiac output.
c. It increases heart size.
d. It increases venous pressure.
A
a. It decreases edema.
22
Q
An 8-year-old child is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than _____ beats/min.
a. 60
b. 70
c. 90
d. 100
A
b. 70
23
Q
A 6-month-old infant is receiving digoxin (Lanoxin). The nurse should notify the practitioner and withhold the medication if the apical pulse is less than _______ beats/min.
a. 60
b. 70
c. 90 to 110
d. 110 to 120
A
c. 90 to 110
24
Q
The nurse is teaching parents about signs of digoxin (Lanoxin) toxicity. Which is a common sign of digoxin toxicity?
a. Seizures
b. Vomiting
c. Bradypnea
d. Tachycardia
A
b. Vomiting
25
The parents of a young child with heart failure tell the nurse that they are “nervous” about giving digoxin (Lanoxin). The nurse’s response should be based on which statement?
a. It is a safe, frequently used drug.
b. It is difficult to either overmedicate or undermedicate with digoxin.
c. Parents lack the expertise necessary to administer digoxin.
d. Parents must learn specific, important guidelines for administration of digoxin.
d. Parents must learn specific, important guidelines for administration of digoxin.
26
The nurse is assessing a child after a cardiac catheterization. Which complication should the nurse be assessing for?
a. Cardiac arrhythmia
b. Hypostatic pneumonia
c. Heart failure
d. Rapidly increasing blood pressure
a. Cardiac arrhythmia
27
José is a 4-year-old child scheduled for a cardiac catheterization. What should be included in preoperative teaching?
a. Directed at his parents because he is too young to understand
b. Detailed in regard to the actual procedures so he will know what to expect
c. Done several days before the procedure so that he will be prepared
d. Adapted to his level of development so that he can understand
d. Adapted to his level of development so that he can understand
28
Which explanation regarding cardiac catheterization is appropriate for a preschool child?
a. Postural drainage will be performed every 4 to 6 hours after the test.
b. It is necessary to be completely “asleep” during the test.
c. The test is short, usually taking less than 1 hour.
d. When the procedure is done, you will have to keep your leg straight for at least 4 hours.
d. When the procedure is done, you will have to keep your leg straight for at least 4 hours.
29
The nurse is caring for a school-age child who has had a cardiac catheterization. The child tells the nurse that the bandage is “too wet.” The nurse finds the bandage and bed soaked with blood. What is the priority nursing action?
a. Notify physician
b. Apply new bandage with more pressure
c. Place the child in Trendelenburg position
d. Apply direct pressure above catheterization site
d. Apply direct pressure above catheterization site
30
The nurse is preparing an adolescent for discharge after a cardiac catheterization. Which statement by the adolescent would indicate a need for further teaching?
a. “I should avoid tub baths but may shower.”
b. “I have to stay on strict bed rest for 3 days.”
c. “I should remove the pressure dressing the day after the procedure.”
d. “I may attend school but should avoid exercise for several days.”
b. “I have to stay on strict bed rest for 3 days.”
31
What outcomes are expected to be achieved within 1 hour after cath lab for a child?
- normalize the temp
- right leg equal in color
- pulses are equal and strong
- dressing is dry/intact
- encourage fluids
- treat pain w/ tylenol
32
What is noted for a post cardiac cath care of an infant?
- call DR if right leg feels cooler than left
- given tylenol for discomfort/pain
- do not remove pressure dressing after 4 hours (must stay for 24 hrs)
- no tub bath for 24 hrs until 3 days
- advance diet if tolerated
33
What should be reported for an adolescent following a cardiac cath?
- right lower extremity pale/cool
- saturation and bleeding of the dressing
- HR increases (apical 112)
- BP decreases
34
The nurse is conducting a staff in-service on childhood-acquired heart diseases. Which is a major clinical manifestation of rheumatic fever?
a. Polyarthritis
b. Osler nodes
c. Janeway spots
d. Splinter hemorrhages of distal third of nails
a. Polyarthritis
35
What would you consider in an acquired cardiovascular disorder?
infectious and inflammatory process
36
Which is the most common causative agent of bacterial endocarditis?
a. Staphylococcus albus
b. Streptococcus hemolyticus
c. Staphylococcus albicans
d. Streptococcus viridans
d. Streptococcus viridans
37
The nurse is admitting a child with rheumatic fever. Which therapeutic management should the nurse expect to implement?
a. Administering penicillin
b. Avoiding salicylates (aspirin)
c. Imposing strict bed rest for 4 to 6 weeks
d. Administering corticosteroids if chorea develops
a. Administering penicillin
38
Which action by the school nurse is important in the prevention of rheumatic fever?
a. Encourage routine cholesterol screenings.
b. Conduct routine blood pressure screenings.
c. Refer children with sore throats for throat cultures.
d. Recommend salicylates instead of acetaminophen for minor discomforts.
c. Refer children with sore throats for throat cultures.
39
What is the most common causative cause of endocarditis rheumatic fever?
strep or staph
40
A nurse is obtaining a health history from a child who has suspected acute rheumatic fever. Which of the following questions should the nurse ask?
A.) "Has your son had a sore throat recently?"
B.) "Was your son born with a cardiac defect?"
C.) "Has your son had an injury recently?"
D.) "Have you given your child aspirin in the past 2 weeks?"
A.) "Has your son had a sore throat recently?"
41
What part of the heart does rheumatic fever cause damage to?
valves, usually mitral
42
When caring for the child with Kawasaki disease, the nurse should know which information?
a. A child’s fever is usually responsive to antibiotics within 48 hours.
b. The principal area of involvement is the joints.
c. Aspirin is contraindicated.
d. Therapeutic management includes administration of gamma globulin and aspirin.
d. Therapeutic management includes administration of gamma globulin and aspirin.
43
What is the tx for Kawasaki disease?
High doses of IV immunoglobulin (IVIG)
Aspirin
ASA
Antiplatelet
44
What should be monitored for Kawasaki disease?
- acute high fever
- strawberry tongue
- skin peeling
- possibile lymphadenopathy
reyes syndrome
45
The nurse is teaching nursing students about shock that occurs in children. What is one of the most frequent causes of hypovolemic shock in children?
a. Sepsis
b. Blood loss
c. Anaphylaxis
d. Congenital heart disease
b. Blood loss
46
Which type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy?
a. Neurogenic
b. Cardiogenic
c. Hypovolemic
d. Anaphylactic
d. Anaphylactic
47
Which clinical manifestation should the nurse expect to see as shock progresses in a child and becomes decompensated shock?
a. Thirst
b. Irritability
c. Apprehension
d. Confusion and somnolence
d. Confusion and somnolence
48
Which occurs in septic shock?
a. Hypothermia
b. Increased cardiac output
c. Vasoconstriction
d. Angioneurotic edema
b. Increased cardiac output
49
What clinical manifestation is included in toxic shock syndrome?
a. Severe hypertension
b. Subnormal temperature
c. Erythematous macular rash
d. Papular rash over extremities
c. Erythematous macular rash
50
What are s/s of toxic shock syndrome?
high fever
low BP
vomiting
rash on palms/soles
51
Which clinical manifestation should the nurse expect to see as shock progresses in a child and becomes decompensated shock? (Select all that apply.)
a. Thirst and diminished urinary output
b. Irritability and apprehension
c. Cool extremities and decreased skin turgor
d. Confusion and somnolence
e. Normal blood pressure and narrowing pulse pressure
f. Tachypnea and poor capillary refill time
c. Cool extremities and decreased skin turgor
d. Confusion and somnolence
f. Tachypnea and poor capillary refill time
52
A nurse is preparing to administer an oral iron supplement to a hospitalized infant. Which should not be given simultaneously with the iron supplement?
a. Milk
b. Multivitamin
c. Fruit juice
d. Meat, fish, poultry
a. Milk
53
What should iron be taken with to increase absorption?
citrus fruits or juice
54
For a pt with hemophilia, what should be done to control bleedining?
rest, elevate, compress
55
The nurse is planning care for a school-age child admitted to the hospital with hemophilia. Which interventions should the nurse plan to implement for this child? (Select all that apply.)
a. Finger sticks for blood work instead of venipunctures
b. Avoidance of IM injections
c. Acetaminophen (Tylenol) for mild pain control
d. Soft tooth brush for dental hygiene
e. Administration of packed red blood cells
b. Avoidance of IM injections
c. Acetaminophen (Tylenol) for mild pain control
d. Soft tooth brush for dental hygiene
56
Parents of a school-age child with hemophilia ask the nurse, “Which sports are recommended for children with hemophilia?” Which sports should the nurse recommend? (Select all that apply.)
a. Soccer
b. Swimming
c. Basketball
d. Golf
e. Bowling
b. Swimming
d. Golf
e. Bowling
57
The nurse is conducting a staff in-service on childhood blood disorders. Which describes the pathology of idiopathic thrombocytopenic purpura?
a. Bone marrow failure in which all elements are suppressed
b. Deficiency in the production rate of globin chains
c. Diffuse fibrin deposition in the microvasculature
d. An excessive destruction of platelets
d. An excessive destruction of platelets
58
What should be monitored for idiopathic thrombocytopenic purpura?
monitor for signs of infection
59
What is a child at risk for who is receiving cancer tx?
tumor lysis syndrome from chemo
peripheral neuropathy from meds
alopecia from meds
spontaneous hemorrhage
60
What are the s/s of non-hodgkin lymphoma?
enlarged lymph nodes
fatigue
weakness
61
As part of the treatment for heart failure, the child takes the diuretic furosemide (Lasix). As part of teaching home care, the nurse encourages the family to give the child foods such as bananas, oranges, and leafy vegetables. These foods are recommended because they are high in which nutrient?
a. Chlorides
b. Potassium
c. Sodium
d. Vitamins
b. Potassium
62
What might be seen in a CHF pt who is receiving tx?
hypokalemic
digoxin (dig toxicity)
bradycardia
63
What orders are indicated vs contraindicated for a patient who has a hx of rheumatic fever and had dental work last week?
indicated:
- antibiotic
- echocardiogram
- blood cultures x3
contraindicated:
- restrict oral hygiene
- strenuous exercise
64
A chest radiograph film is ordered for a child with suspected cardiac problems. The child’s parent asks the nurse, “What will the radiograph show about the heart?” What knowledge about the x-ray should the nurse include in the response to the parents?
a. Bones of chest but not the heart
b. Measurement of electrical potential generated from heart muscle
c. Permanent record of heart size and configuration
d. Computerized image of heart vessels and tissues
c. Permanent record of heart size and configuration
65
The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes that a risk exists of cerebrovascular accidents (strokes). Which is an important objective to decrease this risk?
a. Minimize seizures
b. Prevent dehydration
c. Promote cardiac output
d. Reduce energy expenditure
b. Prevent dehydration
66
Seventy-two hours after cardiac surgery, a young child has a temperature of 101° F. Which action should the nurse take?
a. Keep child warm with blankets.
b. Apply a hypothermia blanket.
c. Record temperature on nurses’ notes.
d. Report findings to physician.
d. Report findings to physician.
67
The nurse is caring for a child after heart surgery. What should the nurse do if evidence of cardiac tamponade is found?
a. Increase analgesia
b. Apply warming blankets
c. Immediately report this to physician
d. Encourage child to cough, turn, and breathe deeply
c. Immediately report this to physician
68
Which should the nurse consider when preparing a school-age child and the family for heart surgery?
a. Unfamiliar equipment should not be shown.
b. Let the child hear the sounds of an ECG monitor.
c. Avoid mentioning postoperative discomfort and interventions.
d. Explain that an endotracheal tube will not be needed if the surgery goes well.
b. Let the child hear the sounds of an ECG monitor.
69
Which is best described as the inability of the heart to pump an adequate amount of blood to the systemic circulation at normal filling pressures?
a. Pulmonary congestion
b. Congenital heart defect
c. Heart failure
d. Systemic venous congestion
c. Heart failure
70
Which is a clinical manifestation of the systemic venous congestion that can occur with heart failure?
a. Tachypnea
b. Tachycardia
c. Peripheral edema
d. Pale, cool extremities
c. Peripheral edema
71
Parents of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurse’s reply should be based on which statement?
a. The child needs opportunities to play with peers.
b. The child needs to understand that peers’ activities are too strenuous.
c. Parents can meet all of the child’s needs.
d. Constant parental supervision is needed to avoid overexertion.
a. The child needs opportunities to play with peers.
72
The nurse is talking to a parent of an infant with heart failure about feeding the infant. Which statement about feeding the child is correct?
a. “You may need to increase the caloric density of your infant’s formula.”
b. “You should feed your baby every 2 hours.”
c. “You may need to increase the amount of formula your infant eats with each feeding.”
d. “You should place a nasal oxygen cannula on your infant during and after each feeding.”
a. “You may need to increase the caloric density of your infant’s formula.”
73
Which is the leading cause of death after heart transplantation?
a. Infection
b. Rejection
c. Cardiomyopathy
d. Heart failure
b. Rejection
74
A nurse is preparing to administer an angiotensin-converting enzyme (ACE) inhibitor. Which drug should the nurse administer?
a. Captopril (Capoten)
b. Furosemide (Lasix)
c. Spironolactone (Aldactone)
d. Chlorothiazide (Diuril)
a. Captopril (Capoten)
75
If a 3 year old is going through a painful procedure, what can the nurse include in the plan of care?
incorporate parents
be organized and quick
incorporate toys
76
What is the correct sequence used when performing an abdominal assessment? Begin with the first technique and end with the last.
a. Auscultation
b. Palpation
c. Inspection
d. Percussion
c. Inspection
a. Auscultation
d. Percussion
b. Palpation
77
When do the fontanels close?
anterior: 18-24 months
posterior: 2-3 months
78
What would you expect from a 6 month old at a wellness check?
weight 2x increase
posterior fontanelle closed
79
Where is the heart rate of an infant measured?
apical (apex of heart)
80
How do you measure the head circumference of an infant?
place tape measure under the head, wrap around and measure above eyebrows
81
A nurse in a clinic is assessing a 7 month-old infant. Which of the following indicates a need for further evaluation?
a. Uses a unidextrous grasp
b. Has a fear of stranger
c. Shows preferences towards foods
d. Babbles one-syllable sounds
d. Babbles one-syllable sounds
82
A nurse in a clinic is assessing a 9-month-old infant. Which of the following findings requires futher intervention?
a. Positive Babinski reflex
b. Positive Moro reflex
c. Negative Doll's eye reflex
d. Negative Crawl reflex
b. Positive Moro reflex
83
Define family centered care
make sure to include parents, child, and careteam
84
What are the benefits a child can get from hospitalization?
- support and recover from their illness
- master stress and learn coping skills
- socialization
85
What would you include when providing health promotion to an adolescent?
- preventative education
- encourage sleep
86
What will help a toddler that is having trouble sleeping?
provide bedtime rituals
87
What actions will a 10 year old who is admitted for an extended period of time need to do to meet Erikson's psychosocial needs?
make sure school work is completed
88
How would you describe a toddler's negative behaviors?
negative behavior result from them trying to be more autonomous
89
When assessing a newborn, what is the primary parameter of the APGAR score?
monitor the baby's heart rate (primary)
color/respiration
last activity/tone
90
What is an abnormality to report to the provider for a 3 month old newborn visit?
cannot raise head when baby is prone
(they should be able to)
91
A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute?
A. "Newborns are abdominal breathers."
B. "Newborns do not expand their lungs fully with each respiration."
C. "Activity will increase the respiratory rate."
D. "The rate and rhythm of breath are irregular in newborns."
D. "The rate and rhythm of breath are irregular in newborns."
92
What is an abnormality to report to the provider for a 10 month old?
cannot sit up w/o support
(they should be able to)
93
A 13-year-old girl asks the nurse how much taller she will get. She has been growing about 2 inches per year but grew 4 inches this past year. Menarche recently occurred. The nurse should base her response on which statement?
a. Growth cannot be predicted.
b. Pubertal growth spurt lasts about 1 year.
c. Mature height is achieved when menarche occurs.
d. Approximately 95% of mature height is achieved when menarche occurs.
d. Approximately 95% of mature height is achieved when menarche occurs.
94
What are the white spots on the nose of a newborn?
milia
95
What milestone should a 2 month old have?
smile w/ their parents
96
What does the hirschberg test for? How is it done?
ocular alignment
take penlight and put it in front of them, checking if it hits the same spots in both eyes
97
What is the term for a child with a smaller than normal jaw?
pierre roban or micrognathia
98
What is the term for a child with 6 toes on one foot?
polydactyl
99
If you notice sacral dimpling, what can this indicate?
spina bifida - meningocele
100
If a 6 week old child has low set ears, what would you describe it as?
only describe as facial dysmorphic feature by itself (purest form)
101
Which patient would you assess first?
a. 1 year old with rosera
b. 7 year with DI with specific gravity of
c. 10 year old with sickle cell with chest pain
d. CHF patient
c. 10 year old with sickle cell with chest pain
102
What would a 6 year old experience being in contact isolation?
sensory deprivation
103
What vaccination would you give during a pre college assessment?
meningococcal vaccine
104
What age can a child come down the stairs by placing both feet onto the steps, stop and hold onto rails?
3 year old
105
What is the best indicator for fluid loss?
body weight
106
Why are 24 hr exams at birth done?
check for congenital anomalies
107
When should we educate to start brushing the child's teeth?
upon first eruption of the teeth
108
What should be a developmental task for a preschooler?
imaginary play
109
Nurse is caring for a 4-year-old child who has croup and wet the bed overnight. When the parents visit the next day, the nurse explains the situation and one of the parents says, "she never wets the bed at home. I am so embarrassed." Which of the following responses should the nurse make?
a) "It is expected for children who are hospitalized to regress. The toileting skills will return when your child is feeling better."
b) "I know this can really be embarrassing. I have kids myself, so I understand, and it doesn't bother me."
c) "Your child did not seem upset, so I wouldn't worry about it if I were you."
d) "Why does it bother you that your child has wet the bed?"
a) "It is expected for children who are hospitalized to regress. The toileting skills will return when your child is feeling better."
110
A nurse is providing anticipatory guidance about child development to the parents of a toddler. Which of the following developmental tasks should the nurse include as expected of a toddler?
a. Explains the difference between right and wrong
b. Prints letters and numbers
c. Separates easily from primary caregiver for short periods of time
d. Cooperates in doing simple chores
c. Separates easily from primary caregiver for short periods of time
111
A nurse in a special education program is planning care for a child who has autistic disorder. Which of the following interventions is appropriate to include in the plan of care?
a) Allow for adjustment of rules to correlate with the child's behavior.
b) Provide a flexible schedule to adjust to the child's interests.
c) Allow for imaginative play with peers without supervision.
d) Establish a reward system for positive behavior.
d) Establish a reward system for positive behavior.
112
A nurse is caring for a 12-month-old toddler who is hospitalized and confined to a room with contact precautions in place. Which of the following toys should the nurse recommend in order to meet the developmental needs of the client?
a. Large building blocks
d. Hanging crib toys
c. Modeling clay
d. Crayons and a coloring book
a. Large building blocks
113
A nurse is caring for an 18-month-old toddler who has been hospitalized for 10 days. After the toddler's mother leaves the room, the nurse observes the toddle sitting quitely in the corner of the crib, cucking her thumb. When the nurse approaches the crib, the toddler turns away from the nurse. The nurse should understand that these behaviors indicate which of the following developmntal reactions?
a. An anxiety reaction
b. Regression
c. Resentment toward the mother
d. Developing autonomy
a. An anxiety reaction
114
A nurse is assessing a 15-month-old toddler. Which of the following findings should the nurse report to the provider?
A. The toddler cannot build a tower of six-to seven cubes
B. The toddler cannot stand upright without support
C. The toddler cannot jump with both feet
D. The toddler cannot turn a doorknob
B. The toddler cannot stand upright without support
115
What is the correct order of VS for a newborn?
RR
HR
temp
116
How should a child be approached for a positive response?
eye level
open stance
talk quietly
117
How will you talk to a toddler about wanting to take their VS?
nonmedical terminology
do not ask yes or no
"I will listen to how fast your heart is beating"
118
A nurse is caring for a 17 year old client who is experiencing a relapse of leukemia and is refusing treatment. The client's mother insists that the client receive treatment. Which of the following actions should the nurse take?
A. Initiative the IV per the patient's request
B. Notify the provider of the situation
C. Administer a sedative to calm the client
D. Offer the client an antiemetic
B. Notify the provider of the situation
119
How can the nurse get a baseline of home activities?
ask the parents to describe what their daily routines are at home with child
120
How are genes passed from parents to child?
passed by both parents
121
Describe trisomy 21
down syndrome
3 copies of chromosome 21
122
Which chromosome is missing genetic material in William syndrome?
chromosome 7
123
How many chromosomes will a newborn inherit from both parents?
46
124
A 4-year-old child is brought to the emergency department experiencing severe respiratory distress. The health care provider has diagnosed epiglottis. What nursing intervention(s) should the nurse include in this child’s plan of care? Select all that apply
a. Have intubation equipment readily available
b. Keep the child quiet
c. Administer prescribed nebulizer treatments
d. Start a peripheral IV
e. Administer oxygen
a. Have intubation equipment readily available
b. Keep the child quiet
c. Administer prescribed nebulizer treatments
125
What would you see in assessment of an otitis media child?
a. Child will be pulling on their ear
b. Drainage present will be purulent, yellow
c. Pain at the earlobe would indicate
d. Redness in the extremity of the ear
a. Child will be pulling on their ear
126
A nurse is caring for a child who is 2 hr postoperative following a tonsillectomy. Which of the following fluid items
should the nurse offer the child at this time?
A. Crushed ice
B. Orange juice
C. Vanilla milkshake
D. Cranberry juice
A. Crushed ice
