The nurse is evaluating the developmental skills of an eight-month-old child recently
adopted from a foreign country. The nurse attempts to get the child to wave “bye-bye”
and to play “patty-cake.” When the child is unable to perform either skill, the nurse
should:
1. Document developmental delay on the child’s record.
2. Refer the child for an electroencephalogram.
3. Encourage the parents to seek medical attention for the child’s developmental delay.
4. Recognize that this child’s language skills and previous experience may not allow for
these activities at this time.
A seven-year-old has just returned to the unit from the operating room after undergoing
an appendectomy. When asked, the child states that his pain is a 1 on a scale of 0 to 10.
Which finding makes the nurse question this response?
1. Lies rigid in bed, refusing to move
2. Eyes closed, flat effect
3. Turning away from the nurse, avoiding eye contact
4. Mother states that the child is in pain.
A nine-year-old child who has been followed in the same pediatric health care home
since birth has come in for a well-child visit. A nurse who measures the height and
weight of the child documents 35th percentile for height and 90th percentile for weight.
How should the nurse interpret these data?
1. The child is obese and needs dietary counseling.
2. The child is beginning a growth spurt.
3. As soon as the child begins the adolescent growth spurt, the height and weight
measurements will normalize.
4. The parents are most likely below the 50th percentile for height and weight.
At delivery, it was discovered that the newborn had a bilateral cleft lip. The parents are
distressed about the appearance of their infant. Nursing behaviors that can help the
parents bond to the infant include:
Standard Text: Select all that apply.
1. Calling the infant by name when referring to the infant.
2. Keeping the infant’s lower face covered with the blanket.
3. Smiling at the infant and talking to the infant in the parents’ presence.
4. Showing the parents before and after pictures of other children with cleft lips.
5. Discussing positive features of their baby.
After years of treatment with chemotherapy and radiation, a child with a brain tumor is
shown to be refractory to treatment, and a DNR (Do Not Resuscitate) has been
obtained. The mother has reached the stage of acceptance; the father is angry that the
medical and nursing team has not been able to ‘save” his child. How would the
multidisciplinary team best support this family?
1. Tell the father that he should have brought his child in earlier for treatment.
2. Continue to include the family in planning care and assure them that the child will be
kept comfortable in the days to come.
3. Initiate a Social Services referral.
4. Contact the on-call chaplain for consultation with the entire family and ask him to
take the father aside for additional assistance.
Following a tornado destroying the family home and injuring all family members, the
four-year-old child is admitted to the Pediatric Intensive Care Unit. All other family
members are hospitalized at a different hospital. The nursing staff can provide the
four-year-old with a sense of security by:
1. Providing new toys for the child.
2. Asking a hospital volunteer to visit the child daily and stay as long as possible.
3. Explaining to the child that mom and dad also are sick and cannot come to visit.
4. Keeping the child’s security blanket with the child at all times.
The nurse is providing anticipatory guidance instructions to the parents of a newborn.
Which of these instructions should the nurse give as disease/injury prevention
strategies?
Standard Text: Select all that apply.
1. SIDS risk reduction
2. Fall prevention
3. Formula safety
4. Immunization schedule
5. Risk of poisoning
A 27-month-old toddler who is in the pediatric office for a well-child visit begins to cry
the moment he is placed on the examination table. The parent attempts to comfort the
toddler, but nothing is effective. Which would be the most appropriate action for the
nurse to take?
1. Instruct the father to hold the toddler down tightly to complete the examination.
2. Allow the toddler to sit on the parent’s lap and begin the assessment.
3. Ask another nurse in the office to hold the toddler, since the parent is not able to
control the toddler’s behavior.
4. Allow the toddler to stand on the floor until the crying stops.
The three-year-old child with cystic fibrosis has just been discharged from the hospital
following a two-week stay due to a respiratory infection. The child has a post-discharge
office visit the next day. During the office visit, the mother mentions that the child was
toilet trained before hospitalization but now is having accidents. Which response by the
nurse would be most appropriate?
1. “This is probably a reaction to the antibiotics and will disappear when the antibiotics
are finished.”
2. “Urinary incontinence is a common symptom of progression of cystic fibrosis. Be
sure to notify the physician of this change.”
3. “The child may have a urinary tract infection and needs to be evaluated.”
4. “Children often regress after hospitalization. Be patient and remind him to go to the
bathroom frequently.”
While working on the pediatric unit, the nurse recognizes a neighbor whose child has
been admitted to the hospital pediatric intensive care. Out of curiosity, the nurse visits
the PICU and reviews the child’s chart for information about the child’s diagnosis. This
nurse:
1. Has violated HIPAA laws.
2. Was working within the legal limitations of his/her job.
3. Was not guilty of violating HIPAA laws unless the nurse shares the information with
someone outside the hospital.
4. Was working as a member of the health care team to provide family-centered
nursing.
The nurse is caring for a child who has been sedated for a painful procedure. What is
the priority nursing activity for this child?
1. Place the child on a cardiac monitor.
2. Allow parents to stay with the child.
3. Monitor pulse oximetry.
4. Assess the child’s respiratory effort.
An infant is born at 24 weeks’ gestational age. Which of these interventions should the
nurse plan when the infant is discharged home?
1. Instructing the parents that infants need warmed milk and to heat the milk in a
microwave for no more than 15 seconds
2. Giving the parents information on HIV screening that is necessary for infants born at
this gestational age
3. Referring the infant for developmental screening
4. No particular instructions are necessary because discharge teaching is completed
immediately after the birth of the infant.
A four”year-old child is seen in the pediatric clinic for a well-child visit. During this
visit, the nurse recognizes that appropriate assessments that should be completed at this
time include:
Standard Text: Select all that apply.
1. Height and weight.
2. Head circumference.
3. Four-year-old required immunizations.
4. Developmental assessment.
5. Safety counseling.
The nurse is completing the intake and output record for a child admitted for fluid
volume deficit. The child has had the following intake and output during the shift:
Intake:
4 ounces of Pedialyte
One-half of an 8 ounce cup of clear orange Jell-O
Two graham crackers
200 cc of D 51/2 sodium chloride IV
Output:
345 cc of urine
50 cc of loose stool
How many milliliters should the nurse document as the client’s total intake? Give
numerical answer only. Do not include any units of measurement.
The nurse is working in a PICU with several children with life-threatening illnesses.
The children come from a variety of cultural and religious groups. Because of their
religious beliefs, the parents of which religious group should not be contacted regarding
organ and tissue donation?
1. Jehovah’s Witness
2. Islam
3. Hinduism
4. Buddhism
To accurately access blood pressure on a child, the nurse would select a cuff:
1. By the cuff labelinfant, child, adult.
2. That covers 2/3 of the upper arm with a bladder that wraps around at least 80% of the
circumference of the arm.
3. Based on availability as the size of the cuff will not influence the blood pressure.
4. That extends up to 50 % of the upper arm and the bladder covers 1/4 of the
circumference of the arm.
A four-year-old child is admitted to the hospital secondary to dehydration. Lab tests
indicate a high hemoglobin and hematocrit, and the serum sodium is below normal
levels. This fluid loss is indicative of which condition?
1. Hypernatremia
2. Metabolic acidosis
3. Hypotonic dehydration
4. Isotonic dehydration
The nurse is taking care of a seven-year-old child who is postoperative. The child’s
mother requests that the child not receive narcotics in the postoperative period because
she is afraid the child will become addicted. The nurse would explain to the mother that
children who do not receive adequate pain control will be at risk for:
1. Respiratory complications.
2. Urinary complications.
3. Cardiac complications.
4. Bowel complications.
A child with a history of asthma presents to the school nurse complaining of wheezing.
The nurse assesses the child and notes that the respiratory rate is 36 and expiratory
wheezes are heard throughout the lung field. The child’s oxygen saturation is 98%.
Which is the best initial action by the nurse?
1. Call the child’s parents to come pick up the child.
2. Have the child use his metered-dose inhaler.
3. Call 911 to request emergency medical assistance.
4. Have the child lie down to see if the symptoms subside.