Immediately after delivery, the nurse prepares to give the newborn a vitamin K
injection. The new father is watching and asks the nurse why the baby is receiving a
‘shot.” The nurse would explain that vitamin K injections are given to newborn infants
to:
1. Activate clotting factors.
2. Break up blood clots.
3. Promote red blood cell function and assist in gas exchange.
4. Promote the production of hemoglobin.
The nurse is examining a 12-month-old who was brought to the clinic for persistent
diaper rash. The nurse finds perianal inflammation with bright red, scaly plaques and
small papules. Satellite lesions are also present. This is most likely caused by which of
the following?
1. Candida albicans (yeast)
2. Impetigo (staph)
3. Infrequent diapering
4. Urine and feces
Following diagnosis of Crohn’s disease, the nurse is explaining dietary modifications to
the teenagers. The nurse would recommend:
Standard Text: Select all that apply.
1. Increased fiber in the diet to promote solid stools.
2. Small, frequent feedings are preferred over three meals a day.
3. Identify foods that cause distress and eliminate them from the diet.
4. High-calorie dietary supplement shakes can help meet nutritional requirements.
5. Socialization is important at mealtime no matter the dynamics.
The community health nurse is planning an education session for recently hired
teachers at a childcare center. It is most important that the nurse teach the staff:
1. The schedule for immunizations.
2. How to interpret health records.
3. Principles of infection control.
4. How to take a temperature.
A child has been admitted to the hospital unit with a diagnosis of minimal change
nephrotic syndrome (MCNS). The clinical manifestations will include which of the
following?
1. Massive proteinuria, hypoalbuminemia, and edema
2. Hematuria, bacteriuria, and weight gain
3. Urine-specific gravity decreased and urinary output increased
4. Gross hematuria, albuminuria, and fever
A 10″month-old infant is seen in the emergency department for a heart rate of 226 beats
per minute. Supraventricular tachycardia is diagnosed. The emergency department
nurse will prepare to assist with which possible treatments?
Standard Text: Select all that apply.
1. Administration of intravenous adenosine (Adenocard)
2. Administration of intravenous amiodarone (Cardarone)
3. Preparation for cardioversion
4. Application of ice to the face
5. Having the child perform a Valsalva maneuver
The mother of an immunocompromised child brings her child to the clinic for a routine
check-up and recommended immunizations. The mother expresses concern that her
child will “catch” the disease from the vaccination. The nurse would explain that which
of the following carry no risk of acquiring the infection?
Standard Text: Select all that apply.
1. Toxoid
2. Killed virus vaccine
3. Live virus vaccine
4. Attenuated vaccine
5. Immunoglobulins
A nurse in the outpatient pediatric clinic is reviewing the records of a preschool-age
child and notes that the parents have missed the last two health care visits. The nurse
also notes that the child has not received the second measles, mumps, and rubella
(MMR) vaccine. The nurse should:
1. Plan to discuss the principles of health supervision at the next scheduled visit.
2. Call the parents and encourage them to bring the child for recommended care.
3. Notify the physician that the child’s immunizations are no longer up to date.
4. Speak firmly with the parents at the next health care visit about the importance of
being compliant.
A seven-year-old girl has been clinging to her mother and refusing to go to school. The
child is diagnosed with separation anxiety disorder, and the treatment plan will include
cognitive-behavioral therapy (CBT). The nurse would explain to the parents that CBT
will include:
Standard Text: Select all that apply.
1. Self-talking.
2. Relaxation.
3. Hypnosis.
4. Anti-depressant medications.
5. Recognition of feelings.
The nurse is planning care for a child with bacterial meningitis. What is the priority
nursing diagnosis?
1. Impaired gas exchange
2. Infection, risk for
3. Anxiety (parental)
4. Acute pain
The mother tells the nurse that her maternity leave is almost over and she will be
returning to work soon. She will need to place her infant in a day care, and she asks the
nurse how to know which day care is best. The nurse will tell the mother to investigate
day care programs that:
Standard Text: Select all that apply.
1. Are close to her work in the event of an emergency
2. Require all staff have criminal background checks
3. Are attractive in appearance, with bright colors and interesting visual stimulation
4. Provide regular training of the staff and administration
5. Have policies regarding child health and emergencies, such as immunization
requirements and emergency medical forms
Unhappy with the treatment progress for their child with cancer, the parents choose to
add dietary supplements, including megavitamins, as complementary medicine to the
treatment plan. What would be the priority nursing diagnosis for this child?
1. Impaired gas exchange
2. Risk for injury
3. Altered family processes
4. Altered parenting
Following hospital discharge for treatment of gastroesophageal reflux, the home health
nurse visits the family. Which finding made by the nurse during the visit requires the
nurse to intervene?
1. The infant’s formula has rice cereal added.
2. The mother hold the infant is a high Fowler’s position while feeding.
3. After feeding, the infant is placed in an infant seat.
4. The mother draws up the ranitidine (Zantac) in a syringe for oral administration.
The nurse is taking care of a child in the ICU. The parent appears very angry and tells
the nurse no one is giving her information about her child. How should the nurse
respond?
1. Inform the parent she will be asked to leave if she continues this behavior.
2. Apologize for the parent’s perception and assure the parent that the staff will keep her
informed. Inform the parent of any change in the child’s condition as soon as possible.
3. Offer to ask the doctor to come and talk with her.
4. Tell the parent her behavior will upset the child.
The nurse is teaching parents how to prevent the spread of infectious disease. Which of
the following is the most important health promotion strategy for all age groups of
children?
1. Keeping child free from colds
2. Proper hand hygiene
3. Keeping all toys clean and free from germs
4. Keeping child away from sick adults
The nurse is partnering with the family of a hospitalized premature infant who suffered
an intraventricular brain hemorrhage. After three months in the neonatal intensive care
unit (NICU), the infant is being discharged. Which activities will the nurse suggest to
the family to help stimulate the infant’s development?
Standard Text: Select all that apply.
1. Using a day care for stimulation
2. Discouraging sibling interaction
3. Holding and rocking the infant
4. Interacting face to face
5. Talking softly and singing to the infant
During the newborn examination, the nurse assesses the infant for signs of
developmental dysplasia of the hip. Which finding would strongly suggest this
disorder?
1. Asymmetric thigh and gluteal folds
2. Positive Babinski’s reflex
3. A negative Moro reflex
4. Flat soles with prominent fat pads
The nurse is teaching a group of mothers of toddlers and preschoolers about oral care
and the prevention of caries. Which statements should the nurse include in the
presentation?
Standard Text: Select all that apply.
1. “The tendency toward dental caries is inherited.”
2. “Fruit juice is an excellent source of vitamin C, so allow your child to drink as much
fruit juice a day as desired.”
3. “If your child is under two, you should use toothpaste without fluoride.”
4. “Three-year-old children are mature enough to be able to brush their teeth
independently.”
5. “The child should see a dentist by one year of age.”