While the nurse is admitting a pediatric patient, the mother blurts out, “I think this
hospital is the most disorganized, inefficient place I have ever been in!” The most
therapeutic response for the nurse to make would be:
1. “This hospital and its staff are extremely competent, and you are receiving the best
possible care.”
2. “Does your child have any allergies or take any medication routinely?”
3. “It happens to be very busy right now, and there are children much sicker than your
child who need to be cared for first.”
4. “It sounds like you are upset with the care your child has received. Is that correct?”
A child is admitted to the hospital with a diagnosis of “rule out” urinary tract infection.
A clean-catch urine specimen is submitted to the lab. When the results return, the nurse
evaluates the findings. Which finding would the nurse question?
1. 2+ White blood cells
2. 1+ red blood cells
3. Urine appearance: cloudy
4. Specific gravity: 1009
All of the following children are inpatients on the pediatric unit. Which child is likely to
be left with a developmental disability?
1. An 18-month-old admitted with a diagnosis of near drowning
2. A school-age child newly diagnosed with type 1 diabetes mellitus
3. A toddler with sepsis
4. A two-year-old child with a fractured femur
Which of these strategies would be most effective for a “teachable moment” for the
parents of a four-year-old child during a routine office visit?
1. Discuss with the parents preparation for school because the child will start
kindergarten next year
2. Review five-year-old anticipatory guidelines with the parents.
3. Select one topic that is a common problem or concern for parents of four-year-olds
and present a brief amount of information on the topic.
4. Review all four-year-old anticipatory guidelines with the parents.
A child with a history of seizures arrives in the emergency department in status
epilepticus. What is the nurse’s initial action?
1. Take vital signs.
2. Establish an intravenous line.
3. Perform rapid neurological assessment.
4. Maintain patent airway.
An infant weighs 9 pounds, 3 ounces at birth. When the infant is seven days old, the
mother calls the pediatrician’s office worried about her child’s weight loss. What is the
lowest acceptable weight the infant should be at this age?
1. 9 pounds
2. 8 pounds, 12 ounces
3. 8 pounds, 2 ounces
4. 7 pounds, 12 ounces
A nurse caring for a nine-year-old notices some swelling in the child’s ankles. The nurse
presses against the ankle bone for five seconds, then releases the pressure, noticing a
markedly slow disappearance of the indentation. Based on these physical findings, the
nurse would be most concerned with assessing:
1. Skin integrity, especially in the lower extremities.
2. Level of consciousness.
3. Urine output.
4. Range of motion and ankle mobility.
A pediatric clinic serves several children who were adopted. The clinic nurse recognizes
that the adopted child who is most likely to blame himself for being “given away” by
the biologic parents is the:
1. Adopted child entering high school.
2. Child under three who was adopted as an infant.
3. Preschooler whose skin color is different from the adopted parents.
4. Child entering kindergarten.
Several children arrived at the emergency department accompanied only by their
fathers. The nurse knows that the father who legally may sign emergency medical
consent for treatment is:
1. The non-biologic one from the heterosexual cohabitating family.
2. The divorced one from the binuclear family.
3. The divorced one when the single-parent mother has custody.
4. The stepfather from the blended or reconstituted family.
The nurse in the newborn nursery is doing the admission assessment on a neonate.
Which assessment finding would lead the nurse to suspect unilateral congenital hip
dysplasia?
1. Lordosis
2. Trendelenburg sign
3. Asymmetry of the gluteal and thigh fat folds
4. Telescoping of the affected limb
After a severe allergic reaction, an EpiPen is prescribed for the 10-year-old child.
Instructions to be given to the child and the family would include:
Standard Text: Select all that apply.
1. The child should always have the EpiPen readily available.
2. The parents should learn to administer the EpiPen as the child is too young to
self-administer.
3. Once an EpiPen has been administered, there is no need for additional follow-up.
4. The EpiPen has an expiration date that should be checked regularly, and the pen
should be replaced as needed.
5. The child should wear a MedicAlert bracelet.
The mother of a six-week-old infant tells the nurse that her baby has had colic for
several days, crying for up to three hours and drawing his legs up on his abdomen. The
mother says she is at “wits end” and wonders what she can do. The nurse learns that the
infant is formula fed and gaining weight satisfactorily. The nurse would recommend:
Standard Text: Select all that apply.
1. Breastfeeding the infant.
2. Switching to a bottle that has a collapsible bag inside.
3. Putting the infant in a baby swing after feeding.
4. Burping the baby more frequently.
5. Giving the baby a suppository once each morning.
The nurse administers the flu vaccine to a school age child. After administering the
vaccine, the nurse will document:
Standard Text: Select all that apply.
1. The date of the last flu vaccine.
2. The site of the vaccination.
3. The lot and serial number of the vaccine.
4. The date and time of administration.
5. Who assisted in restraining the child.
Mandatory testing in the newborn nursery determines that the infant has
hypothyroidism. When discussing the treatment with the new mother, the mother states
that she doesn”t believe in taking medications. The nurse would explain that failure to
treat the infant with the appropriate medication will result in:
1. Heart disease.
2. Mental retardation.
3. Renal failure.
4. Thyroid storm.
A child with leukemia has a granulocyte count of 250/mm3 and a platelet count
150,000/mm3. Nursing intervention would include which of the following?
1. Fluid restriction
2. Avoidance of mouth care
3. Strict isolation
4. Good hand washing
A child with rhabdomyosarcoma is to undergo radiation therapy after surgical removal
of the tumor. The parents should be taught to:
1. Apply lotion to the area before radiation therapy.
2. Apply sunscreen to the area when the child is exposed to sunlight.
3. Remove any markings left after each radiation treatment.
4. Vigorously scrub the area when bathing the child.
The school nurse is reviewing the records of all incoming kindergarten students. The
nurse recognizes that an individualized education plan (IEP) will be required for which
children?
Standard Text: Select all that apply.
1. The child with diabetes controlled with insulin
2. The child with a casted arm due to a fracture
3. The child with a hearing deficit
4. The child with autism
5. The child with an IQ of 60
The nurse has received a child from the emergency department with a diagnosis of
decreased level of consciousness secondary to increased intracranial pressure. Which
physician’s order would the nurse question?
1. Passive range-of-motion exercises
2. Oxygen at 2L nasal cannula to keep saturation above 95%
3. Hourly vital signs and neuro checks
4. Elevate head of bed 30 degrees
Which nursing diagnosis would be most appropriate for an infant with acute
bronchiolitis due to respiratory syncytial virus (RSV)?
1. Activity intolerance
2. Tissue perfusion, ineffective (peripheral)
3. Pain, acute
4. Decreased cardiac output