An infant was born at 34 weeks’ gestation and is being treated in the NICU for apnea of
prematurity. The infant is in an isolette with an apnea monitor and intravenous fluids.
The apnea monitor sounds, and the nurse checks the infant to find the infant is not
breathing. The initial intervention by the nurse would be to:
1. Administer oxygen.
2. Perform back blows and chest thrusts.
3. Call a code.
4. Stroke the infant’s back.
The nurse is caring for a four-year-old child who is intellectually disabled and is
scheduled for surgery tomorrow. The nurse wants to plan postoperative care and pain
relief. The nurse will determine the best pain assessment tool by observing the child’s:
Standard Text: Select all that apply.
1. Language skills.
2. Understanding of the concept of more and less or otherwise has the ability to
quantify pain.
3. Ability to sit for a ten minute evaluation.
4. Ability to perceive pain.
5. Ability to understand pain.
A child who is medically fragile is being discharged home after a long hospital stay.
The child will require someone to provide medical treatments several times a day. In
planning discharge, the nurse will:
1. Train all members of the family to take part in the child’s care.
2. Plan for a home health nurse to visit the child four times a day to provide the medical
treatment.
3. Determine with the family which family members may be trained to provide care for
the child.
4. Evaluate the size of the child’s room for therapy.
The nurse can assist a child who has a mild hearing loss and reads lips to adapt to
hospitalization by:
1. Touching the child lightly before speaking.
2. Using a picture board as the main means of communication.
3. Speaking in a loud voice while facing the child.
4. Speaking directly to the parents for communication.
A nurse is working with the family of a pediatric client. The nurse is planning to obtain
an accurate family assessment. The initial step would be to:
1. Select the most relevant family assessment tool.
2. Establish a trusting relationship with the family.
3. Focus primarily on the mother, learning her greatest concern.
4. Observe the family in the home setting, since this step always proves indispensable.
A young child is admitted to the hospital following a serious injury while on a field trip
with his school class. When the parents arrive at the emergency room, the nurse
recognizes that the parents have only limited English. The nurse will:
1. Speak slowly and clearly so the parents can understand.
2. Have a translator/interpreter present when the nurse and physician describe the
child’s condition to the parents.
3. Have a family member who speaks English translate for the family
4. Give the parents a pamphlet written in their primary language that describes the
hospital routine.
A baby is born at 32 weeks’ gestation and is admitted to the NICU. After 4 difficult
weeks, the child’s condition has improved and survival seems guaranteed. The mother
comes every day to feed the infant. Between feedings, the mother sits alone in the
waiting room. The mother tells the nurse that she feels her life is in a holding pattern,
not yet being a parent but no longer anticipating the excitement of the planned delivery.
The nurse recognizes that the mother’s reaction could be defined as:
1. Shock and disbelief.
2. Anticipatory waiting.
3. Readjustment.
4. Mourning.
The nurse at a high school is screening students for mental health issues. The nurse
would want to refer the adolescent for depression if the child shows which symptoms of
depression?
Standard Text: Select all that apply.
1. Agoraphobia
2. Somatic complaints
3. Focus on violence
4. Poor self-care
5. Poor school performance
A mother of two children, an 8-year-old and a 10-year-old, tells you that her husband
has recently been deployed to the Middle East. The mother is concerned about the
children’s constant interest in watching TV news coverage of activities in the Middle
East. The most appropriate suggestion for the nurse to make to this mother would be:
1. “Spend time with your children, and take cues from them about how much they want
to discuss.”
2. “Allow the children to watch as much television as they want. This is how they are
coping with their father’s absence.”
3. “The less that you discuss this, the quicker the children will adjust to their father’s
absence. Try to keep them busy and use distractions to keep their mind off of it.”
4. “It will just take some time to adjust to their father’s absence and then everything will
return to normal.”
The nurse is off-duty and watching a youth baseball game when one of the players gets
hit in the chest with a ball. The child immediately drops to the ground and is
unresponsive. What is the priority action for the nurse to initiate?
1. Initiate CPR.
2. Call 911.
3. Find the parents and offer them comfort.
4. Check the child for hemorrhage.
Following a facial injury of a 12-year-old youth during a baseball game, a nurse speaks
with the league administrators about first aid for teeth that may be lost. The nurse will
instruct the administration that appropriate first aid will include:
Standard Text: Select all that apply.
1. Not worrying about the tooth loss, as children this age still have their “baby” teeth.
2. Only handling the lost tooth by the roots and avoiding touching the crown of the
tooth.
3. Rinsing the lost tooth with sterile saline.
4. Placing the tooth back into its socket and taking the child to an emergency dental
facility.
5. Keeping the tooth clean and dry during transport to an emergency dental facility.
The mother of several children is talking with the nurse. She asks the nurse why her
younger child seems to sunburn easier than her older children. The nurse would explain
that the skin of younger children:
1. Is thinner than that of adolescents.
2. Has less melanin.
3. Has smaller, nonfunctional apocrine sweat glands.
4. More readily absorbs chemicals.
The nurse is teaching the caregiver of a child who is newly diagnosed with type 1
diabetes mellitus how to minimize pain with insulin injections. Which interventions to
minimize pain will the nurse include in the teaching?
Standard Text: Select all that apply.
1. Do not reuse needles.
2. Remove all bubbles from the syringe before injecting.
3. Have the child flex the muscle during injection.
4. Inject insulin when it is cold.
5. Do not change the direction of the needle during insertion or withdrawal.
The pediatric clinic has set a goal that 95% or more of the children attending the clinic
will be fully immunized. To reach this goal, clinic nurses will teach the families that:
1. The benefits of immunizations outweigh the risks of communicable diseases.
2. Immunizations should be completed by the time the child starts school.
3. Once a child receives a vaccination, that individual has lifelong immunity against
that disease.
4. Vaccinations are 100% safe.
A newborn who is 24 hours old is suspected of having cystic fibrosis. As the child is
being prepared for transfer to a pediatric hospital, the mother asks the nurse what
symptoms made the physician suspect cystic fibrosis. The nurse would reply that the
clinical manifestation of cystic fibrosis that is seen first is:
1. Rectal prolapse.
2. Constipation.
3. Steatorrheic stools.
4. Meconium ileus.
While evaluating development of children, the nurse notes that the development of
secondary sexual characteristics follows a typical pattern. Place the appearance of
secondary sexual characteristics in the female in order of appearance from earliest to
latest.
Standard Text: Click and drag the options below to move them up or down.
Choice 1. Appearance of pubic hair
Choice 2. Menarche
Choice 3. Breast budding
Choice 4. Breast Tanner stage 5, areola strongly pigmented
The pregnant woman has had no prenatal care and arrives at the hospital fully dilated.
Assessment of the newborn indicates a probable gestational age of 35 weeks combined
with intrauterine growth restriction. The nurse will monitor the infant for signs of
neonatal abstinence syndrome, including:
Standard Text: Select all that apply.
1. Poor feeding.
2. Difficult to arouse.
3. Constipation.
4. Seizures.
5. Yawning.