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A 16-month-old child is seen in the clinic for a checkup for the first time. The nurse notices that the toddler limps when walking. Which of the following would be appropriate to use when assessing this toddler for developmental dysplasia of the hip?
- A. I couldn'ts maneuver.
- B. Barlow's maneuver.
- C. Adam's position.
- D. Trendelenburg's sign.
Correct Answer: B
Rationale: Barlow's maneuver is used to assess for hip instability in infants and toddlers, appropriate for detecting developmental dysplasia of the hip.
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An adolescent with a history of losing weight and fatigue is admitted to the hospital with a diagnosis of stage I chronic renal failure. Based on these fi ndings, the nurse should:The chart shows:
- A. Continue monitoring intake and output.
- B. Notify the physician.
- C. Restrict the client’s fluids.
- D. Increase the client’s fluids.
Correct Answer: B
Rationale: The nurse would expect a person with a normal GFR to have approximately equal inputs and outputs. Chronic renal failure has fi ve stages. In stage I the glomerular fi ltration rate (GFR) is approximately ≥90 mL/minute/1.73 m2. In stage II the GFR decreases to approximately 60 to 89 mL/minute/1.73 m2. The decreased urine output may indicate worsening disease and should be reported. Assessing the client’s intake and output is still important, but notifying the provider is the priority. Fluids are restricted based on decreased sodium. Clients are encouraged to drink to thirst. Therefore, there is not enough information to suggest increasing or restricting fl uids.
A 9-month-old child with cystic fibrosis does not like to take a pancreatic enzyme supplement with meals and snacks. The mother does not like to force the child to take the supplement. The most important reason for the child to take the pancreatic enzyme supplement with meals and snacks is:
- A. The child will become dehydrated if the supplement is not taken with meals and snacks.
- B. The child needs these pancreatic enzymes to help the digestive system absorb fats, carbohydrates, and proteins.
- C. The child needs the pancreatic enzymes to aid in liquefying mucus to keep the lungs clear.
- D. The child will experience severe diarrhea if the supplement is not taken as prescribed.
Correct Answer: B
Rationale: Pancreatic enzyme supplements are essential in cystic fibrosis to aid digestion and absorption of fats, carbohydrates, and proteins, compensating for pancreatic insufficiency.
A 12-year-old child has had a traumatic head injury from playing in a football game. He is admitted to the emergency department and transferred to the pediatric intensive care unit. He has an I.V. of dextrose 5% in water at a 'keep-open' rate and nasal oxygen at 2 L/minute. The nurse is assessing the child at the beginning of the shift (11:00 p.m.) and reviews the Glasgow Coma Scale flow sheet. The nurse notes that the child responds to pain, is making incomprehensible sounds, and has abnormal flexion of the limbs. What should the nurse do first?
- A. Notify the physician.
- B. Administer pain medication.
- C. Increase oxygen flow.
- D. Document the findings.
Correct Answer: A
Rationale: A Glasgow Coma Scale score indicating pain response, incomprehensible sounds, and abnormal flexion (approximately 6-8) suggests severe neurological impairment, warranting immediate physician notification.
An infant has been transferred from the ICU to the pediatric floor after undergoing surgery to correct a heart defect. Which tasks can the nurse delegate to the licensed practical nurse (LPN)?
- A. Administering oral medications.
- B. Administering I.V. morphine.
- C. Obtaining vital signs.
- D. Recording the input and output.
- E. Administering blood products.
- F. Morning hygiene.
- G. Circulation checks.
Correct Answer: A,C,D,F,G
Rationale: LPNs can handle oral medications, vital signs, input/output, hygiene, and circulation checks. I.V. morphine and blood products require RN oversight.
The nurse is teaching the parents of an 8-month-old about what the child should be eating. The nurse should include which of the following points in the teaching plan?
- A. Items from all four food groups should be introduced to the infant by the time the child is 10 months old.
- B. Solid foods should not be introduced until the infant is 10 months old.
- C. Iron deficiency rarely develops before 12 months of age, so iron-fortified cereals should not be introduced until the infant is 12 months old.
- D. The infant's diet can be changed from formula to whole milk when the infant is 12 months old.
Correct Answer: D
Rationale: Whole milk can be introduced at 12 months, as infants need the fat content for brain development.