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A nurse is caring for a 4-year-old child who is postoperative following abdominal surgery. Which of the following statements should the nurse make to encourage the child to take deep breaths?
- A. This will not be painful, just a little uncomfortable.
- B. Let's play a game of blowing cotton balls across your table.
- C. Do you want to take deep breaths for me now?
- D. You can't go to the playroom until you finish doing your deep breathing.
Correct Answer: B
Rationale: This makes deep breathing fun and engaging for the child encouraging them to participate.
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A nurse is preparing a 4-year-old child for discharge following a bilateral myringotomy with tympanostomy tube placement. The mother asks what to do if the tubes fall out. The nurse should give the parent which of the following instructions?
- A. Gently reinsert the tubes.
- B. Call the health care clinic to report that the tubes have fallen out.
- C. Reassure the mother that the tubes will not fall out.
- D. Take the child to an emergency department.
Correct Answer: B
Rationale: The healthcare provider needs to be informed to assess if new tubes are necessary.
A nurse is caring for a 6-month-old child. The child's provider has ordered a diphtheria, tetanus, and pertussis (DTaP) vaccine to be administered. Which of the following should cause the nurse to question the administration of this vaccine?
- A. New onset of seizure disorder in the child's sibling
- B. Evidence of sensitivity to egg antigens
- C. Afebrile otitis media
- D. Temperature of 40.5° C (104.9° F) after last DTaP
Correct Answer: D
Rationale: A high fever following a previous dose of DTaP may indicate a severe reaction.
A nurse is assisting with the care of a school-age child who has respiratory failure due to pneumonia. Which of the following positions should the nurse encourage to allow maximal lung expansion?
- A. Supine
- B. Prone
- C. Upright
- D. Side-lying
Correct Answer: C
Rationale: Sitting upright or in a high Fowler's position is optimal for lung expansion.
A nurse is collecting data from an infant who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?
- A. Absent plantar reflexes
- B. Inwardly turned foot on the affected side
- C. Asymmetric thigh folds
- D. Lengthened thigh on the affected side
Correct Answer: C
Rationale: Asymmetric thigh folds is a common finding in DDH.
A nurse is collecting data from a 1-year-old child who has Wilms' tumor. Which of the following findings should the nurse expect?
- A. Diarrhea
- B. Jaundice
- C. Swollen joints
- D. Abdominal mass
Correct Answer: D
Rationale: Wilms' tumor often presents as an asymptomatic abdominal mass.