Nokea
A nurse is collecting data from an infant. Which of the following sites is the most reliable location to check the infant's pulse?
- A. Temporal
- B. Carotid
- C. Apical
- D. Dorsalis pedis
Correct Answer: C
Rationale: The apical pulse is the most reliable method for assessing heart rate in infants.
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A nurse is collecting data from an infant who hit her head when she fell off of a dressing table. The nurse should identify which of the following findings as indicating increased intracranial pressure?
- A. Brisk pupillary reaction to light
- B. Irritability
- C. Tachycardia
- D. Increased sensory response to painful stimuli
Correct Answer: B
Rationale: Irritability is a common early sign of increased ICP in infants. Changes in behaviour such as increased irritability or lethargy can indicate a neurological problemincluding increased pressure within the skull.
A nurse is preparing to administer a dexamethasone 1.5 mg/kg/day PO to divide equally every 6 hr to a preschool-age child who weighs 22 lb. Available is dexamethasone oral solution 1 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 3.8 mL
- B. 2.8 mL
- C. 4.8 mL
- D. 1.8 mL
Correct Answer: 3.8
Rationale: Calculation: 22 lb ÷ 2.2 = 10 kg; 1.5 mg/kg/day × 10 kg = 15 mg/day; 15 mg ÷ 4 doses = 3.75 mg/dose; 3.75 mg × 1 mL/1 mg = 3.8 mL.
A nurse at a pediatric hotline receives a call from a mother who plans to administer aspirin to a toddler for a fever and wants to know the dosage. Which of the following statements by the nurse is an appropriate response?
- A. Give her acetaminophen, not aspirin.
- B. You'll have to call your physician.
- C. Follow the directions on the aspirin bottle for her age and weight.
- D. Give her no more than three baby aspirin every 4 hours.
Correct Answer: A
Rationale: Acetaminophen is commonly recommended for treating fever in children as it is safer and does not carry the risk of Reye's syndrome.
A nurse is assisting with the admission of a 2-year-old toddler who has acute gastroenteritis. Which of the following actions should the nurse take first?
- A. Determine if the toddler is voiding.
- B. Request evaluation of the toddler's serum electrolytes.
- C. Initiate isotonic fluids with 20 mEq/L potassium chloride.
- D. Collect a stool sample from the toddler.
Correct Answer: A
Rationale: Assessing urine output is crucial for determining the child's hydration status. Voiding is an important indicator of kidney function and fluid balance.
A nurse is collecting data from an adolescent. Which of the following represents the greatest risk for suicide?
- A. Active psychiatric disorder
- B. Availability of firearms
- C. Family conflict
- D. Homosexuality
Correct Answer: A
Rationale: The presence of an active psychiatric disorder