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A parent brings a toddler, age 19 months, to the clinic for a regular check-up. When palpating the toddler’s fontanels, what should the nurse expects to find?
- A. Closed anterior fontanel and open posterior fontanel
- B. Open anterior and fontanel and closed posterior fontanel
- C. Closed anterior and posterior fontanels
- D. Open anterior and posterior fontanels
Correct Answer: C
Rationale: By 19 months, both the anterior and posterior fontanels should be closed as the skull bones have fused.
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Nurse Alice is providing cardiopulmonary resuscitation (CPR) to a child, age 4. the nurse should:
- A. Compress the sternum with both hands at a depth of 1½ to 2†(4 to 5 cm)
- B. Deliver 12 breaths/minute
- C. Perform only two-person CPR
- D. Use the heel of one hand for sternal compressions
Correct Answer: D
Rationale: For a 4-year-old, the heel of one hand is appropriate for sternal compressions to achieve the correct depth and avoid injury.
Which clinical manifestation should the nurse expect to see as shock progresses in a child and becomes decompensated shock?
- A. Thirst
- B. Irritability
- C. Apprehension
- D. Confusion and somnolence
Correct Answer: D
Rationale: Confusion and somnolence are beginning signs of decompensated shock. Thirst, irritability, and apprehension are signs of compensated shock.
What is the Duke Treadmill score for a patient who exercised for 10 minutes (12 METS) and had a maximum of 1 mm ST depression at peak exercise without angina?
- A. 5
- B. 7
- C. 9
- D. 10
Correct Answer: C
Rationale: The Duke Treadmill score is calculated based on exercise duration
While looking through the chart of an infant with a congenital heart defect (CHD) of decreased pulmonary blood flow, the nurse would expect which laboratory finding?
- A. Decreased platelet count
- B. Polycythemia
- C. Decreased ferritin level
- D. Shift to the left
Correct Answer: B
Rationale: Chronic hypoxemia in CHD leads to polycythemia as a compensatory mechanism.
Which is the most appropriate nursing action related to the administration of digoxin (Lanoxin) to an infant?
- A. Counting the apical rate for 30 seconds before administering the medication
- B. Withholding a dose if the apical heart rate is less than 100 beats/min
- C. Repeating a dose if the child vomits within 30 minutes of the previous dose
- D. Checking respiratory rate and blood pressure before each dose
Correct Answer: B
Rationale: As a rule, if the pulse rate of an infant is below 100 beats/min, the medication is withheld and the physician is notified.