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A six-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child?
- A. List of achievement timeline for developmental milestones.
- B. Reactions to any previous hospitalizations.
- C. A history of rubella, rubeola, or chicken pox.
- D. Mother's use of alcohol, drugs, or cigarettes during pregnancy.
Correct Answer: B
Rationale: Previous hospitalization reactions help anticipate and address fears, aiding in care planning.
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The nurse is providing education to parents about preventing otitis media recurrence in their infant. Which instruction should the nurse include?
- A. Avoid smoke exposure.
- B. Inspect the infant's ears daily.
- C. Position prone after feeding.
- D. Breastfeed frequently.
Correct Answer: A
Rationale: Avoiding smoke exposure reduces the risk of otitis media recurrence, a known risk factor.
The nurse is caring for an adolescent with scoliosis who is recovering after a surgical spinal instrumentation. Which technique should the nurse use when moving this client?
- A. Cross the arms and legs.
- B. Perform a log roll.
- C. Raise the hips.
- D. Flex the knees.
Correct Answer: B
Rationale: The log roll technique maintains spinal alignment, critical after surgical spinal instrumentation.
When advising a new mother on caring for a child with croup, which symptom should be a priority concern for the telephone triage nurse?
- A. Fever of 101.0°F (38.3°C)
- B. Cries often when nursing
- C. Difficulty swallowing secretions.
- D. Barking cough, worse at night
Correct Answer: C
Rationale: Difficulty swallowing secretions indicates potential airway obstruction, a critical concern requiring immediate attention.
The nurse is monitoring a child with hydrocephalus who received a repeat ventriculoperitoneal (VP) shunt yesterday. Which assessment finding indicates to the nurse that the shunt is functioning normally?
- A. The child has grown in height since the previous shunt placement.
- B. The child is afebrile with normal vital signs postoperatively.
- C. An intracranial pressure (ICP) monitoring probe is in place.
- D. The child reports no evidence of continuous headaches.
Correct Answer: D
Rationale: The absence of continuous headaches indicates the VP shunt is functioning normally by relieving pressure on the brain, a primary symptom of hydrocephalus.
A 1-year-old child with respiratory syncytial virus (RSV) has been admitted to the pediatric unit. The nurse observes that the child has a fever, rhinorrhea, frequent coughing, and sneezing. Which additional finding should alert the nurse that the child is in acute respiratory distress?
- A. Flaring of the nares.
- B. Bilateral bronchial breath sounds.
- C. Diaphragmatic respirations.
- D. A resting respiratory rate of 35 breaths/min.
Correct Answer: A
Rationale: Nasal flaring indicates increased respiratory effort, a sign of acute respiratory distress.