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During a routine clinic visit, a nurse finds that a 5-year-old girl's systolic blood pressure is above the 90th percentile. What should be the nurse's subsequent action?
- A. Refer the child to the healthcare provider and schedule a blood pressure evaluation in two weeks.
- B. Perform a comprehensive assessment and avoid repeated blood pressure measurements during the examination.
- C. Take the child's blood pressure three times during the visit and record the highest reading.
- D. Measure the blood pressure twice more during the visit and calculate the average of the three readings.
Correct Answer: D
Rationale: Averaging three readings ensures accuracy of elevated blood pressure findings.
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The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?
- A. Demonstrates startle reflex
- B. Plays “peek-a-booâ€
- C. Has doubled birth weight
- D. Turns head to locate sound
Correct Answer: A
Rationale: The startle reflex should disappear by 6 months; its presence suggests neurological issues.
The parents of a newborn with hypospadias are anxious about the timing of the surgical correction. What information should the nurse share with them?
- A. Surgery should be performed within one month to prevent bladder infections.
- B. Postponing the repair until the child reaches school age can alleviate fears of castration.
- C. The repair should be completed before the child is toilet-trained.
- D. The urethral repair should be carried out after the child reaches sexual maturity.
Correct Answer: C
Rationale: Repair before toilet training supports normal urinary function and reduces psychological impact.
A newborn with a repaired gastroschisis is transferred to the pediatric unit after several days in the pediatric intensive care unit. The infant is receiving parenteral nutrition and continuous enteral feedings. To maintain normal growth and development of the infant, which action should the nurse include in the plan of care?
- A. Speak to the healthcare provider about instituting physical therapy.
- B. Offer a pacifier for non-nutritive sucking.
- C. Ensure placement of the enteral tube with an abdominal x-ray.
- D. Use sterile technique during feedings.
Correct Answer: B
Rationale: Offering a pacifier for non-nutritive sucking promotes oral feeding skills and emotional stability, supporting normal growth and development in infants with gastroschisis repair.
The nurse is caring for a child with sickle cell disease who is experiencing a sickle cell crisis. Which finding should the nurse report to the healthcare provider immediately?
- A. Jaundice
- B. Swelling in the hands or feet
- C. Ulcers on the legs
- D. Chest pain
Correct Answer: D
Rationale: Chest pain may indicate acute chest syndrome, a life-threatening complication requiring immediate reporting.
The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. What additional finding should the nurse expect to observe?
- A. Hypotension and tachycardia
- B. Vigorous feeding and satiation
- C. Fever
- D. Hemiplegia
Correct Answer: A
Rationale: Aortic stenosis can reduce cardiac output, leading to hypotension, with tachycardia as a compensatory response.