Essential of Pediatric Nursing Test Bank

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The nurse has determined the rate of both the child's radial pulse and heart. What is the normal finding when comparing the two rates?

  • A. Are the same
  • B. Differ, with heart rate faster
  • C. Differ, with radial pulse faster
  • D. Differ, depending on quality and intensity
Correct Answer: A

Rationale: In a normal healthy individual, the rate of the radial pulse (peripheral pulse) and the heart rate (apical pulse) should be the same. This is because each heartbeat should result in a corresponding pulse felt at the radial artery in the wrist. The pulse is generated by the heart's contraction and the subsequent ejection of blood into the arteries, causing a wave of pressure that can be felt as the pulse. Therefore, in a healthy individual, the radial pulse rate should match the heart rate. If there is a significant difference between the two rates, it may indicate a cardiovascular abnormality or other underlying health condition that warrants further investigation.

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By which age should the nurse expect an infant to be able to pull to a standing position?

  • A. 6 months
  • B. 8 months
  • C. 11 to 12 months
  • D. 14 to 15 months
Correct Answer: B

Rationale: By the age of 8 months, most infants are able to pull themselves up to a standing position by holding onto furniture or other support. This milestone signifies the development of leg strength and coordination required for standing. While some infants may achieve this skill earlier or later, on average, 8 months is a common age for this milestone to be reached.

A 5 months child is brought for routine care. During auscultation of heart you find a short systolic murmur at left upper sternal border with soft 2nd heart sound. The most likely diagnosis is?

  • A. Ventricular septal defect
  • B. Atrial septal defect
  • C. Patent ductus arteriosus
  • D. Pulmonary stenosis
Correct Answer: B

Rationale: Atrial septal defect (ASD) often presents with a systolic ejection murmur at the left upper sternal border and a fixed split second heart sound.

The nurse is using the FLACC scale to rate the pain level in a 9-month-old. Which is the nurse's best response to the father's question of what the FLACC scale is?

  • A. It estimates a child's level of pain utilizing vital sign information.
  • B. It estimates a child's level of pain based on parents' perception.
  • C. It estimates a child's level of pain utilizing behavioral and physical responses.
  • D. It estimates a child's level of pain utilizing a numeric scale from 0 to 5.
Correct Answer: C

Rationale: The FLACC scale uses observable behavioral and physical responses (facial expression, leg movement, activity, cry, and consolability) to estimate pain.

Between 2-6 months of life, all are true about infant sleep EXCEPT

  • A. total sleep hours are about 14-16 hr/24 hr
  • B. sleeps about 9-10 hr concentrated at night
  • C. sleeps 2 naps/day
  • D. the sleep cycle time is similar to that of adults
Correct Answer: D

Rationale: Infant sleep cycles are shorter and differ from adult patterns.

Which chromosomal abnormality is often characteristic of infantile ALL?

  • A. t(4;11)
  • B. t(12;21)
  • C. t(9;22)
  • D. t(1;19)
Correct Answer: A

Rationale: The t(4;11) translocation is commonly found in infantile ALL and is associated with a poor prognosis.

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