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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.
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The nurse is providing nutrition education to the parents of an infant with failure to thrive (FTT). Which statement made by the parent should the nurse recognize as an appropriate understanding of interventions?
- A. Breast milk provides adequate calories for the child.
- B. Regular syringe feedings promote rapid weight gain.
- C. High-calorie formula encourages increased growth.
- D. Fruit juice increases the child's daily vitamin intake.
Correct Answer: C
Rationale: High-calorie formula provides the increased caloric intake needed to promote growth in infants with FTT.
Which snack selected by a school-aged child with gastroesophageal reflux indicates to the nurse that the child understands the dietary restrictions?
- A. Sugar cookies.
- B. Pizza.
- C. Tacos.
- D. Chocolate milkshake.
Correct Answer: A
Rationale: Sugar cookies are low-fat and low-sugar, suitable for gastroesophageal reflux, unlike high-fat or acidic options.
The nurse is assessing a 2-week-old male infant in a community health clinic and notes that his sclera appear slightly yellow. Additionally, urine in his diaper appears tea-colored. This child should receive follow-up assessment for what condition?
- A. Intussusception.
- B. Biliary atresia.
- C. Hirschsprung's disease.
- D. Huntington's disease.
Correct Answer: B
Rationale: Jaundice and tea-colored urine suggest biliary atresia, requiring urgent follow-up to prevent liver damage.
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.
A child who weighs 30 kg is experiencing a grand mal seizure. The healthcare provider prescribes diazepam 0.3 mg/kg/dose intravenous (IV) STAT. The medication is available in 5 mg/mL vials. How many mL should the nurse administer?
- A. 1.8 mL
Correct Answer: A
Rationale: The dose is calculated as 30 kg x 0.3 mg/kg = 9 mg. Dividing by 5 mg/mL gives 1.8 mL, which is the correct volume to administer.