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When measuring the head circumference of an infant, where should the nurse place the tape measure?
- A. Across the eyebrows and around the occipital lobe
- B. Over the zygomatic arches and around the parietal areas
- C. Around forehead and around the crown of the head
- D. Above the eyebrows and pinnas, and around the occipital lobe
Correct Answer: D
Rationale: Head circumference is measured in children up to 36 months above the eyebrows and pinnas, and around the occipital lobe.
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When the newly admitted 2-year-old who was potty-trained before admission begins to wet the bed, the mother is frightened. What statement by the nurse will be most helpful to the mother?
- A. Don't be concerned. Accidents happen.
- B. Let's put a diaper on your child until this gets better.
- C. The stress of hospitalization makes children regress a little.
- D. Your child will relearn 'potty-training' if you are patient.
Correct Answer: C
Rationale: It is not unusual for children to regress when hospitalized. Explaining that regression is normal during hospitalization will help allay the mother's anxiety.
What is the purpose of a mist tent?
- A. To provide a constant oxygen supply
- B. To liquefy respiratory secretions
- C. To aid in lowering temperature
- D. To improve the infant's hydration
Correct Answer: B
Rationale: The purpose of the mist tent is to liquefy respiratory secretions. A constant oxygen supply can be given by methods other than a mist tent. A mist tent does not lower temperature or improve hydration.
Why does obtaining the respirations of an infant require a modified approach from that of an adult?
- A. Infants breathe through their noses.
- B. Infants have very rapid respirations.
- C. Infants' respirations are thoracic in nature.
- D. Infants' respiratory movements are abdominal.
Correct Answer: D
Rationale: In children under 6 or 7 years of age, respiratory movements are abdominal or diaphragmatic. Abdominal movements must be observed when counting respirations.
A disfiguring facial wound would have the most significant developmental impact on which child?
- A. 4-year-old
- B. 6-year-old
- C. 10-year-old
- D. 14-year-old
Correct Answer: D
Rationale: The adolescent fears a change in body image associated with surgery.
The pediatric nurse, along with the primary caregiver(s), has a special duty to the child and the family.
Correct Answer: teach
Rationale: The pediatric nurse is in a position to assess, instruct, and support children and their families about developmental progress, nutrition, and possible undiagnosed anomalies.