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Which of the following statements obtained from the nursing history of a toddler should alert the nurse to suspect that the child has had a febrile seizure?
- A. The child has had a low-grade fever for several weeks.
- B. The family history is negative for convulsions.
- C. The seizure occurred with a necessary arrest.
- D. The seizure occurred when the child had a respiratory infection.
Correct Answer: D
Rationale: Febrile seizures are associated with acute fever, often during infections like respiratory infections, in young children.
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When developing a teaching plan for the parents of a child with Down syndrome, the nurse focuses on activities to increase which of the following for the parents?
- A. Affection for their child.
- B. Responsibility for their child's welfare.
- C. Understanding of their child's disability.
- D. Confidence in their ability to care for their child.
Correct Answer: D
Rationale: Building parental confidence empowers them to manage their child's needs effectively, fostering positive outcomes.
After teaching the parents about the urethral catheter placed after surgical repair of their son's hypospadias, the nurse determines that the teaching was successful when the mother states that the catheter in her child's penis accomplishes which of the following?
- A. Decreases pain at the surgical site.
- B. Keeps the new urethra from closing.
- C. Measures his urine correctly.
- D. Prevents bladder spasms.
Correct Answer: B
Rationale: The catheter keeps the urethra open.
An 18-month-old with a congenital heart defect is to receive digoxin twice a day. The nurse should instruct the parents about which of the following?
- A. Digoxin enables the heart to pump more effectively with a slower and more regular rhythm.
- B. Signs of toxicity include loss of appetite, vomiting, increased pulse, and visual disturbances.
- C. Digoxin is absorbed better if taken with meals.
- D. If the child vomits within 15 minutes of administration, the dosage should be repeated.
Correct Answer: A
Rationale: Digoxin improves heart function by increasing contractility and regulating rhythm. Toxicity signs are correct but not the focus here, absorption is not meal-dependent, and repeating a vomited dose risks overdose.
A 6-month old infant has had a cardiac arrest and the rapid response team has been paged. The nurse arrives in the client's room and observes a physician assistant (PA) administering CPR to an infant (see figure). To assist the PA with CPR, the nurse should:
- A. Tell the PA to use the heel of the hand on the infant's sternum.
- B. Place one hand on the infant's sternum for chest compressions while the PA ventilates the lungs at a rate of one breath to every 5 compressions.
- C. Obtain an Ambu bag and give breaths at a rate of 2 breaths per 15 compressions.
- D. Encircle the infant's chest with the thumbs=on top to provide compression while the PA uses an Ambu bag to administer rescue breaths after every 15 compressions.
Correct Answer: C
Rationale: For an infant, the nurse should obtain an Ambu bag and deliver 2 breaths per 15 compressions, following pediatric CPR guidelines for 2-rescuer CPR.
When developing the teaching plan for parents using the Pavlik harness with their child, what should be the nurse's initial step?
- A. Assessing the parents' current coping strategies.
- B. Determining the parents' knowledge about the device.
- C. Providing the parents with written instructions.
- D. Giving the parents a list of community resources.
Correct Answer: B
Rationale: Determining the parents' knowledge about the Pavlik harness is the initial step to tailor teaching to their understanding and needs.