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While obtaining the vital signs of a 10-year-old child who had a tonsillectomy this morning, the nurse observes the child swallowing every 2 to 3 minutes. Which assessment should the nurse implement?
- A. Inspect the posterior oropharynx.
- B. Touch the tonsillar pillars to stimulate the gag reflex.
- C. Ask the child to speak to evaluate change in voice tone.
- D. Assess for teeth clenching or grinding.
Correct Answer: A
Rationale: Frequent swallowing may indicate postoperative bleeding, so inspecting the oropharynx is critical.
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The nurse begins collecting the medical history of a child when the child screams and tries to hide behind the parent, dropping a stuffed toy. Which intervention should the nurse implement?
- A. Obtain the essential information as quickly as possible.
- B. Document interactions between the parent and the child.
- C. Ignore the child's behavior, directing questions to a parent.
- D. Include the child's toy in the collection of information.
Correct Answer: D
Rationale: Including the child's toy can comfort and engage the child, facilitating a more effective medical history collection.
The nurse is caring for an infant who was recently diagnosed with a congenital heart defect. Which assessment finding is most important for the nurse to report to the healthcare provider?
- A. Audible heart murmur.
- B. Heart rate of 162 beats/minute.
- C. Poor oral intake and suckling effort.
- D. Weight gain of 2.2 lbs. (1 kg) in the last 48 hours.
Correct Answer: C
Rationale: Poor oral intake and suckling effort indicate feeding difficulties, which can lead to dehydration and poor weight gain, requiring immediate reporting.
The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. Which additional finding should the nurse expect to obtain?
- A. Hemiplegia.
- B. Fever.
- C. Vigorous feeding and satiation.
- D. Hypotension and tachycardia.
Correct Answer: D
Rationale: Aortic stenosis can lead to heart failure and pulmonary edema, causing bilateral fine crackles, with hypotension and tachycardia as additional signs of decreased cardiac output.
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.
The nurse is providing teaching to a school-age child with left femoral osteomyelitis and the child's parent prior to discharge. Which instruction should the nurse provide related to the initial phase of treatment?
- A. Administer topical antibiotic therapy daily.
- B. Provide passive range of motion exercises.
- C. Ensure no weight bearing on the affected extremity.
- D. Schedule ice pack applications to the infected area.
Correct Answer: C
Rationale: No weight bearing on the affected extremity prevents further damage during the initial treatment phase of osteomyelitis.