ANSWER AND RATIONALE PEDIATRIC NURSING POST TEST PHASE I JULY 2011

1. When completing an assessment of a healthy adolescent client, which of the following would be most appropriate

A. Obtain a detailed account of the adolescents prenatal and early developmental history B. Discuss sexual preference and behaviors with the parents present for legal reasons C. Discuss the clients smoking with parents present in the room D. Assess the adolescent in private; gather additional information from the parents

2. During the assessment of a small infant admitted with a diagnosis of meningitis, the infant becomes less responsive to stimuli and exhibits bradycardia, slight hypertension, irregular respirations and a temperature of 39.5 C. the infants fontanel also seems tense. What will the nurse do first?

A. Ask the nurse to verify the findings B. Notify the physician of the findings C. Raise the head of the head D. Administer antipyretics

3. After undergoing a barium enema, which of the following indicates that the infant has adequately evacuated the barium?

A. Absence of fecal mass in the lower abdomen B. Stools that progress from clay colored to brown C. Bowel sounds of 30 per minute D. Stool guaiac that is negative

4. Which of the following would be best to help prepare a preschool aged child for an injection?

A. Having an older child explain that shots do not hurt B. Helping the child ti imagine she is in a different place C. Giving the child a play syringe and a bandage to give a doll injections D. Giving the child a pounding board to encourage expressions of anger

5. Which of the following would the nurse include when developing the plan of care for a neonate prior to surgical repair of a myelomeningocele?

A. Applying thin layers of tincture of benzoin around the defect B. Positioning the neonate on the side C. Covering the defect with moist, sterile saline dressings D. Leaving the defect exposed to air

6. A 4 year old child asks the nurse if t will hurt to have the tonsils and adenoids taken out. Which is the best response of the nurse?

A. It wont hurt because you are going to put you to sleep B. It wont hurt because you are such a big boy C. It will hurt because of he incisions made in the throat D. It will hurt, but we have medicine to help you feel better

7. When preparing to give a neonate the first feeding by nipple, for which of the following reasons would the nurse anticipate using a 5 ml feeding of sterile water first?

A. Ascertain the patency of the neonates esophagus B. Determine if the neonate can retain the feeding C. Ensure that the neonate has the energy to take oral feedings D. Ensure that the mother will be able to feed the neonate

8. An 18 year old senior tells the nurse. everyone does it, so its all right, to justify rule breaking behavior. The nurse realizes this is an example of which level or stage of moral reasoning development as described by Kohlberg?

a. Preconventional c. Postconventional b. Conventional d. Autonomous

Level 1 (Pre-Conventional)
1. Obedience and punishment orientation (How can I avoid punishment?) 2. Self-interest orientation (What's in it for me?) (Paying for a benefit)

Level 2 (Conventional)
3. Interpersonal accord and conformity (Social norms) (The good boy/good girl attitude) 4. Authority and social-order maintaining orientation (Law and order morality)

Level 3 (Post-Conventional)
5. Social contract orientation 6. Universal ethical principles (Principled conscience)

9. Which of the following methods would the nurse use to feed an infant after surgical repair of cleft lip?

A. Gastric lavage B. Intravenous fluids C. Rubber- tipped medicine dropper D. Bottle with lambs nipple

 LAMB NIPPLES.

10. Parents ask for advice about handling their 2 year olds negativism. Which of the following would be the best recommendation.

A. Ignore this behavior because it is a stage the child is going through B. Set realistic limits for the child, then be sure to stick to them C. Encourage the grandmother to visit frequently to relieve them D. Punish the child for misbehaving or violating set, strict limits.

11. Which of the following suggestions would be most appropriate in helping parents to prepare their children for starting school?

A. Have an older sibling tell the chi9ild about school B. Orient the child to the schools physical environment C. Offer to stay with the child for the first few days of school D. Discuss school with the child if he or she asks about it

12. Which of the following would be best to offer first to a 4 year old child who has had tonsillectomy?

a. Yellow popsicle b. Chocolate milk

c. Cherry fruit drink d. Vanilla pudding

13. Upon the childs return from the post anesthesia recovery unit (PACU) after a tonsillectomy, the nurse would place the child in which of the following positions?

a. Trendelendburg c. Prone b. Supine d. Lithotomy

14. Before corrective surgery, the newborn with tracheoesophageal fistula (TEF) is placed on his back in a crib with his head and shoulders elevated. The nurse positions the infant to accomplish which of the following?

A. Reduce cardiac workload that has been increased by the anomaly B. Alleviate the pressure of the distended abdominal contents on the diaphragm C. Enhance pooling of secretions in the bottom of the upper esophageal pouch D. Allow air to escape from the fistula into the trachea to educe gastric distention

15. A parent group is discussing different types of punishment. The parents ask the nurse to discuss corporal punishment. The nurse tells the group that corporal punishment:

A. Does not physically harm the child B. Can result in children becoming accustomed to spanking C. Reinforces the idea that violence is not acceptable D. Can be beneficial in teaching children what they do

16. An 8 year old child with severe cerebral palsy is underweight and undersized for his age. He is being fed a diet of pureed foods and liquids through a syringe. An appropriate nursing diagnosis for this child would be Imbalanced nutrition: Less than Body Requirements related to:

A. Increased metabolism B. Inability to metabolize fats C. Impaired oral motor control D. Increased intracranial pressure

17. When developing a [plan of care for the mother of a child diagnosed with spastic cerebral palsy, which of the following descriptions would the nurse include?

A. Increased muscle tone and stretch reflexes B. Slow, wormlike writhing movements C. Wide- based gait and poor muscle coordination D. Tremors and lack of active movement

18. When discussing the appropriate iron rich food selections with the mother of an 11 month old infant with iron deficiency anemia, which of the following choices verbalized by the mother indicates successful teaching?

A. Eggs, fortified cereals, meats and green vegetables B. Fruits, cereals, milk, and yellow vegetables C. Eggs, fruits, milk and mixed vegetables D. Juices, fruits, fortified cereals and milk

19. A male neonate with a 3 cm by 5 cm sac in the lumbar region of his back is diagnosed with myelomenigocele. Which of the following would the nurse expect to find when inspecting this sac?

A. Serosanguineous fluid and fatty tissue B. Bits of hair covered by skin C. Spinal fluid and meninges D. Spinal fluid, nerve tissue, and spinal bony defect

20.The parents of a child with rheumatic fever express concern that their other children will develop the disease. Which of the following would be the nursess best response?

A. This disease is usually not contagious B. Your other children are easily as likely to develop this disease C. Medicine is available to prevent this, so check with your doctor D. Your other children are all girls. So there is no need to worry.

21. After having surgery to reduce he invagination of intussusceptions, the infant has a nasogastric tube in place, is receiving intravenous fluids, and is allowed nothing by mouth. In addition to the body weight, which of the following parameters would the nurse use to calculate the amount of intravenous fluid and electrolyte solution to be infused over the next 24 hours?

A. Stool output B. Urine output C. Gastric output D. Degree of temperature elevation

22. After teaching the parents of an infant who has had pyloromyotomy about proper postoperative feeding techniques, the nurse determines that they have understood the teaching when they position the infant in the brib after feeding with the head elevated and lying on which of the following?

a. Left Side B, Abdomen

c. Right Side d. Back

23. A mother brings her 2 year old child to the clinic because of her concerns about the childs nutritional status. For the last week, he has refused to eat anything except crackers and peanut butter. Which of the following measures would be most appropriate for the nurse to suggest.

A. Giving the child a small reward if he eats extra food given to him B. Consulting a physician because this behavior could lead to nutritional deficiency C. Not worrying about this behavior food fads last only a short time and common in toddlers D. Insisting the child eat small portions of the familys meal to maintain adequate nutrition

24. On admission for heart surgery to repair tetralogy of Fallot. The nurse observes that a 6 year old child is cyanotic. The nurse judges that the parents understand this disorder when they explain that one of the underlying causes of their childs cyanosis is related to which of the following?

A. Construction of the aorta B. Stenosis of the mitral valve C. Stenosis of the pulmonary artery D. Aorta receiving blood directly from the vena cava

25. A 10 year old child with history of bronchial asthma triggered by exposure to cold, smoke and nuts and is brought to the hospitals emergency room by his mother. Appearing restless and anxious. The childs respiratory rate is 36 breaths per minute and a pulse rate of 160 bpm. Which of the following findings would be of greatest concern to the nurse?

A. Increased respiratory effort B. Moist, loose cough C. Absence of wheezing D. Prolonged expiratory phase

26. On initial assessment of a 7 year old with rheumatic fever, which of the following would require contacting the physician immediately?

A. Heart rate of 150 bpm B. Swollen and painful joints C. Twitching in the extremities D. Red rash on the trunk

27. Which of the following statements indicates that the parents understand the need for their child to receive long term antibiotic therapy after an episode of rheumatic fever.

A. It will prevent further streptococcal infections B. It will protect against further joint damage C. The inflammation will subside more quickly D. The inflammation will be reduced with future attacks

28. The adolescent client who is very body conscious asks the nurse that he would like to lose weight and asks the nursess opinion on how to accomplish his goal. Which of the following suggestions would be most appropriate?

A. Exercising more often B. Severely limiting caoric intake C. Participating in an adolescent weight reduction program D. Cutting fown on sweets and other snacks

29. Which of the following activities would the nurse include in the teaching plan for a mother to help channel her 4 year old childs energy?

A. Participation in parallel play B. Play involving a game such as Simon says C. Bicycle riding D. Stringing of large beads

30. Which of the following behaviors absent in an 18th month old would cause the nurse to be concerned?

A. Copying a circle B. Playing with pull toys C. Playing tag with other children D. Building a tower of 8 blocks

31. Which of the following nursing diagnoses would the nurse identify as the priority for a 4 month infant with heart failure and congenital heart disease?

A. Activity Intolerance B. Risk for Infection C. Impaired Mobility D. Ineffective Health Maintenance

32. The mother, concerned about her infants surgery for inguinal hernia repair, asks the nurse if her infant would have been scheduled for surgery even if the hernia had been asymptomatic. Which of the following statements offers the best explanation why the surgical repair would be done at this time?

A. An infant is better to tolerate the physical stress of surgery than an older adult child is. B. The experience of surgery is less frightening for the younger child C. Less and danger and fewer complications result when surgery is an elective procedure D. Doing surgery near the genital organs is preferred before a child becomes conscious of sexual identity

33. Mark 9 years old conceives death as:

A. A person B. Temporary C. A form of sleep D. Cessation of corporal life

34. Your patient, Tyrone is 15 years old and is admitted in the hospital for Hemophilia. Which factor would be least important when assigning Tyrone to a room unit?

A. Ensuring Tyrones privacy B. Placing Tyrone with another Hemophiliac, regardless of age C. Ensuring the opportunity for peer interaction while resting in bed D. Ensuring that the room is close to the teen agers lounge

35. The nurse is instructing a mother about the nutritional needs of her full-term breastfeeding infant at age 2 months. Which of the following responses show that the mother understands the infants dietary needs?

A. B. C. D.

We wont start any new foods now. Well start any new foods now. Well introduce cereal into the diet now. We should add new fruits to the diet one at a time.

36. SITUATION: Raphael, a 6 year old pupil is seen at the clinic for growth and development monitoring. Which of the following characterize the rate of growth during this period?

A. Most rapid period of growth B. A decline in growth rate C. Growth spurt D. Slow and uniform growth rate

37. You typically gag children to inspect the back of their throat. When is it important not to elicit a gag reflex?

A. When children are under 5 years of age B. When a child has symptoms of epiglottitis C. When a boy has a possible inguinal hernia D. When a girl has a geographic tongue

38. Elisa, a 14-month-old, is admitted to the hospital with laryngotracheobronchitis (croup). On assessment, the nurse would expect to find:

A. Cyanosis and dyspnea B. Productive coughing and a high fever C. Pale laryngeal tissue and dyspnea D. Barking cough and inspiratory stridor

39. A four-year-old is experiencing an acute asthma attack. Why should the nurse avoid chest percussion with this child?

A. Chest percussion may lead to increased bronchospasm and more respiratory distress. B. Chest percussion may cause mucous plugging of the alveoli. C. Chest percussion is useful in removing airway secretions and should be used. D. Chest percussion will produce increased coughing and thereby enhance respiratory distress.

SITUATION: Three-year old Dugyot gas been admitted to the Pediatric Unit. His blood pressure 100/700 mmHg; pulse rate, 110 beats per minute; temperature, 38C and weight, 18 kg. Impression: Nephrotic Syndrome. 40. During his previous afew days ago. check-up, his blood pressure was 95/60 mmHg; PR was 110 beats per minute and weighed 15 kg. Which assessment finding would support the impression of nephrotic syndrome? a. Blood pressure c. Temperature b. Weight d. Pulse rate

41. The nurse is caring for an infant whose cleft lip was repaired. Important aspects of this infants postoperative care include which of the following?

A. Arm restraints, postural drainage, mouth irrigations B. Cleansing suture line, supine and side-lying positions, arm restraints C. Mouth irrigations, prone position, cleaning suture line D. Supine and side-lying positions, postural drainage and restraints.

42. Which of the following statements from the nursing history would support the medical diagnosis of febrile seizure?

A. The child has bad a low-grade fever for several weeks B. The family history is negative for convulsions C. The seizure resulted in respiratory arrest D. The seizure occurred when the child had a cough, rhinorrhea, and complaints of ear pain

43. The nurse identifies the teaching plan of the parents of a child with cystic fibrosis. The mother demonstrates correct understanding about a childs medication when she says:

A. Ill dilute the enzyme in a glass of milk and give it to him after his meal. B. Ill dilute the enzyme in hot soup and give it to him in between meals. C. Ill mix the enzyme in a small amount of food and give to him before each meal. D. I dont have to give him the enzyme if he has a good bowel movement.

44. Which information should not be included in discharge teaching for a child with cystic fibrosis?

A. The childs diet should be low in fat content B. Restrict the childs fluid to reduce excessive sweating C. Encourage physical activities D. High-salt foods as pretzels should be regular part of the childs diet

45. Which information should not be included in discharge teaching for a child with cystic fibrosis?

A. The childs diet should be low in fat content B. Restrict the childs fluids to reduce excessive sweating C. Encourage physical activities D. High-salt foods such as pretzels should be regular part of the childs diet

46. Which of the following statements by the parents of a child with school phobia would indicate the need for further teaching?

A. Well keep him at home until the phobia subsides B. Well work with his teachers and counselors at school C. Well try to encourage him to talk about his problems D. Well discuss possible solutions with him and a counselor

47. For which of the following reasons would the nurse expect to institute intravenous fluid therapy and nothing by mouth (NPO) status for an infant with bronchiolitis?

a. Tachypnea

c. Fever

48. Situation- Graciela 1 year old is admitted the hospital the emergency room with a fracture of the left femur due to a fell down a flight of stairs. The nurse notes that the fall might also cause a possible head injury. She will be observed for signs of increased intracranial pressure which include:

A. Narrowing of the pulse pressure B. Vomiting C. Periorbital edema D. A positive Kernigs sign

49. When teaching a child how to perform coughing and deep-breathing exercises before corrective surgery for Tetralogy of Fallot, which of the following teaching and learning principles would the nurse address first?

A. Organizing information to be taught in a logical sequence B. Arranging to use actual equipment for demonstrations C. Building the teaching on the childs current level of knowledge D. Presenting the information in order from simplest

50. In choosing toys for an infant, what criteria should be considered a priority?

A. Educational Purposes B. Development Function C. Safety D. Recreation use

51. A recently hospitalized 2 years old client scream and shouts he wants a bottle. His parents are puzzled and state he has drunk from a cup for the past year. The nurse explains that:

A. Irritability is exhibited in all age groups. B. Temper tantrums often represent the childs need for parental attention C. Various forms of punishment are necessary when such behavior occur D. Regression to an earlier behavior often helps the child cope with stress and anxiety

52. A 2 mos. Old infant is suspected of having coarctation of the aorta. The sign of this defect is.

A. Dubbing of the digits and circumoral cyanosis B. Pedal edema and portal congestion C. Systolic ejection murmur D. Upper extremity hypertension

53. Left to right shunting is seen in:

A, ASD b. VSD

c. TOF d. Both A and B

54. Nurse explains that a child with athetoid cerebral palsy most will demonstrate.

A. exaggerated hyperactive reflexes B. normal intelligence level C. slow, wormlike writing movements D. unsteady gait and clumsy, uncoordinated upper extremity function

55. In choosing an appropriate toy for a 9 year old asthmatic child the nurse would choose:

A. A board game B. Sponge Bob the movie C. A coloring book D. A set of building blocks

56. The mother discusses with the nurse that her toddlers asks every night for a bedtime story. The mother asks why the child does this. The nurse would explain that this behavior demonstrates.

A. Ritualism B. Object permanence C. Dependency D. Conservation

57. During a post of period for child who has had a ventriculoperitoneal shunt repair the nurse know that the child should be positioned:

A. On the unoperated side, HOB elevated 90 degrees. B. High flowlers position. C. On the operated side, flat. D. On the unoperated side, flat for the first 24 hours

58. When caring for a child and family with a different cultural background, the nurse will conceive which of the following as an appropriate goal?

A. Strive to keep the background from interfering with health needs B. Discourage continuation of cultural practices in the hospital C. Gently attempt to change the familys belief D. Adapting the familys cultural beliefs to the health needs as necessary

59. Which is the most likely associated with a stroke from a congenital heart disease?

A. Polycythemia B. Cardiomyopathy C. Endocarditis D. Low blood pressure

60. A Moro reflex is the single best assessment of neurologic ability in a newborn. What is the best way to test this reflex?

A. Observe the infant while she is on her abdomen to see whether she can turn her head. B. Lift the infants head while she is supine and allow it to fall back 1 inch. C. Shake the infants crib until the infant responds by flailing her arms. D. Make a sharp noise, such as clapping your hands, to wake the infant.

61. Bryans mother is concerned about him developing baby-bottle syndrome. What would be her best action to prevent this?

A. Use plastic rather than glass bottles B. Boil formula to reduce the curd C. Dont put Bryan to bed with a bottle D. Check the expiration date on formula

62. You teach Robin imaging to help reduce pain from blood drawing. Why does a technique such as imagery work well for children?

A. Childrens pain is not as acute as in adults. B. Intravenous pain relief is not effective in children. C. Childrens imaginations are at their peak. D. Childrens muscles are less tense than adults muscles.

62. Barrys mother tells you she often makes milkshakes with raw eggs. What infectious organism is easily spread this way?

a. Pneumococcus b. Salmonella

c. Streptococcus A d. H. pylori

64. What is typically the first symptom of acute glomerulonephritis?

A. Low blood pressure from excessive aldosterone. B. Old blood in urine from kidney bleeding. C. Dependent edema from protein accumulation D. Pain on urination from urethra inflammation.

65. What information would you want parents to know about their child with cerebral palsy?

A. Symptoms of cerebral palsy usually fade by puberty. B. All children with cerebral palsy are cognitively challenged. C. Cerebral palsy may be associated with a vaccine. D. Symptoms may seem to grow worse as fine motor skill is needed.

66. Another concern in the care of toddlers is toilettraining. Which of the following is the most important factor for a successful toilet-training?

A. Age of the child B. Developmental readiness of the child C. Toilet-training at scheduled time D. Mothers flexibility for growth and development

67. His mother expresses concern about her sons, Rico 1 year old, slow development.. Upon assessment, the nurse observes that Ricos motor development is normal for his age. Which of the following is inappropriate for his stage?

A. Sits down from standing position without help B. Walks alone C. Walks with support D. Stands for a moment without support

68. Rico currently weighs 9 kg. His mother asks if this is normal for him because his previous birth weight was 3 kg. Which of the following is an appropriate response?

A. Yes, because at 1 year old, he usually weighs three times his birth weight. B. His weight is below normal. You should give him food supplements. C. He should have doubles his birth weight by now. D. You need not worry. His weight is advance for his age.

69. An infant with respiratory synctial virus (RSV) is on (Virazole) therapy. The nurse would be correct to explain that:

A. The prescribed medication would be given intravenously B. The child will receive the medication once a week for 4 weeks C. Individuals who are pregnant should not visit during treatments D. The child will be put in protective isolation during treatments

70. Immediately after the first oral feeding after correcting pyloric stenosis, a 4 month old infant becomes fussy and restless. Which of the following actions is considered appropriate?

A. Encourage parents to hold the child B. Hang a mobile toy over the crib C. Give he infant more food to eat D. give the infant pacifier to suck on

71. Which of the following is a cardiovascular disease of the infant?

A. Rheumatic heart disease B. Coronary artery disease C. Acute glomerulonephritis D. Congenital heart disease

72. SITUATION: Baby Nicole is born with myelomeningocele. The nurse explains to Baby Nicoles parents that even if surgery is successful, Nicole will need the continued health supervision of a:

a. Cardioloist b. Dental hygienist

c. Urologist d. Speech therapist

73. Daily weights need be taken of children having all of the following disorders EXCEPT

a.cardiac failure c. vomiting b. edema d. anemia

74. Passage of meconium after birth indicates patency of the gastrointestinal tracts. A nurse should become concerned if a newborn infant still has not passed meconium

A. 6 hours after birth B. 12 hours after birth C. 18 hours after birth D. 24 hours after birth

75. In helping a family cope with the birth of an abnormal child, a nurse should first

A. discuss the abnormality and its probable cause B. discuss the effects the abnormality will have on the growth and development of the child C. encourage the family to verbalize their feelings and reactions D. present the childs positive features and minimize the negative ones

76. Which of the following findings in a baby most suggest the presence of Wilms tumor (nephroblastoma)?

a. alopecia b. bleeding gums

c. tight diapers d. muscle spasticity

77. Ms.S. asks how much her 3-day-old baby weighs. When the nurse tells her 5 lb 11 oz (2580g), she starts to cry because the baby is losing weight. The baby weighed 6 lb 6 oz (2863) at birth. What is the expected weight loss pattern in newborn?

a. None b. 5%

c. 5%- 10% d. 10%-15%

78. A child is to receive radiation therapy following surgery for Wilms tumor. Which of the following measures would be important to include in the care plan prior to radiation therapy.

A. Give compazine every six hours for nausea. B. Place a sign over the bed that reads no needle punctures. C. Practice lying in the required position D. Encourage play appropriate to age.

79. A nine-year-old girl with rheumatic fever is asking to play. Which diversional activity is the nurse likely to offer?

A. B. C. D.

Walking to the gift store. Coloring books and crayons. A 300 piece puzzle. A dancing contest.

80. An infant with cardiac disease has been admitted to the nursery from the delivery room. Which finding helps the nurse to differentiate between a cyanotic and an acyanotic defect?

A. Infants with cyanotic heart disease feed poorly. B. The pulse oximeter does not read above 93%. C. Infant with cyanotic heart disease usually go directly to the operating room. D. Cyanotic heart disease causes high fevers.

81. A male newborn was just admitted to the pediatric floor with a myelomeningocele. When developing the preoperative plan of care, the nurse lists high risk for infection of and trauma to the nonepithelialized lesion as the diagnosis of most concern. The most effective strategy to prevent infection and trauma to the lesion would be to:

A. leave the lesion uncovered and open to the air and place the baby supine. B. cover the lesion with sterile, saline-soaked gauze and place the baby supine. C. apply lotion to the lesion and place the baby on his side. D. cover the lesion with moist sterile gauze and place the baby prone.

82. The most common manifestation in RFs major criteria is

A. Sydenhams Choreas B. Migratory polyarthritis C. Erythema marginatum D. St. Vitus Dance

83. The nurse administers which of the following vaccines to help prevent the development of epiglottitis?

A. Diphtheria/tetanus/acellular pertussis (DTaP) combination vaccine B. Varicella vaccine (Varivax) C. Haemophilus influenzae vaccine (HIB) D. Pneumococcal polysaccharide vaccine (Prevnar)

84. As a schooler what psychological task should be developed by him at his age?

A. Intimacy vs. isolation B. Initiative vs. guilt C. Industry vs. inferiority D. Identity vs. role diffusion

85. The mother of one of the children was told to have her daughter confined. One of the effects of hospitalization for children is separation. At what stage are children most likely to experience separation anxiety?

a. Pre-school age b. Adolescence

c. Toddler d. Newborn

86. The primary nursing intervention that can be used to help a 1 month old infant tolerate hospitalization?

A. Using consistent caregivers B. Providing sensorimotor stimulation C. Following home schedule as closely as possible D. Keeping the infant warm and dry

87. After teaching a group of parents of preschoolers attending a well-child clinic about oral hygiene and teeth brushing, the nurse determines that the teaching has been successful when the parents state that the children can begin to brush their teeth with minimum help at which of the following ages?

a. 3 years b. 5 years

c. 7 years d. 9 years

88. Which of the following must be monitored preoperatively before a child has a tonsillectomy and adenoidectomy?

A. Clotting times B. Serum electrolyte levels C. Urinalysis D. White blood cell differential

89. While discussing a plan of care for the neonate, the mother asks if her baby will be at risk for any other defects. The nurses answer would be based on the fact the myelomeningocele is frequently associated with:

A. an abnormal increase in cerebrospinal fluid (CSF) within the cranial cavity B. an abnormally small head C. congenital absence of the cranial vault D. premature fusion of the cranial sutures

90. After cleft palate repair feeding is done through: a. A soup spoon c. A plastic syringe b. A dessert fork d. An infant spoon

91. An infants blood pressure is reported to be very high. What is the most appropriate nursing action to take?

A. Take it again in 20 minutes. B. Call the house officer. C. Measure the cuff width to the infants arm. D. Prepare to give an antihypertensive.

92. A child with tetralogy of Fallot has been admitted. What equipment is most important to have at the bedside?

A. Morphine B. A blood pressure cuff. C. A thermometer D. An oxygen setup

93. An 18-month-old presents with nasal flaring, intercostals and substernal retractions, and a respiratory rate of 50. What is the most appropriate nursing diagnosis?

A. Knowledge deficit. B. Ineffective breathing pattern. C. Ineffective D. High risk for altered body temperature

94. An 8 year-old presents to an urgent care center with respiratory distress and cyanosis. Parents report an initial episode of choking. What is the best initial action for the nurse to take?

A. Call 911 and have parents wait for an ambulance to transport the child to a pediatric hospital. B. Administer oxygen by face mask and call the childs pediatrician. C. Perform thrusts as described in the Heimlich maneuver. D. Start CPR after the child loses consciousness.

95. A baby girl is born prematurely to a mother with polyhydramnios. The baby is diagnosed with esophageal atresia with tracheosophageal fistula. What assessment finding would the nurse be likely to note?

A. B. C. D.

Jaundice, high bilirubin Seed yellow stools. Projectile emesis. Forthy saliva, drooling.

96. A six-month old boy is treated at home with saline enemas due to his Hirschsprungs disease. His mother asks if she can use tap water to reduce costs. The nurse responds,

A. Yes, tap water is as effective as saline, just be sure to boil it first. B. No, saline enemas must be used to maintain his electrolyte balance. C. Yes, you can use tap water after letting it run for one minute to clear any lead from the pipes. D. No, tap water enemas are not allowed, but soap suds enemas are just as effective.

97. The nurse is planning care for a two-year old who has AGN and is in remission. What type of diet would the nurse plan to feed this child?

A. High protein, low calorie. B. High calorie, low protein. C. Low sodium low fat. D. Regular diet, no added salt.

98. In counseling parents about controlling fever in their child, a nurse should advise them to do all of the following EXCEPT

A. Give fluids every two hours B. Keep the environmental temperature at 32C (80F) or more C. Dress the child in light clothing D. Take the childs temperature every two hours when the fever is above 37C (100F)

99. If 200 ml of 5% dextrose in 0.25% normal saline (D51/4 NaCL) is to be given over a period of 8 hours, the flow should be adjusted to how many microdrops per minute?

A. 2 B. 4 C. 8 D. 25

100. A hospitalized child who has increased intracranial pressure must be monitored closely for

A. decreased bowel sounds B. diarrhea C. fecal incontinence D. constipation

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