Q&A Hero

Q: The school nurse notices a sixth-grade girl with bald patches in her hair. The hair itself is clean and shiny. Prior to referring the girl to her healthcare provider for alopecia, the nurse would want to watch the child for signs of: 1. Lice. 2. Dietary imbalances. 3. Schizophrenia. 4. Trichotillomania.

Q: A mother brings her 11-year-old son to the pediatric clinic for investigation of stomach complaints. The mother says that for the last two months, the child has complained of abdominal pain three to four mornings per week. The mother states the child usually complains on school days and always seems to be better by afternoon. The child was able to attend a weekend Boy Scout camp without difficulty but has missed several days of school due to complaints. The nurse would suspect which mental health disorder? 1. Separation anxiety 2. Depression 3. School phobia 4. Bipolar disorder

Q: The school nurse and teacher are working on a plan to improve the behavior and learning of a child recently diagnosed with attention deficit/hyperactivity disorder (ADHD). Which activities will the nurse suggest be included in the plan? Standard Text: Select all that apply. 1. Asking the mother to seek a prescription for methylphenidate (Ritalin) for the child 2. Placing the child's desk at the back of the room to reduce distractions 3. Developing a consistent routine for the classroom 4. Limiting the decorations in the classroom 5. Determining areas where the child performs well and using these areas to promote self-esteem

Q: The waiting room of the mental health clinic is full of children with various mental health issues. The nurse watches the children and notes that which child is displaying symptoms of autism? 1. Four-year-old girl who doesn"t make eye contact with mother and resists the mother's touch 2. Three-year-old boy who joins one group of children then moves to another group of children without joining their activities 3. 18-month-old child who walks around the area using the furniture to provide balance 4. Six-year-old boy who chatters constantly to anyone who will listen

Q: The nurse is working with the mother of a child with autism. The goal of the session is to plan strategies to increase the child's socialization. The nurse is explaining behavior modification as a treatment process. The nurse will encourage the mother to: 1. Create a reward system when the child interacts with a person. 2. Punish the child when the child's social behaviors are inappropriate. 3. Use dolls to demonstrate appropriate social interactions to the child. 4. Enroll the child in a day care to encourage interaction with other children.

Q: A seven-year-old girl has been clinging to her mother and refusing to go to school. The child is diagnosed with separation anxiety disorder, and the treatment plan will include cognitive-behavioral therapy (CBT). The nurse would explain to the parents that CBT will include: Standard Text: Select all that apply. 1. Self-talking. 2. Relaxation. 3. Hypnosis. 4. Anti-depressant medications. 5. Recognition of feelings.

Q: A nurse is performing a developmental assessment on several children in a clinic setting. Which children exhibit a delay in meeting developmental milestones? Standard Text: Select all that apply. 1. An 18-month-old toddler who is unable to speak in sentences 2. A two-year-old who is unable to cut with scissors 3. A two-year-old who cannot recite her phone number 4. A six-year-old who is unable to sit still for a short story 5. A five-year-old who is unable to button his shirt

Q: The nurse is assessing a child with Down syndrome. The child is at greater risk of developing which illness than children who do not have Down syndrome? 1. Rheumatic heart disease 2. Glomerulonephritis 3. Leukemia 4. Hepatitis

Q: A nine-year-old has been diagnosed with a learning disorder that is characterized by problems with manual dexterity and coordination. The nurse teaches parents that this disorder is called: 1. Dysgraphia. 2. Dyscalculia. 3. Dyspraxia. 4. Dyslexia.

Q: A child with autism is being admitted to the hospital with dehydration. Upon admission, the nurse should: 1. Encourage the parents to avoid bringing favorite toys from home that might be lost. 2. Take the child on a tour of the pediatric unit. 3. Assign the child to his single-bed hospital room. 4. Take the child to the playroom for arts and crafts.

Q: The nurse knows that the mother of a six-year-old needs more teaching about her son's diagnosis of ADHD when she states: 1. "I will develop a reward system for desired behaviors." 2. "I will take my child to the physician every three months for a weight and height check." 3. "I will let him do his homework while he is watching his favorite television show." 4. "I will stick to the same routine each day after school."

Q: The nurse at a high school is screening students for mental health issues. The nurse would want to refer the adolescent for depression if the child shows which symptoms of depression? Standard Text: Select all that apply. 1. Agoraphobia 2. Somatic complaints 3. Focus on violence 4. Poor self-care 5. Poor school performance

Q: The mother of a six-year-old brings her son to the physician because his teacher thinks he might have attention deficit/hyperactivity disorder (ADHD). The nurse is interviewing the mother about the child's history. The nurse knows that which factors could be associated with ADHD? 1. Measles, mumps, and rubella vaccine 2. Advanced parental age 3. Prenatal exposure to smoke 4. Immune response

Q: The nurse is assessing a four-year-old child with a possible alteration in mental health. Which findings indicate a need for further investigation? Standard Text: Select all that apply. 1. Fails to make eye contact 2. Flinches when touched on the arm 3. History of limited prenatal care and precipitant delivery 4. Head circumference has not changed in over one year 5. Flat facial expressions

Q: When the home health nurse visits the home of a 10-month-old child, she observes the environment for risks for injury to the child. Which observation will the nurse discuss with the mother? 1. The mother leaves the filled mop bucket on the floor while in another room. 2. The mother turns all pan handles to the back of the stove. 3. The mother fills the bath tub before bringing the baby into the bathroom. 4. When riding in a car, the child is in a car seat in the middle of the back seat.

Q: The pregnant woman has had no prenatal care and arrives at the hospital fully dilated. Assessment of the newborn indicates a probable gestational age of 35 weeks combined with intrauterine growth restriction. The nurse will monitor the infant for signs of neonatal abstinence syndrome, including: Standard Text: Select all that apply. 1. Poor feeding. 2. Difficult to arouse. 3. Constipation. 4. Seizures. 5. Yawning.

Q: The mother brings her five-month-old infant to the clinic for a well-child visit. The mother tells the nurse that the baby's father had febrile seizures when he was an infant. The mother says she is concerned her baby will have a febrile seizure and wants to know what she should do to prevent it. The nurse explains: Standard Text: Select all that apply. 1. That the baby has no more risk of febrile seizures than any other baby. 2. When the infant has a fever, the mother should give the baby dose-appropriate aspirin. 3. That the baby should be sponged with cold water. 4. The mother should increase the child's fluid intake. 5. That after the tepid bath, the child should be patted dry.

Q: Following an outbreak of chicken pox in the school, the school nurse is concerned that children are at risk for Reye syndrome. The nurse sends home letters reminding the parents not to administer aspirin and describes the initial symptoms of Reye syndrome which are: 1. Nausea, vomiting, and confusion. 2. Headache, vomiting, and seizures. 3. Sore throat, moist respirations, and cough. 4. Fever, rash, and photophobia.

Q: The teacher is speaking to the school nurse about one of the girls in the fifth grade. The girl has always been a good student but lately seems to be daydreaming a lot. The teacher says, "Sometimes when I ask her a question, she will just stare at me for 15 seconds, then blink and ask me to repeat the question. What do you think is going on with her?" Based on this data, the nurse will suspect: 1. The girl has a crush on a boy in the class. 2. The girl has increased intracranial pressure. 3. The child may have had a head injury. 4. The girl is experiencing absence seizures.

Q: A child has been diagnosed with a basilar skull fracture. The nurse should monitor this child for: 1. Periorbital ecchymosis. 2. Subdural hematoma. 3. Protruding bone. 4. Epidural hematoma.

Q: A seven-year-old with a head injury is hospitalized after losing consciousness when he was hit in the head with a bat at baseball practice. The child was not wearing a helmet. The last set of vital signs showed heart rate 48, BP 148/74, respiratory rate 28 and irregular. The nurse suspects that these vital signs are: 1. A sign that this child has a spinal cord injury. 2. A sign of increased intracranial pressure. 3. Typical for a sleeping child at this age. 4. A sign that the child's condition is improving.

Q: A nine-month-old who is not sitting independently has been diagnosed with ataxic cerebral palsy (CP). Which clinical manifestations would the nurse expect to see in the baby? 1. Hypotonia and muscle instability 2. Hypertonia and persistence primitive reflexes 3. Tremors and exaggerated posturing 4. Hemiplegia and hypertonia

Q: The nurse is teaching the kindergarten teacher about a five-year-old with cerebral palsy who will be starting school. The child has a continuous baclofen pump. The nurse informs the teacher of possible side effects of this drug, including: 1. Diarrhea. 2. Hypertonia. 3. Hypotonia. 4. Restlessness.

Q: In caring for a hospitalized eight-year-old child with myelodysplasia, the nurse should remember to: Standard Text: Select all that apply. 1. Expect the child to have normal intelligence. 2. Use latex precautions. 3. Allow the child to do her own self-catheterization. 4. Ensure that the child has a low-fiber diet. 5. Encourage the child to shift positions hourly when in her wheelchair.

Q: A baby just born with a meningomyelocele is to have surgery in the morning. The nurse knows the care of this newborn includes: 1. Applying a diaper to prevent contamination of sac. 2. Positioning the newborn in a side-lying position. 3. Encouraging the mother to hold the newborn, because she will not be able to pick him up after surgery. 4. Positioning the newborn in a prone position.

Q: The nurse is caring for a nine-month-old who just returned from the PACU after a shunt placement for hydrocephalus. Which of the physician's orders would the nurse question? 1. Vital signs and neuro checks hourly 2. Small, frequent formula feedings 3. Elevate head of bed 4. Daily head circumference

Q: The nurse is planning care for a child with bacterial meningitis. What is the priority nursing diagnosis? 1. Impaired gas exchange 2. Infection, risk for 3. Anxiety (parental) 4. Acute pain

Q: A young child admitted to the pediatric unit has fever, irritability, and vomiting. The physician suspects bacterial meningitis. The nurse would expect the cerebrospinal fluid (CSF) to show: 1. Decreased protein count. 2. Clear, straw-colored fluid. 3. Positive for RBCs. 4. Decreased glucose level.

Q: The nurse is teaching a mother of a young child with a newly diagnosed seizure disorder. The child has been put on valproic acid (Depakote) for control of seizures. The nurse knows that the mother does not understand the effects of valproic acid when she states: 1. "I will not use carbonated beverages to dilute his medication." 2. "I will give his medicine on an empty stomach so he will absorb it better." 3. "I will not let him chew his tablet." 4. "I will bring him to the physician office for regular blood work to check bleeding times."

Q: A child with a history of seizures arrives in the emergency department in status epilepticus. What is the nurse's initial action? 1. Take vital signs. 2. Establish an intravenous line. 3. Perform rapid neurological assessment. 4. Maintain patent airway.

Q: A four-year-old with intractable seizures has been on a ketogenic diet for the last six months, with a decrease in seizure activity. This child is now admitted to the pediatric unit with left-sided pain. The nurse knows that possible complications of the ketogenic diet include: 1. Appendicitis. 2. Bowel obstruction. 3. Urinary tract infection. 4. Kidney stones.

Q: The nurse has received a child from the emergency department with a diagnosis of decreased level of consciousness secondary to increased intracranial pressure. Which physician's order would the nurse question? 1. Passive range-of-motion exercises 2. Oxygen at 2L nasal cannula to keep saturation above 95% 3. Hourly vital signs and neuro checks 4. Elevate head of bed 30 degrees

Q: The nurse is doing an assessment on a four-month-old infant. Which assessment finding would the nurse consider abnormal? 1. The posterior fontanel is open. 2. The infant has good head control when held upright. 3. The infant is able to roll only from abdomen to back. 4. The anterior fontanel is open and soft.

Q: When the newborn female is born with ambiguous genitalia, the follow-up investigation discovers adrenogenital syndrome (also called congenital adrenal hyperplasia). The parents question why the baby's genitalia looks more male than female. The nurse would explain that: 1. The disorder caused the infant to be a hermaphrodite with both male and female sex organs. 2. The changes in the genitalia are due to increased androgens secondary to deficient cortisol. 3. The excessive cortisol caused the enlargement of the female tissue, creating a male appearance. 4. The child has only one sex chromosome resulting in an XO configuration.

Q: During the hospital stay in the newborn nursery, the infant is tested for galactosemia. When the test is positive, the parents are educated about treatment for galactosemia. The infant will be placed on what type of infant feeding? 1. Goat's milk formula 2. Breast milk 3. Cow's milk-based formula 4. Meat-based formula such as Nutramigen

Q: A three-year-old child was born with congenital adrenal insufficiency and is being treated with oral hydrocortisone. When the child develops pneumonia and is admitted to the hospital, the nurse would expect the dose of hydrocortisone to be: 1. Stopped. 2. Reduced by 50%. 3. Continued as previously prescribed. 4. Increased.

Q: Based on physical findings, including a webbed neck and low hairline, the newborn female infant is suspected of having Turner's syndrome. The baby is in the newborn nursery while preparations are made for further evaluation including karyotyping. The nurse will want to monitor this baby for common associated conditions including: 1. Club foot (talipes equinovarus). 2. Congenital heart anomalies. 3. Hyperbilirubinemia due to liver abnormalities. 4. Diaphragmatic hernia.

Q: The child was diagnosed with phenylketonuria shortly after birth and has been treated by the endocrine clinic for the last four years. The mother has missed the last three appointments. When the child keeps the next appointment, the mother assures the nurse that the child has followed the dietary restrictions. Which finding would make the nurse question this statement? 1. The child's body has a musty odor. 2. This child is a blue-eyed blond. 3. The child appears sleepy and uninterested in the surroundings. 4. The child has a sunburn over his entire body.

Q: The school nurse has noticed an increase in the number of children in the school being diagnosed with type 2 diabetes. Which changes could the nurse implement at school to help reduce students' risk for developing type 2 diabetes? Standard Text: Select all that apply. 1. Increase the amount of daily physical activity. 2. Meet with all parents and explain the risk that is associated with obesity. 3. Test each child's urine monthly. 4. Teach the parents to avoid administering aspirin to their children. 5. Work with the cafeteria to decrease the amount of fat in the foods served.

Q: Mandatory testing in the newborn nursery determines that the infant has hypothyroidism. When discussing the treatment with the new mother, the mother states that she doesn"t believe in taking medications. The nurse would explain that failure to treat the infant with the appropriate medication will result in: 1. Heart disease. 2. Mental retardation. 3. Renal failure. 4. Thyroid storm.

Q: The nurse is caring for a hospitalized three-year-old admitted with a history of syndrome of inappropriate antidiuretic hormone (SIADH). He has just received his breakfast tray. Which food should the nurse remove from his tray? 1. Oatmeal 2. Yogurt 3. Biscuit 4. Cantaloupe

Q: The nurse is teaching the caregiver of a child who is newly diagnosed with type 1 diabetes mellitus how to minimize pain with insulin injections. Which interventions to minimize pain will the nurse include in the teaching? Standard Text: Select all that apply. 1. Do not reuse needles. 2. Remove all bubbles from the syringe before injecting. 3. Have the child flex the muscle during injection. 4. Inject insulin when it is cold. 5. Do not change the direction of the needle during insertion or withdrawal.

Q: The nurse is teaching a teenage client newly diagnosed with type 1diabetes about complications of the disease. The nurse explains that clients with type 1 diabetes can avoid lipoatrophy by: 1. Rotating injection sites. 2. Checking blood sugars at mealtime and bedtime. 3. Using a sliding scale for additional coverage. 4. Administration of insulin via insulin pump.

Q: A 12-year-old has been selected to be a cheerleader for her middle school. This child has been recently diagnosed with type 1 diabetes. In teaching this child's mother about care for her child, the nurse wants the mother to understand that with increased physical activity, the child will need: 1. Decreased food intake. 2. Increased doses of insulin. 3. Increased food intake. 4. Decreased doses of insulin.

Q: A teenager has arrived in the emergency department (ED) with confusion. The physician suspects diabetic ketoacidosis (DKA). A stat serum glucose is done, and the result is 76l5 mg/dL. The nurse expects that this teen has which symptoms? 1. Tachycardia, dehydration, and abdominal pain 2. Sweating, photophobia, and tremors 3. Dry mucous membranes, blurred vision, and weakness 4. Dry skin, shallow rapid breathing, and dehydration

Q: The nurse is caring for a child just admitted with diabetic ketoacidosis (DKA). Which of the physician's orders should the nurse question? 1. Neurological checks hourly 2. Insert urinary catheter and measure output hourly. 3. NPH insulin IV at 0.1 units/kg per hour 4. Stat serum electrolytes

Q: The nurse is giving discharge instructions to the parents of a child whose adrenal glands have been removed due to a tumor. The nurse knows that the mother needs more instructions when the mother states: 1. "I will call the doctor if my child has restlessness and confusion." 2. "If my child has any gastric irritation, I will give him antacids." 3. "If my child has vomiting and diarrhea, I will hold his hydrocortisone." 4. "I will give my child his hydrocortisone in the morning."

Q: A hospitalized child has been diagnosed with SIADH (syndrome of inappropriate antidiuretic hormone), a complication of his meningitis. What would the nurse expect to see on this child's lab results? 1. Hyponatremia 2. Hypocalcemia 3. Hyperglycemia 4. Hypernatremia

Q: An adolescent female with untreated Graves' disease is admitted to the hospital. The nurse expects to find which signs and symptoms in this client? 1. Hyperglycemia, ketonuria, and glucosuria 2. Weight gain, hirsutism, and muscle weakness 3. Tachycardia, fatigue, and heat intolerance 4. Dehydration, metabolic acidosis, and hypertension

Q: A five-year-old with a history of being treated for hypopituitarism comes to the physician with complaints of right hip and leg pain. The nurse understands that this symptom might be related to which medication that is used to treat hypopituitarism? 1. Daily growth hormone 2. Insulin before meals and bedtime 3. DDAVP (desmopressin acetate) at HS 4. Cortisone injections

Q: A child weighing 18.2 kg with a history of diabetes insipidus has been admitted to the hospital. Which of the physician's orders would the nurse question? 1. Stat electrolytes 2. Urine specific gravity with each void 3. DDAVP (desmopressin) PO 4. Restrict oral fluids to 500 mL every 24 hours.

Q: The nurse is providing information to a teenager newly diagnosed with diabetes and his parents. The nurse teaches them that the signs of diabetic ketoacidosis (DKA) include: Standard Text: Select all that apply. 1. Change in mental status. 2. Tachycardia. 3. Fruity breath odor. 4. Rapid, shallow respirations. 5. Abdominal pain.

Q: The home health nurse is visiting a three-month-old who has been diagnosed with congenital hypothyroidism and is taking daily thyroxine. The baby is on soy formula and is at the 50th percentile for height and weight. It is important that the mother understands that: 1. Parents may stop the thyroxine as long as the baby remains in the 50th percentile for height and weight. 2. Soy-based formula can interfere with the absorption of thyroxine. 3. Dairy-based formula is contraindicated when an infant is taking thyroxine. 4. As long as the baby is growing along the same growth curve, no interventions are necessary.

Q: A child is admitted to the hospital with a diagnosis of "rule out" urinary tract infection. A clean-catch urine specimen is submitted to the lab. When the results return, the nurse evaluates the findings. Which finding would the nurse question? 1. 2+ White blood cells 2. 1+ red blood cells 3. Urine appearance: cloudy 4. Specific gravity: 1009

Q: A baby is born with bladder exstrophy. Immediate care for this infant will include which intervention? 1. Measuring intake and output 2. Inserting a Foley catheter 3. Covering the defect with sterile plastic wrap 4. Palpating the bladder mass to ensure urine is expelled

Q: A four-year-old girl has been treated for three urinary tract infections (UTI) in the last two years. Which instructions can the nurse give to the mother to help reduce the child's risk of acquiring another UTI? Standard Text: Select all that apply. 1. Wear only nylon underwear for better air flow. 2. Teach the child to wipe from front to back. 3. Encourage the child to take long baths by allowing the child bubbles and toys in the tub. 4. Encourage the child to drink additional fluids throughout the day. 5. Plan potty breaks every two hours throughout the day.

Q: A child with acute renal failure is being treated with peritoneal dialysis. Following medical orders, the dialysate has been infused into the child's abdomen. When the dialysate is drained, the nurse notes the following findings. Which finding requires notification of the physician? 1. The dialysate is clear on return. 2. The volume of drained dialysate is less than the volume infused. 3. The child is restless, wanting to get up and play. 4. The child's vital signs are basically the same as were noted on infusion.

Q: A teenage girl sees the school nurse to ask about a vaginal discharge that she has had for a month. The nurse suspects a sexually transmitted disease. What is the nurse's next step? 1. Notify the girl's parents. 2. Determine the girl's sexual partners. 3. Encourage the girl to go to the free clinic or her private health care provider for an examination and possible treatment. 4. Notify the health department of the sexually transmitted disease.

Q: The surgeon is discussing plans for orchiopexy with the parents of an infant born with cryptorchidism. The parents are overwhelmed and do not hear much of the discussion. The nurse will clarify the surgeon's explanation by discussing that the risk of undescended testes include: Standard Text: Select all that apply. 1. Sperm production will be affected after puberty. 2. Abdominal testes are subject to injury. 3. Abdominal testes have a higher risk of developing cancer. 4. Hormonal production will be affected. 5. The testes are at greater risk of torsion.

Q: Following a hypospadias repair, the 10-month-old child returns from the operating room with a urethral stent. It is now four hours since the child's surgery. Which assessment finding should be reported to the surgeon? 1. The infant has bloody urine. 2. The infant has voided one time since returning from surgery. 3. The infant seems to be having bladder spasms that respond favorably to anticholinergic medications. 4. Double diapering the infant has resulted in the stent being free from stool contamination.

Q: A child is undergoing hemodialysis. The child should be monitored closely for: Standard Text: Select all that apply. 1. Migraines. 2. Hypotension. 3. Infections. 4. Fluid overload. 5. Shock.

Q: A child is scheduled for a kidney transplant. The nurse has completed the preoperative teaching to prepare the child and parents for the surgery and postoperative considerations. Which statement indicates that the parents understand the process involved with a kidney transplant? 1. "We're happy our child won't have to take any more medicine after the transplant." 2. "We understand our child won't be at risk anymore for catching colds from other children at school." 3. "We'll be glad we won't have to bring our child in to see the doctor again." 4. "We know it's important to see that our child takes prescribed medications after the transplant."

Q: A child in renal failure has hyperkalemia. The nurse plans to instruct the child and her parents to avoid which foods? 1. Carrots and green, leafy vegetables 2. Spaghetti and meat sauce with breadsticks 3. Hamburger on a bun and cherry gelatin 4. Chips, cold cuts, and canned foods

Q: A child has undergone a kidney transplant and is receiving cyclosporine. The parents ask the nurse about the reason for the cyclosporine. The nurse should explain that the drug is given to: 1. Suppress rejection. 2. Decrease pain. 3. Improve circulation. 4. Boost immunity.

Q: Which sets of symptoms are characteristic of a preschool-age child with a urinary tract infection? 1. Headache, hematuria, and vertigo 2. Foul-smelling urine, elevated blood pressure, and hematuria 3. Urgency, dysuria, and fever 4. Severe flank pain, nausea, and headache

Q: A nurse is preparing to admit a child with possible obstructive uropathy. What labs should the nurse expect to draw on this child? 1. Platelet count 2. Blood urea nitrogen (BUN) and creatinine 3. Partial thromboplastin time (PTT) 4. Blood culture

Q: A four-year-old has acute glomerulonephritis (AGN) and is admitted to the hospital. The priority nursing diagnosis for this child would be: 1. Risk for injury related to hypertension. 2. Altered growth and development related to a chronic disease. 3. Risk for infection related to hypertension. 4. Fluid volume excess related to decreased plasma filtration.

Q: A child is admitted with acute glomerulonephritis. The nurse would expect the urinalysis during this acute phase to show which of the following? 1. Bacteriuria and increased specific gravity 2. Hematuria and proteinuria 3. Proteinuria and decreased specific gravity 4. Bacteriuria and hematuria

Q: A child with nephritic syndrome is severely edematous. The primary health care provider has placed the child on bed rest. An important nursing intervention for this child would be to: 1. Monitor BP every 30 minutes. 2. Reposition the child every two hours. 3. Limit visitors. 4. Encourage fluids.

Q: A child has been admitted to the hospital unit with a diagnosis of minimal change nephrotic syndrome (MCNS). The clinical manifestations will include which of the following? 1. Massive proteinuria, hypoalbuminemia, and edema 2. Hematuria, bacteriuria, and weight gain 3. Urine-specific gravity decreased and urinary output increased 4. Gross hematuria, albuminuria, and fever

Q: The nurse who works in the newborn nursery must be alert for infants with congenital gastrointestinal defects. Defects that might be diagnosed in the newborn nursery would include: Standard Text: Select all that apply. 1. Pyloric stenosis. 2. Biliary atresia. 3. Hirschsprung's disease. 4. Umbilical hernia. 5. Diaphragmatic hernia.

Q: A toddler is admitted to the surgical unit for planned closure of the temporary colostomy. The nurse completes the admission assessment and reviews the medical orders. Which order should the nurse question? 1. Clear liquids today. NPO tomorrow 2. Type and cross-match for one unit of packed red blood cells. 3. Rectal temperatures every four hours 4. Start an intravenous line with D5NS at 20 ml per hour.

Q: A woman pregnant at term arrives at the small rural hospital in active labor. She has received no prenatal care. At delivery, it is discovered that the newborn has a gastroschisis defect. Immediate transfer to a pediatric hospital is planned. Nursing care to prepare the infant for discharge would include: 1. Covering the exposed intestines with sterile moist gauze. 2. Wrapping the infant warmly in two or three blankets. 3. Providing a sterile water feeding to maintain hydration during transport. 4. Preventing the parents from seeing the infant prior to transfer to reduce their anxiety.

Q: Following hospital discharge for treatment of gastroesophageal reflux, the home health nurse visits the family. Which finding made by the nurse during the visit requires the nurse to intervene? 1. The infant's formula has rice cereal added. 2. The mother hold the infant is a high Fowler's position while feeding. 3. After feeding, the infant is placed in an infant seat. 4. The mother draws up the ranitidine (Zantac) in a syringe for oral administration.

Q: Following diagnosis of Crohn's disease, the nurse is explaining dietary modifications to the teenagers. The nurse would recommend: Standard Text: Select all that apply. 1. Increased fiber in the diet to promote solid stools. 2. Small, frequent feedings are preferred over three meals a day. 3. Identify foods that cause distress and eliminate them from the diet. 4. High-calorie dietary supplement shakes can help meet nutritional requirements. 5. Socialization is important at mealtime no matter the dynamics.

Q: A nasogastric tube to suction is ordered for a child newly diagnosed with a diaphragmatic hernia. The nurse notes that the surgeon has not ordered fluid replacement for the NG drainage. What might occur if large amounts of gastric drainage are noted without replacement? 1. The infant may lose weight due to loss of nutrition. 2. The infant will develop metabolic alkalosis. 3. The infant will become dehydrated. 4. The infant will develop hyperbilirubinemia.

Q: The woman has a normal pregnancy except for polyhydramnios. The delivery goes well and the baby is born and receives APGAR scores of seven and nine. Upon admission to the newborn nursery, the nurse is unsuccessful in inserting a nasogastric tube. The infant is suspected of having an esophageal atresia/tracheoesophageal fistula. While waiting for the pediatrician to see the infant, the nurse should: 1. Position the infant in semi-Fowler position. 2. Allow the infant to be taken to the mother's room for bonding. 3. Offer the infant formula feeding instead of breastfeeding. 4. Wrap the infant in blankets and place in a crib by the viewing window.

Q: At delivery, it was discovered that the newborn had a bilateral cleft lip. The parents are distressed about the appearance of their infant. Nursing behaviors that can help the parents bond to the infant include: Standard Text: Select all that apply. 1. Calling the infant by name when referring to the infant. 2. Keeping the infant's lower face covered with the blanket. 3. Smiling at the infant and talking to the infant in the parents' presence. 4. Showing the parents before and after pictures of other children with cleft lips. 5. Discussing positive features of their baby.

Q: A child returns from exploratory abdominal surgery following a gunshot wound to the abdomen. Which nursing intervention would the nurse omit from the plan of care for this child? 1. NPO status until bowel sounds return 2. Frequent assessment of the surgical site 3. Avoiding narcotics to prevent depression of the respiratory system 4. Allow parents at the bedside as soon as possible.

Q: A nurse is preparing for the delivery of a newborn with a known diaphragmatic hernia defect. Which equipment should the nurse prepare for use? 1. Appropriate bag-valve-mask system 2. Sterile gauze and saline 3. Soft arm restraints 4. Equipment for intubation