HESI RN PEDIATRICS

1.The nurse is planning postoperative care for a child who has had a cleft lip repair.
What is the most important reason to minimize this child's crying during the
recovery period?
A. Tear formation increases salivation.
B. This behavior increases respirations.
C. Excessive hysteria can lead to vomiting.
D. Crying stresses the suture line
Rationale:
Prevention of stress on the lip suture line is essential for optimum healing and the
cosmetic appearance of a cleft lip repair. Although crying also causes options A, B,
and C, these conditions do not create a problem for the child with a cleft lip repair.
2. An infant is receiving digoxin for congestive heart failure. The apical heart rate
is assessed at 80 beats/min. What intervention should the nurse implement?
A. Call for a portable chest radiograph.
B. Obtain a therapeutic drug level.
C. Reassess the heart rate in 30 minutes.
D. Administer digoxin immune Fab stat.
Rationale:
Sinus bradycardia (heart rate <90 to 110 beats/min in an infant) is an indication of
digoxin toxicity, so assessment of the client's digoxin level has the highest priority.
Option A is not indicated at this time. Option C provides helpful assessment data
but does not address the cause of the problem and delays needed intervention.
Option D is indicated for a serious, life-threatening overdose with digoxin.

3. The nurse admits a child to the intensive care unit with a possible diagnosis of
Wilms tumor - What is the most safety precaution for child?
A. maintain NPO status
B. Limit visitors to the immediate family
C. Place a do not palpate abdomen sign on head of
bed
D. Encourage ambulation in the pre-operative period
Rationale:
Protect child from injury; place a sign on bed stating "no abdominal palpation" (to
prevent accidental fragmentation and dislodging into the abdominal cavity). The
other option choices are not relevant at this time.
4. The nurse is preparing a teaching plan for the mother of a child who has been
diagnosed with celiac disease. Choosing which lunch will be within the therapeutic
management of a child with celiac disease?
A. Turkey salad, milk, and oatmeal cookies
B. Baked chicken, coleslaw, soda, and frozen fruit
dessert
C. Tuna salad sandwich on whole wheat bread, milk,
and ice cream
D. Turkey sandwich on rye bread, orange juice, and
fresh fruit
Rationale:
A child with celiac disease is managed on a gluten-free diet, which eliminates food
products containing oats, wheat, rye, or barley.
5. A 6-month-old male infant is admitted to the postanesthesia care unit with elbow
restraints in place. He has an endotracheal tube and is ventilator-dependent but will
be extubated soon following recovery from anesthesia. Which nursing intervention
should be included in this child's plan of care?
A. Keep restraints on at all times to prevent
unplanned extubation.
B. Remove restraints one at a time and provide
range-of-motion exercises.
C. Remove all restraints simultaneously and provide
play activities.
D. Document the reason for application of the
restraints every 72 hours.
Rationale:
Removing restraints one at a time is safer than option C. The infant should have
the restrained extremities assessed frequently for signs of neurologic or vascular
impairment, and range-of-motion exercises should be performed with these
assessments. Under no circumstances should restraints be applied to the client
continuously. Documentation of assessment findings regarding the restrained
extremities must occur much more frequently than every 72 hours; however, the
reason for using restraints must be justified and should be stated in the medical
record.
6. The nurse assigns an unlicensed assistive personnel (UAP) to provide morning
care to a newly admitted child with bacterial meningitis. What is the most
important instruction for the nurse to review with the UAP?
A. Use designated isolation precautions.
B. Keep the lighting in the room dim.
C. Allow the parents to assist with care.
D. Report any pain that the child experiences.
Rationale:
All these are important measures to review with the UAP, but the most important is
option A. Improper use of isolation precautions can place other staff and clients at
risk for infection. Options B, C, and D promote client comfort and reduce anxiety
but are of a lower priority than option A.
7. The nurse is caring for a child with intussusception who is scheduled for a
barium enema prior to a surgical procedure. Which action should the nurse take
first?

A. Evacuate the bowel of impacted feces

B. Admnister magnesium sulfate
C. Place the child on a clear liquid diet
D. Assess the stool for white color
Rationale:
Intussusception, an invagination or telescoping of one portion of the intestine into
another, causes intestinal obstruction in children (usually occurs between 3 months
and 5 years of age). Nonsurgical treatment is attempted with hydrostatic pressure
created by barium instillation, which often reduces the area of bowel
intussusception. In preparation for a barium enema, the client should first be placed
on a clear liquid diet for the entire day; then magnesium sulfate is administered for
bowel evacuation. A barium enema is likely to cause option A. After the enema,
white stool may be seen as the body naturally removes any remaining barium.
8. A 3-week-old infant is referred to an orthopedic clinic because the pediatrician
heard a click when flexing the child's right hip during a routine physical
examination. The orthopedic physician suspects that the child might have
developmental dysplasia of the hip (DDH). The parents ask the nurse to identify
risk factors commonly associated with DDH. Which response is accurate?

A. Vertex delivery
B. Male gender
C. Breech presentation
D. Second-born child
Rationale:
Developmental dysplasia of the hip (DDH) occurs more often in infants who
present in the breech position, not the vertex (head-first) position. Twice as many
females as males present in the breech position; thus, 80% of children with DDH
are females, not males. Of breech presentations, 60% occur with first-born
children, not subsequent siblings, possibly because of the unstretched uterus and
compaction of the surrounding abdominal contents, which tend to increase
compression on the uterus in the nulliparous woman.
9. The nurse is teaching the parents of a 2-year-old child with a congenital heart
defect about signs and symptoms of congestive heart failure. Which information
about the child is most important for the parents to report to the health care
provider?

A. Sits or squats frequently when playing outdoors

B. Exhibits a sudden and unexplained weight gain
C. Is not completely toilet-trained and has some
accidents
D. Demonstrates irritation and fatigue 1 hour before
bedtime
Rationale:
Sudden and unexplained weight gain can indicate fluid retention and is a sign of
congestive heart failure. Option A is used by the child to reduce chronic hypoxia,
especially during exercise. Option C is common; 2-year-olds are not expected to be
toilet-trained. Option D is normal.
10. A newborn female whose mother is HIV-positive is scheduled for the first
follow-up assessment with the nurse. If the child is HIV-positive, which initial
symptom is she most likely to exhibit?

A. Shortness of breath
B. Joint pain
C. Persistent cold
D. Organomegaly
Rationale:
Respiratory tract infections commonly occur in the pediatric population, but the
child with AIDS has a decreased ability to defend the body against these common
infections. Thus, the most typical presenting symptom of a child who contracted
AIDS through vertical transmission (i.e., from the mother during delivery) is a
persistent cold or respiratory infection. Options A, B, and D are symptoms of
AIDS complications that may occur later as the disease progresses.
11. Following the administration of immunizations to a 6-month-old girl, the nurse
provides the family with home care instructions. Which statement by the mother
indicates that further teaching is needed?

A. "I will give her a baby aspirin every 4 hours as

needed for fever."
B. "I will call the clinic if her cry becomes high-
pitched or unusual."
C. "I know I can expect her to be irritable over the
next 2 days."
D. "I will exercise her legs regularly to decrease the
soreness."
Rationale:
Although fever may occur, non–aspirin-containing medications should be used
because of the risk of Reye syndrome. Option B indicates a severe reaction,
whereas option C is a common side effect. Option D decreases soreness in the
thigh injection site.
12. Which preoperative nursing intervention should be included in the plan of care
for an infant with pyloric stenosis?

A. Monitor for signs of metabolic acidosis.

B. Estimate the quantity of diarrhea stools.
C. Place in a supine position after feeding.
D. Observe for projectile vomiting.

Rationale:
Projectile vomiting, the classic sign of pyloric stenosis, contributes to metabolic
alkalosis. Metabolic acidosis is the opposite imbalance from alkalosis and is not an
expected finding. An antidiarrheal agent is not indicated. Option C is dangerous
because of the potential for aspiration with frequent vomiting.
13. A child breaks out with varicella infection (chickenpox) while hospitalized for
a minor surgical procedure. Which intervention should the nurse implement first?

A. Place a mask on the child before transporting the

child outside the room.
B. Immunize exposed family members with the
varicella vaccine.
C. Place the child in strict isolation to prevent an
outbreak on the unit.
D. Determine which staff have had varicella before
making assignments.
Rationale:
The period of communicability of varicella is 2 days before the rash appears until
all lesions are crusted; varicella is spread by direct or indirect contact of saliva or
vesicles. Strict isolation is indicated to prevent further exposure to staff and others.
Staff who have had varicella or the vaccine are not susceptible to contracting or
spreading the virus and should be the only personnel assigned to care for this
client. Option A is not sufficient to prevent exposure to others. Option B must be
done prior to exposure.
14. The nurse observes a 4-year-old boy in a day care setting. Which behavior
should the nurse expect this child to exhibit?

A. Throws a temper tantrum when told he must

share the toys.
B. Plays by himself for most of the day.
C. Boasts aggressively when telling a story.
D. Cries and is fearful when separated from his
parents.
Rationale:
Four-year-old children are aggressive in their behavior and enjoy telling tales.
Options A and D are typical toddler behaviors. A preschooler's play is usually
cooperative, so playing alone is not typical.
15. During routine screening at a school clinic, an otoscope examination of a
child's ear reveals a tympanic membrane that is pearly gray, slightly bulging, and
not movable. Based on these findings, what action should the nurse take?

A. No action is required because this is an expected

finding for a school-aged child.
B. Ask if the child has had a cold, runny nose, or any
ear pain lately.
C. Send a note home advising parents to have the
child evaluated by a health care provider.
D. Call the parents and have them take the child
home from school for the rest of the day.
Rationale:
More information is needed to interpret these findings. The tympanic membrane is
normally pearly gray, not bulging, and moves when a client blows against
resistance or when a small puff of air is blown into the ear canal. Because these
findings are not completely normal, further assessment of history and related signs
and symptoms are needed to interpret the findings accurately. Based on the data
obtained from the otoscope examination, options A, C, and D are not indicated.
16. When caring for a child with congenital heart disease and polycythemia, which
nursing intervention has the highest priority?

A. Administering oxygen therapy continuously

B. Restricting fluids as ordered
C. Maintaining adequate hydration
D. Maintaining digoxin levels
Rationale:
The key word in this question is polycythemia. Hydration decreases blood
viscosity and the risk for thrombus formation, the most common complication of
polycythemia. Options A and D are nursing interventions for the cardiac client but
do not treat polycythemia. Fluid intake should be increased, not restricted.
18. The nurse is conducting an initial admission assessment of a 12-month-old
child in celiac crisis. Which intervention is most important for the nurse to
implement?

A. Assess the child's mucous membranes and skin

turgor.
B. Contact food services about needed menu
restrictions.
C. Determine the child's food likes and dislikes.
D. Ask the parents about the child's recent dietary
intake.
Rationale:
An infant having a celiac crisis has severe diarrhea and is at high risk for fluid
volume deficit. The nurse should first assess for indications of fluid volume deficit
and then implement options B, C, and D.
19. When inserting a nasogastric tube into the stomach of a 3-month-old infant,
which nursing intervention is most important to implement?

A. Use a blanket as a mummy restraint.

B. Monitor the infant's heart rate.
C. Lubricate the catheter with saline.
D. Explain the procedure to the parents.
Rationale:
All interventions may be implemented during nasogastric tube insertion, but the
most important nursing action is to monitor the infant's heart rate, which may
decrease because of vagal nerve stimulation and can occur when the tube is
inserted. Options A, C, and D are of lower priority than option B.
20. In making the initial assessment of a 2-hour-old infant, which finding should
lead the nurse to suspect a congenital heart defect?

A. Irregular respiration and heart rate

B. Gagging
C. Blue feet and hands
D. Diminished femoral pulses
Rationale:
Diminished femoral pulses could indicate coarctation of the aorta. In the normal
transition period, options A and B occur during the 4 to 6 hours after birth (second
period of reactivity). Option C is a normal finding in the newborn.
21. At which point during the physical examination should a child with asthma be
assessed for the presence or absence of intercostal retractions?

A. Inspiration
B. Coughing
C. Apneic episodes
D. Expiration
Rationale:
Intercostal retractions result from respiratory effort to draw air into restricted
airways. The retractions will not be noticeable when air is expelled from the lungs,
such as when the client is coughing or expiring. During apnea, the client is not
attempting to draw air into the airways. Apnea indicates that the respiratory effort
is absent.
22. Which interventions should the nurse include in the teaching plan for the
mother of a 6-year-old who is experiencing encopresis secondary to a fecal
impaction? (Select all that apply.)

A. Provide a low-fiber diet.

B. Administer mineral oil daily.
C. Decrease the daily fluids.
D. Eliminate dairy products.
E. Initiate consistent toileting routine.
Rationale:
Encopresis is fecal incontinence, usually as the result of recurring fecal impaction
and an enlarged rectum caused by chronic constipation. Encopresis is managed
through bowel retraining with mineral oil, eliminating dairy products, and
initiating a regular toileting routine. A high-fiber diet, not option A, and increased
daily fluids, not option C, are components of care for a child with encopresis.
23. The nurse is examining a male child experiencing an exacerbation of juvenile
rheumatoid arthritis (JRA) and notes that his mobility is greatly reduced. What is
the most likely cause of the child's impaired mobility?

A. Pathologic fractures

B. Poor alignment of joints

C. Dyspnea on exertion

D. Joint inflammation
Rationale:
Joint inflammation and pain are the typical manifestations of an exacerbation of
JRA. Options A, B, and C are not specifically related to JRA.
24. A 3-month-old infant returns from surgery with elbow restraints and a Logan
bow over a cleft lip suture line. Which intervention should the nurse implement to
maintain suture line integrity during the initial postoperative period?

A. Place the infant upright in an infant seat position.

B. Provide mittens with the use of elbow restraints.
C. Use soft rubber catheters for nasal suctioning.
D. Apply water-soluble lubricant to the suture line
Rationale:
The use of an infant seat simulates a supine position with the head elevated and
also prevents aspiration. Prone positioning should be avoided to prevent disruption
of the protective Logan bow and prevent the infant from rubbing the face on the
bed surface. Mittens are not necessary and decrease the ability to provide sensory
comfort, such as hand holding. Nasal suctioning should be avoided to prevent
trauma or dislodging clots at the surgical site. Water-soluble lubricant will dry the
suture line and cause crusting, which predisposes the suture line to poor healing
and scarring.
25. A 7-month-old infant with a rotavirus causing severe diarrhea is admitted for
treatment. Which intervention should the nurse implement first?

A. Obtain a scale to weigh the infant's diapers.

B. Instruct the mother to offer Pedialyte regularly.
C. Insert an intravenous (IV) line and begin IV
fluids.
D. Obtain a stool specimen for analysis.
Rationale:
An infant with severe diarrhea is at high risk for dehydration, so the nurse's priority
is to initiate IV fluids to rehydrate the infant. Options A, B, and D can then be
implemented as needed.
26. The nurse is assessing a male adolescent client's knowledge of contraception.
The teen states, "I have all the info I need." What is the best response by the nurse?

A. "Tell me what you know about birth control."

B. "Do you know how to apply a condom?"
C. "Teen pregnancy should not be taken lightly."
D. "You need to visit with your guidance counselor."
Rationale:
Teens often obtain information from peers, which may not be accurate. Knowing
the source of the information may assist the nurse in evaluating the information
that the teenager has regarding contraception. It would be best for the nurse to ask
a more general question, such as option A. Option B is narrow in focus. Options C
and D are blocks to any further communication.
27. A 3-month-old infant weighing 10 lb 15 oz has an axillary temperature of 98.9°
F. What caloric amount does this child need?

A. 400 calories/day
B. 500 calories/day
C. 600 calories/day
D. 700 calories/day
Rationale:
An infant requires 108 calories/kg/day. The first step is to change 10 lb 15 oz to
10.9 lb. Then convert pounds to kilograms by dividing pounds by 2.2, which is
10.9/2.2 = 4.954 kg, rounded to 5 kg. The second step is to multiply 108
calories/kg/day (108 × 5 = 540 calories/day). However, this infant requires 10%
more calories because of the 1° F temperature elevation. Ten percent of 540
(calories/day) is 54, and 540 + 54 = 594. This infant will require approximately
600 calories/day. Options A, B, and D are incorrect.
28. The nurse should teach the parents of a child with a cyanotic heart defect to
perform which action when a hypercyanotic spell occurs?

A. Place the child's head flat, with the knees on

pillows above the level of the heart.
B. Have the child lie on the right side, with the head
elevated on one pillow.
C. Allow the child to assume a knee-chest position,
with the head and chest slightly elevated.
D. Encourage the child to sit up at a 45-degree angle,
drink cold water, and take deep breaths.
Rationale:
Assuming a knee-chest position with the head and chest slightly elevated will help
restore hemodynamic equilibrium. Options A and B are incorrect positions and
may hinder the child's condition. Option D may cause chest pain or a vasovagal
response, with resulting hypotension.
29. A 2-year-old child with trisomy 21 (Down syndrome) is brought to the clinic
for a routine evaluation. Which assessment finding suggests the presence of a
common complication often experienced by those with Down syndrome?

A. Presence of a systolic murmur

B. New onset of patchy alopecia
C. Complaints of long bone pain
D. Recent projectile vomiting
Rationale:
Congenital heart disease occurs in 40% to 50% of children with trisomy 21 (Down
syndrome). Defects of the atrial or ventricular septum that create systolic murmurs
are the most common heart defects associated with this congenital anomaly.
Options B, C, and D are not recognized as common complications of trisomy 21.
30.The nurse is teaching an adolescent girl with scoliosis about a Milwaukee brace
that her health care provider has prescribed. Which instruction should the nurse
provide to this client?

A. Remove the brace 1 hour each day for bathing

only.
B. Remove the brace only for back range-of-motion
exercises.
C. Wear the brace against the bare skin to ensure a
good fit.
D. Wearing the brace will cure the spinal curvature.
Rationale:
The Milwaukee brace is designed to slow the progression in spinal curvature while
the adolescent is growing. The brace should be worn 23 hours a day and removed a
total of 1 hour a day for hygiene. There are no specific exercises for increasing the
range of motion in the back that should be performed. A T shirt should be worn
next to the body and the brace put on over the T shirt to protect the skin. The brace
will not cure the spinal curvature but should slow the progression of the scoliosis.
31. Prophylactic antibiotics are prescribed for a child who has mitral valve
damage. The nurse should advise the parents to give the antibiotics prior to which
occurrence?

A. Adjustment of orthodontic appliances or braces

B. Loss of deciduous teeth (baby teeth)
C. Urinary catheterization
D. Insect bites
Rationale:
Prophylactic antibiotics are usually prescribed prior to any invasive procedure for
children who have valvular damage. Of the choices listed, only urinary
catheterization is an invasive procedure. Options A, B, and D are not invasive and
do not require administration of prophylactic antibiotics.
32. A 7-month-old male infant diagnosed with spastic cerebral palsy is seen by the
nurse in the clinic. Which statement by the parent warrants immediate intervention
by the nurse?

A. "My son often chokes while I am feeding him."

B. "Is it normal for my child's legs to cross each
other?"
C. "He gets stiff when I pull him up to a sitting
position."
D. "My 4-year-old son is jealous of his little
brother."
Rationale:
Airway obstruction is always a priority when caring for any client. Options B and
C are characteristics of spastic cerebral palsy and may involve one or both sides.
These children have difficulty with fine motor skills, and attempts at motion
increase abnormal postures. Option D is an expected behavior and may need to be
addressed, but it is not a priority over choking.
33. Which nursing diagnosis has the highest priority when planning care for an
infant with eczema?

A. High risk for altered parenting related to feelings

of inadequacy
B. Altered comfort (pruritus) related to vesicular
skin eruptions
C. Altered health maintenance related to knowledge
deficit of treatment
D. Risk for impaired skin integrity related to
eczema
Rationale:
Altered comfort (pruritus) has the highest priority because itching will cause the
infant to scratch, creating complications such as scarring or infection. Options A,
C, and D are all important nursing diagnoses and should be considered when
developing the infant's plan of care, but they do not have the priority of option B.
34.The nurse notes that a 16-year-old male client is refusing visits from his
classmates. Further assessment reveals that he is concerned about his edematous
facial features. Based on these assessment findings, the nurse should plan
interventions related to which nursing diagnosis?

A. Social isolation
B. Altered health maintenance
C. Knowledge deficit
D. Ineffective coping
Rationale:
Peer acceptance and body image are significant issues in the growth and
development of adolescents. Option A addresses the problem of a lack of contact
with peers stemming from his desire to protect his ego. Options B, C, and D are not
supported by the assessment finding.
35. A child is admitted to the hospital for confirmation of a diagnosis of acute
lymphoblastic leukemia. During the initial nursing assessment, which symptoms
will this child most likely exhibit?

A. Bone pain, pallor

B. Weakness, tremors
C. Nystagmus, anorexia
D. Fever, abdominal distention
Rationale:
Option A lists the most common presenting symptoms of leukemia. Leukemic cells
invade the bone marrow, gradually causing a weakening of the bone and a
tendency toward pathologic fractures. As leukemic cells invade the periosteum,
increasing pressure causes severe pain and anemia results from decreased
erythrocytes, causing pallor. Options B and C could be associated with central
nervous system disorders. Option D commonly occurs in children but is not
specific for leukemia.
36. A father of a 5-year-old boy calls the nurse to report that his son, who has had
an upper respiratory infection, is complaining of a headache, and his temperature
has increased to 103° F, taken rectally. Which intervention has the highest priority?

A. Determine if the child has any allergies to

antibiotics.
B. Instruct the parent to give the child tepid baths.
C. Instruct the parent to increase the child's fluid
intake.
D. Tell the parent to take the child to the emergency
department.
Rationale:
The child is exhibiting symptoms that may indicate possible meningitis, and the
parents should be encouraged to get immediate evaluation. Options A, B, and C are
all valuable interventions after the client is assessed and diagnosed.
37. A child with a permanent tracheostomy is confined to a wheelchair and is
going to school for the first time tomorrow. During the school day, which
intervention should be implemented for this child?

A. Cover the tracheostomy site with clothing so that

other children will not notice.
B. Apply suction for 30 seconds when inserting a
catheter into the stoma.
C. Discourage the child from coughing deeply to
remove mucous secretions.
D. Place suctioning supplies on the back of the
wheelchair when transporting.

Rationale:
Suctioning supplies should always be readily available for use with any client who
has a tracheostomy. Options A, B, and C do not describe safe practices for this
child with a tracheostomy.
38. An 18-month-old child returns to the unit following a cardiac catheterization
with a cannulated femoral artery site. Which intervention should the nurse
implement?

A. Teach the parents how to ambulate the child in

the room safely.
B. Show the parents how to hold the child with the
extremity extended.
C. Restrain the child's lower extremities for a
minimum of 4 hours.
D. Place the child in a prone position to apply
pressure to the site.

Rationale:
The extremity should be extended to prevent trauma to the femoral catheterization
site. Options A and D increase the risk for complications and are contraindicated.
Option C is not necessary. Only the extremity that was catheterized requires
immobilization.
39. A burned child is brought to the emergency department, and the nurse uses a
modified rule of nines to estimate the percentage of the body burned. When
calculating the percentage of burn, which parts of the child's body are
proportionally larger than an adult's?

A. Head and neck

B. Arms and chest
C. Legs and abdomen
D. Back and abdomen
Rationale:
The standard rule of nines is inaccurate for determining burned body surface areas
with children because a child's head and neck are proportionately larger than an
adult's. Specially designed charts are commonly used to measure the percentage of
burn in children. Options B, C, and D are not proportionately different.
40. The nurse is preparing a health teaching program for parents of toddlers and
preschoolers and plans to include information about the prevention of accidental
poisonings. It is most important for the nurse to include which instruction?

A. Tell children that they should not taste anything

but food.
B. Store all toxic agents and medicines in locked
cabinets.
C. Provide special play areas in the house and
restrict play in other areas.
D. Punish children if they open cabinets that contain
household chemicals.
Rationale:
The only reliable way to prevent poisonings in young children is to make the items
inaccessible. Teaching children not to taste anything but food is important but
ineffective for young children. Options C and D will not control a child's curiosity.
41. Which nursing interventions are therapeutic when caring for a hospitalized
toddler? (Select all that apply.)

A. Require parents to leave the room when

performing invasive procedures.
B. Allow the toddler to choose a colored Band-Aid
after an injection.
C. Give brief but simple explanations to the child
before procedures.
D. Insert a urinary catheter if bedwetting occurs
during hospitalization.
E. Do not allow any toys to be brought in from the
child's home.
Rationale:
Giving the toddler a choice may increase autonomy in the hospitalized setting.
Brief but simple explanations are beneficial with the toddler. Separation from the
parent can cause emotional distress. Regression is expected, and bedwetting is not
an indication for a urinary catheter. The nurse should encourage age-appropriate
toys to be brought in from home.
42. A mother calls the clinic because her 6-year-old son, who has been taking
prescribed antibiotics for 7 of the previous 10 days, continues to have a cough that
she reports is worsening. Further questioning by the nurse reveals that the cough is
nonproductive. What advice should the nurse provide to this mother?

A. Watch the boy a few more days and see if the

cough begins to produce sputum.
B. The full 10-day course of antibiotics must be
completed before effectiveness can be evaluated.
C. Give the child plenty of fluids and an over-the-
counter cough suppressant.
D. Bring the child to the clinic today for an
examination related to the cough.
Rationale:
The child should be evaluated as soon as possible for pneumonia. Antibiotics
usually improve symptoms during the first few days of treatment but should be
continued for the full prescribed course. A continued cough after 7 days of
antibiotic treatment may indicate an infectious process in the lower lungs, which
could cause a nonproductive cough. Children with pneumonia can deteriorate
unexpectedly and rapidly and can become seriously ill, with no sputum production.
Option B delays evaluation too long. Although giving fluids is advisable, cough
suppressants might mask symptoms of a serious condition.
42. A nurse is preparing to end the shift and receives a laboratory report stating
that a child with asthma has a theophylline level of 15 mcg/dL. Which action
should the nurse take?
A. Communicate the result to the oncoming nurse
and document.
B. Tell the oncoming nurse that the level is
dangerously high.
C. Ask the laboratory to redo the test because the
result is faulty.
D. Hold the next dose of theophylline based on this
finding.
Rationale:
The therapeutic level of theophylline is 10 to 20 mcg/dL, so the child's level is
within the therapeutic range. This information evaluates the prescribed therapy and
should be communicated in the nurse's report. Based on the laboratory finding,
options B, C, and D are not indicated.
43. Ampicillin, 75 mg/kg, is prescribed for a 22-lb child. It is available in a
solution that contains 250 mg/5 mL. How many milliliters should the nurse
administer in one dose?

A. 10
B. 15
C. 20
D. 25
Rationale:
2.2 lb/1 kg = 22 lb/x kg
x = 10 kg

1 kg/75 mg = 10 kg/x mg
x = 750 mg
250 mg/5 mL = 750 mg/x mL
x = 15 mL
44. Following the reduction of an incarcerated inguinal hernia, a 4-month-old boy
is scheduled for surgical repair of the inguinal hernia. Under which circumstance
should the parents notify the health care provider prior to surgery?

A. Crying that is unrelieved by comforting measures

B. Presence of an inguinal bulge after gentle
palpation
C. Refusal to take oral feedings
D. Straining during defecation
Rationale:
The parents should notify the health care provider if the hernia remains irreducible
after implementing simple measures, such as gentle palpation, warm bath, and
comforting to reduce crying. If a loop of intestines is forced into the inguinal ring
or scrotum and incarcerates, swelling can follow and possible strangulation of the
bowel, intestinal obstruction, or gangrene of the bowel loop can occur,
necessitating emergency surgical release. Options A and D may cause the hernia to
protrude but do not necessitate notification of the health care provider. Option C
may not be specific to the hernia.
45. A child comes to the school nurse complaining of itching. Further assessment
reveals that the child has impetigo. What action should the nurse take?

A. Send the child home with the parents to see the

health care provider before returning to school.
B. Send the child home with the parents and report
this to the health department.
C. Cover the lesion with a dry gauze dressing and
send the child back to class.
D. Wash the lesion with antimicrobial soap, air-dry,
and send the child back to class.
Rationale:
Impetigo is a staphylococcal infection and is transmitted by person-to-person
contact. The child should be sent home with a note to the parents explaining the
condition. Option B is not necessary because this is not a public health hazard.
Option C slows the healing process and can contribute to spread of the infection.
The lesions should be washed with soap and water, topical ointment applied, and
left open to the air to dry. This will occur at the child's home.
46. The nurse expects a 2-year-old child to exhibit which behavior?

A. Build a house with blocks.

B. Ride a small tricycle 6 feet.
C. Display possessiveness with toys.
D. Look at a picture book for 15 minutes.

Rationale:
Two-year-old children are egocentric and unable
to share with other children. Options A, B, and D
are behaviors of a preschooler.
47. A woman whose first child died at 6 weeks of age because of sudden infant
death syndrome (SIDS) is being discharged following the birth of her second child.
The mother tells the nurse that she is fearful that this infant will also develop SIDS.
Which response is best for the nurse to provide this woman?

A. "You can prevent SIDS if your baby sleeps on the

side or back. You will have to monitor the baby
carefully."
B. "The fear of losing another child to SIDS is very
realistic. Have you thought about what support
you may need?"
C. "An apnea monitor will alert you if the baby stops
breathing. This will give you the peace of mind
that you need."
D. "My neighbor's baby died of SIDS last year, and
she went to a SIDS support group. That really
helped her."
Rationale:
The most effective way to provide emotional support is to acknowledge what
clients may be feeling, be a sounding board for them so they can listen to
themselves, and allow them to discover their own solutions. Option A implies to
the mother that she can prevent SIDS from occurring, which is an unrealistic
expectation. Offering a personal opinion about what will help this client or about
what has helped a neighbor is not as effective as helping the client discover what
would be best for her.
48. A 4-year-old child has cystic fibrosis. Which stage of Erikson theory of
psychosocial development is the nurse addressing when teaching inhalation
therapy?

A. Autonomy
B. Industry
C. Trust
D. Initiative
Rationale:
Children 4 to 5 years of age are in the "Initiative vs. Guilt" stage of Erikson theory
of psychosocial development. They enjoy being active and participating in role
playing. "Autonomy vs. Shame and Doubt" occurs at 1 to 3 years of age. "Industry
vs. Inferiority" occurs at 6 to 11 years; "Trust vs. Mistrust" occurs from birth to 1
year of age.
49. Which assessment findings should the nurse expect when caring for a child
with cystic fibrosis? (Select all that apply.)
Select option(s), then click Submit.
A. Steatorrhea
B. Obesity
C. Foul-smelling stools
D. Delayed growth
E. Pulmonary congestion
Rationale:
Options A, C, D, and E are all common assessment findings in the client with
cystic fibrosis. Weight loss, not weight gain, is associated with cystic fibrosis.
50. The nurse is taking the family history of a 2-year-old child with atopic
dermatitis (eczema). Which statement by the mother is most important in
formulating a plan of care for this child?

A. "Our first child was born with a cleft lip."

B. "We are very careful not to get sunburns in our
family."
C. "My first child sometimes got a diaper rash."
D. "My husband and our daughter are both lactose-
intolerant."
Rationale:
Environmental exposure to allergens (milk) and a positive family history for milk
allergies are important data in planning care of the child with atopic dermatitis
because milk allergies can contribute to the child's outbreaks. Option A is not a
contributing factor. Option B is an environmental factor in other skin diseases but
does not have a strong correlation with eczema in children. Option C is not unusual
and occurs in the diaper area, whereas atopic dermatitis occurs most often on the
face and extensor aspects of the arms and legs