Question

A nurse in a pediatrician's office is caring for an infant.

Answer 1

Correct Answers

Blank 1 Correct Option: Dehydration
Blank 2 Correct Option: Failure to thrive

Rationale :

🧴The infant’s forceful projectile vomiting, persistent hunger after vomiting, and palpable right upper quadrant mass are classic findings associated with hypertrophic pyloric stenosis.

💧Repeated vomiting causes substantial loss of fluid and electrolytes, placing the infant at significant risk for dehydration.

📉The minimal weight gain over 2 weeks suggests inadequate nutritional retention and increasing risk for failure to thrive.

⚠️Persistent gastric outlet obstruction can worsen nutritional deficiency, dehydration, and electrolyte abnormalities if untreated.

📌Core Message

Persistent projectile vomiting from suspected pyloric stenosis places an infant at major risk for dehydration and failure to thrive because fluids and nutrients cannot be adequately retained.

Answer 2

Correct Answers:

Circular burns on the soles of the toddler's feet

Rationale :

🔥Circular or patterned burns in unusual locations are highly suspicious for deliberately inflicted injuries and possible child maltreatment.

👣The soles of the feet are normally protected from accidental contact burns, making injuries in this location particularly concerning.

🩺Intentional burns often demonstrate recognizable shapes, patterns, or sharply defined borders that reflect the causative object or method.

🛡️The nurse should recognize suspicious injuries promptly because identifying nonaccidental trauma is essential for protecting the child from further harm.

📌Core Message

A patterned burn on a normally protected body surface such as the soles strongly suggests nonaccidental injury and requires evaluation for child maltreatment.

Answer 3

Correct Answers:

Lethargy

Rationale :

🧠New lethargy after ventriculoperitoneal shunt placement can indicate increased intracranial pressure caused by shunt obstruction or malfunction.

⚠️Changes in level of consciousness are high-priority neurological findings because they can signal worsening cerebral dysfunction.

💧A malfunctioning shunt can prevent adequate drainage of cerebrospinal fluid, causing intracranial pressure to rise rapidly.

🚨Because neurological deterioration can become life-threatening, lethargy requires immediate assessment and provider notification.

📌Core Message

Postoperative lethargy following VP shunt insertion can signal increasing intracranial pressure from shunt malfunction and requires immediate intervention.

Answer 4

Correct Answers:

Elevate the child's residual limb for 48 hr.

Rationale :

🦿Immediately after amputation, elevating the residual limb helps reduce postoperative edema and promotes venous return.

💧Swelling is expected after surgery, so short-term elevation helps control tissue edema during the early postoperative period.

⏱️Elevation should be limited to the initial postoperative period because prolonged flexion can eventually contribute to joint contractures.

💁‍♂️After the initial period, positioning and exercises should emphasize prevention of hip and knee flexion contractures while maintaining mobility.

📌Core Message

Short-term elevation of the residual limb after amputation helps minimize postoperative edema, while prolonged elevation should later be avoided to prevent contractures.

Answer 5

Correct Answers:

The infant has an absent grasp reflex.

Rationale :

👶The primitive palmar grasp reflex normally disappears at approximately 3 to 4 months of age as voluntary motor control develops.

🧠Loss of primitive reflexes at the expected age demonstrates normal maturation of the infant's central nervous system.

🙈Stranger anxiety generally develops later in infancy, commonly around 6 to 8 months rather than at 4 months.

🔄Rolling completely from the back to the abdomen generally develops later than 4 months, although infants may begin rolling in one direction around this period.

📌Core Message

At approximately 4 months, disappearance of the palmar grasp reflex reflects expected neurological maturation and increasing voluntary motor control.

Answer 6

Correct Answers:

Clarify the feeding prescription with the provider.

Rationale :

🩺A nasojejunal tube delivers feeding directly into the small intestine rather than allowing food to enter the stomach.

⏳The small intestine cannot accommodate a large volume suddenly, so jejunal feedings should generally be delivered continuously rather than as bolus feedings.

⚠️A prescription for bolus nasojejunal feeding therefore creates a potential safety concern that must be clarified before implementation.

📞The nurse must resolve an unsafe or questionable provider prescription before performing subsequent feeding-related interventions.

📌Core Message

Because jejunal feeding normally requires controlled continuous administration, a prescription for a bolus feeding should be clarified before implementation.

Answer 7

Correct Answers:

Nutritionist

Rationale :

⚖️The toddler has a BMI of 28, indicating a significant weight-for-height concern that warrants focused nutritional evaluation.

🥛The dietary recall shows excessive consumption of milk, juice, refined carbohydrates, and calorie-dense foods, contributing to excessive caloric intake.

🥦A nutritionist or dietitian can assess portion sizes, nutrient balance, beverage intake, and age-appropriate dietary modifications for healthy growth.

🏃The toddler's reported gross motor, fine motor, language, and toileting development are generally appropriate, making developmental therapy referrals less indicated.

📌Core Message

The toddler's excessive weight relative to height and calorie-dense dietary pattern indicate the need for a nutrition referral rather than developmental therapy.

Answer 8

Correct Answers:

"I will give my child stool softeners for constipation."

Rationale :

🧬Children with cystic fibrosis produce abnormally thick secretions that can contribute to intestinal obstruction and constipation.

🚽Prescribed stool softeners or osmotic agents can be used to promote bowel elimination and reduce complications related to thick intestinal contents.

🍽️Children with cystic fibrosis generally require a high-calorie, high-protein diet rather than restriction of fat and carbohydrates because energy requirements are increased.

💊Pancreatic enzyme capsules should be swallowed or their granules sprinkled on appropriate acidic foods rather than chewed because chewing can damage the protective coating.

📌Core Message

Children with cystic fibrosis can develop constipation from thick intestinal secretions, while adequate nutrition, pancreatic enzyme therapy, and regular physical activity remain important components of home care.

Answer 9

Correct Answers:

"I should increase my intake of sugar-free fluids when I am sick."
"I should eat a snack 30 minutes before my baseball game starts."
"I should eat extra food on busy days when I am more active."

Rationale :

💧During illness, children with type 1 diabetes should maintain adequate hydration by increasing intake of sugar-free fluids when blood glucose is not low.

⚾Eating a carbohydrate-containing snack before prolonged exercise helps prevent exercise-induced hypoglycemia caused by increased glucose utilization.

🏃On days of increased physical activity, additional carbohydrate intake may be necessary to maintain appropriate blood glucose levels.

🩸Balancing insulin, carbohydrate intake, activity, and illness management is essential for preventing both hypoglycemia and hyperglycemia.

📌Core Message

Effective type 1 diabetes management requires adequate sugar-free hydration during illness and appropriate carbohydrate adjustments around increased physical activity to reduce glucose instability.

Answer 10

Correct Answers:

Assess for changes in level of consciousness.
Administer factor VIII.

Rationale :

🩸A child with hemophilia A has a deficiency of clotting factor VIII, which creates a high risk for prolonged or internal bleeding after significant trauma.

🧠Assessing for changes in level of consciousness is important following a motor vehicle crash because neurological deterioration can indicate intracranial bleeding associated with trauma.

💉Administration of factor VIII concentrate replaces the deficient coagulation factor and promotes effective clot formation to control or prevent hemorrhage.

🚨Because abdominal trauma can cause occult internal hemorrhage, rapid assessment and replacement of the deficient factor are critical components of emergency management.

📌Core Message

A child with hemophilia A who experiences major trauma requires immediate assessment for internal hemorrhage and replacement of factor VIII to promote adequate coagulation.

1 :
A nurse in a pediatrician's office is caring for an infant.

Correct Answers

2 :
A nurse is assessing a toddler. Which of the following findings should the nurse identify as an indication of potential child maltreatment?

3 :
A nurse is assessing a 4-year-old child who is 2 days postoperative following insertion of a ventriculoperitoneal shunt. Which of the following findings is the nurse's priority?

4 :
A nurse is planning care for a child who is postoperative following a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care?

5 :
A nurse is assessing a 4-month-old infant at a well-child visit. Which of the following findings should the nurse expect?

6 :
A nurse is caring for an infant who is not tolerating enteral feeding through a nasogastric tube. The provider inserts a nasojejunal feeding tube and prescribes bolus enteral feedings. Which of the following actions should the nurse take first?

7 :
A nurse is caring for a client.

Answer Options

8 :
The parent of a school-age child who has cystic fibrosis about home care. Which of the following statements by the parent indicates an understanding of the teaching?

📌Core Message

9 :
A school nurse is providing dietary teaching for an 11-year-old child who has type 1 diabetes mellitus. The nurse should identify which of the following responses by the child indicates an understanding of the teaching? Select all that apply.

10 :
A nurse in the emergency department is caring for a preschool-age child who has hemophilia A and sustained an abdominal trauma following a motor vehicle crash. Which of the following actions should the nurse take? Select all that apply.

1 : A nurse in a pediatrician's office is caring for an infant.

Correct Answers

2 : A nurse is assessing a toddler. Which of the following findings should the nurse identify as an indication of potential child maltreatment?

3 : A nurse is assessing a 4-year-old child who is 2 days postoperative following insertion of a ventriculoperitoneal shunt. Which of the following findings is the nurse's priority?

4 : A nurse is planning care for a child who is postoperative following a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care?

5 : A nurse is assessing a 4-month-old infant at a well-child visit. Which of the following findings should the nurse expect?

6 : A nurse is caring for an infant who is not tolerating enteral feeding through a nasogastric tube. The provider inserts a nasojejunal feeding tube and prescribes bolus enteral feedings. Which of the following actions should the nurse take first?

7 : A nurse is caring for a client.

Answer Options

8 : The parent of a school-age child who has cystic fibrosis about home care. Which of the following statements by the parent indicates an understanding of the teaching?

📌Core Message

9 : A school nurse is providing dietary teaching for an 11-year-old child who has type 1 diabetes mellitus. The nurse should identify which of the following responses by the child indicates an understanding of the teaching? Select all that apply.

10 : A nurse in the emergency department is caring for a preschool-age child who has hemophilia A and sustained an abdominal trauma following a motor vehicle crash. Which of the following actions should the nurse take? Select all that apply.

1 :
A nurse in a pediatrician's office is caring for an infant.

2 :
A nurse is assessing a toddler. Which of the following findings should the nurse identify as an indication of potential child maltreatment?

3 :
A nurse is assessing a 4-year-old child who is 2 days postoperative following insertion of a ventriculoperitoneal shunt. Which of the following findings is the nurse's priority?

4 :
A nurse is planning care for a child who is postoperative following a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care?

5 :
A nurse is assessing a 4-month-old infant at a well-child visit. Which of the following findings should the nurse expect?

6 :
A nurse is caring for an infant who is not tolerating enteral feeding through a nasogastric tube. The provider inserts a nasojejunal feeding tube and prescribes bolus enteral feedings. Which of the following actions should the nurse take first?

7 :
A nurse is caring for a client.

8 :
The parent of a school-age child who has cystic fibrosis about home care. Which of the following statements by the parent indicates an understanding of the teaching?

9 :
A school nurse is providing dietary teaching for an 11-year-old child who has type 1 diabetes mellitus. The nurse should identify which of the following responses by the child indicates an understanding of the teaching? Select all that apply.

10 :
A nurse in the emergency department is caring for a preschool-age child who has hemophilia A and sustained an abdominal trauma following a motor vehicle crash. Which of the following actions should the nurse take? Select all that apply.