Question

A newborn with a repaired gastroschisis is transferred to the pediatric unit after several days in the pediatric intensive care unit. The infant is receiving parenteral nutrition and continuous enteral feedings. To maintain normal growth and development of the infant, which action should the nurse include in the plan of care?

Answer 1

Correct Answers:

Offer a pacifier for non-nutritive sucking.

Rationale :

🍼Offering a pacifier promotes oral-motor development, which is crucial for infants unable to feed orally.

🧠Non-nutritive sucking supports neurological organization and self-soothing behaviors.

👶It also helps maintain the sucking reflex, which is essential for later transition to oral feeding.

🛏️Providing this oral stimulation encourages sensorimotor integration, aiding in overall development.

📈This is a developmentally supportive intervention for infants recovering from gastroschisis surgery.

📌Core Message

Non-nutritive sucking supports oral-motor skills, neurological development, and comfort in infants recovering from gastrointestinal surgery.

Answer 2

Correct Answers:

Place the child in a quiet environment.

Rationale :

🤫Kawasaki disease often causes extreme irritability, which can be alleviated by minimizing sensory input.

🛌A calm setting helps reduce stress and discomfort, improving rest and healing.

📉Lowering environmental stimuli can also decrease metabolic demand on the child’s cardiovascular system.

👂It provides an opportunity for focused monitoring and detection of any changes in condition.

🧸A quiet space is one of the most immediate non-pharmacologic interventions for irritability in pediatrics.

📌Core Message

A quiet environment helps manage irritability, reduce sensory overload, and promote rest in children with Kawasaki disease.

Answer 3

Correct Answers:

1.8

Rationale :

🧮The prescribed dose is 0.3 mg/kg × 30 kg = 9 mg total.

💉The vial concentration is 5 mg/mL, so 9 ÷ 5 = 1.8 mL.

📏Precise dosing is essential when administering IV medications like diazepam.

⚠️Overdosing can cause respiratory depression, especially in pediatric patients.

✅Calculating to the nearest tenth ensures safe and effective drug administration.

📌Core Message

Safe pediatric dosing requires accurate weight-based calculations and knowledge of concentration conversions.

Answer 4

Correct Answers:

Ask the boy to describe a typical day at school.

Rationale :

🗣️Allowing the child to express his school experience can uncover emotional or social triggers.

🔍This approach provides insight into issues like bullying, academic pressure, or social isolation.

📚Frequent school nurse visits for vague complaints often reflect school-related anxiety or adjustment issues.

🧩This strategy empowers the child to participate in his care and enables targeted interventions.

🧠It avoids assumptions and guides the nurse toward a psychosocially-informed plan of care.

📌Core Message

Exploring the child’s school day helps identify emotional distress or adjustment difficulties, guiding appropriate psychosocial support.

Answer 5

Correct Answers:

Exercise in a swimming pool.

Rationale :

🏊Aquatic exercise provides low-impact resistance, making it ideal for joint movement in JIA.

💪Water supports the body while allowing muscle strengthening without strain.

🤸It encourages full range of motion while minimizing the risk of joint injury.

🌊The buoyancy of water reduces weight-bearing pressure, supporting long-term joint health.

🧘It also improves flexibility, coordination, and endurance in adolescents with chronic arthritis.

📌Core Message

Swimming is a safe and effective method to enhance mobility, reduce joint stress, and build strength in adolescents with JIA.

Answer 6

Correct Answers:

Digoxin

Rationale :

💓Digoxin should be withheld in infants with an apical pulse below 90–110 bpm, depending on age.

📉A heart rate of 88 bpm is too low for an 8-month-old, indicating potential digoxin toxicity.

⚠️Administering it now could worsen bradycardia and compromise cardiac output.

📋It is critical to notify the healthcare provider before proceeding with administration.

🩺Monitoring pulse rate is a key safety step when giving cardiac medications to infants.

📌Core Message

Digoxin must be withheld when the infant’s heart rate is too low, due to risk of bradycardia and cardiac complications.

Answer 7

Correct Answers:

Immediately report the findings to the healthcare provider

Rationale :

🚨Severe testicular pain, redness, and swelling suggest testicular torsion, a surgical emergency.

🕐Immediate intervention is needed to preserve testicular viability within 6 hours of symptom onset.

📞Delaying care can lead to permanent damage or loss of the testicle.

👨‍⚕️Prompt reporting allows for urgent diagnostic imaging and surgical consultation.

⚠️This condition is not managed with routine comfort care and requires emergency evaluation.

📌Core Message

Testicular torsion signs require immediate provider notification due to the risk of tissue loss without urgent intervention.

Answer 8

Correct Answers:

Ensure no weight bearing on the affected extremity

Rationale :

🦴In the initial treatment phase of osteomyelitis, immobilization prevents spread of infection and minimizes pain.

🚫Weight-bearing could disrupt infected bone tissue and worsen inflammation.

💉Treatment usually includes IV antibiotics and immobilization until infection resolves.

📆Once stable, physical therapy and mobilization can begin gradually.

👣Avoiding stress on the limb aids in healing and infection control.

📌Core Message

Non-weight-bearing is essential during early osteomyelitis treatment to support healing and infection management.

Answer 9

Correct Answers:

Hypotension and tachycardia

Rationale :

💗Aortic stenosis impairs cardiac output, leading to compensatory tachycardia and low blood pressure.

🌬️Crackles in both lungs indicate pulmonary congestion due to left-sided heart failure.

🩺The heart works harder to perfuse organs, resulting in sympathetic nervous system activation.

🧪These symptoms reflect volume overload and impaired perfusion, hallmark features of significant stenosis.

📉This combination suggests the heart is failing to meet circulatory demands, especially during feeding or exertion.

📌Core Message

Hypotension and tachycardia in an infant with aortic stenosis reflect reduced cardiac output and left-sided heart failure.

Answer 10

Correct Answers:

1.3

Rationale :

🧮The child weighs 18 lbs, which converts to approximately 8.2 kg (18 ÷ 2.2).

📏The total daily dose is 25 mg/kg/day × 8.2 kg = 205 mg/day, divided into two doses of 102.5 mg each.

💉The concentration is 400 mg per 5 mL, or 80 mg per mL, so 102.5 ÷ 80 = 1.28 mL, rounded to 1.3 mL per dose.

⚖️Accurate weight-based dosing ensures therapeutic effectiveness and prevents underdosing or toxicity.

📌Core Message

Precise calculation using weight conversion and medication concentration ensures correct amoxicillin dosing in pediatrics.

2 :
A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?

4 :
A 10-year-old boy has been seen frequently by the school nurse over the past three weeks after school begins in the fall. He reports headaches, stomach aches, and difficulty sleeping. Which intervention should the nurse implement?

5 :
The nurse is planning care for a 16-year-old, who has juvenile idiopathic arthritis (JIA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement?

7 :
A male adolescent comes to the clinic reporting severe testicular pain that started during a high school football practice. The nurse notes significant redness and swelling of the scrotum. What should the nurse do next?

8 :
The nurse is teaching a school-age child with left femoral osteomyelitis and the child's parent before discharge. What instruction should the nurse give related to the initial phase of treatment?

9 :
The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. What additional finding should the nurse expect to observe?

2 : A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?

4 : A 10-year-old boy has been seen frequently by the school nurse over the past three weeks after school begins in the fall. He reports headaches, stomach aches, and difficulty sleeping. Which intervention should the nurse implement?

5 : The nurse is planning care for a 16-year-old, who has juvenile idiopathic arthritis (JIA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement?

7 : A male adolescent comes to the clinic reporting severe testicular pain that started during a high school football practice. The nurse notes significant redness and swelling of the scrotum. What should the nurse do next?

8 : The nurse is teaching a school-age child with left femoral osteomyelitis and the child's parent before discharge. What instruction should the nurse give related to the initial phase of treatment?

9 : The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. What additional finding should the nurse expect to observe?

2 :
A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?

4 :
A 10-year-old boy has been seen frequently by the school nurse over the past three weeks after school begins in the fall. He reports headaches, stomach aches, and difficulty sleeping. Which intervention should the nurse implement?

5 :
The nurse is planning care for a 16-year-old, who has juvenile idiopathic arthritis (JIA). The nurse includes activities to strengthen and mobilize the joints and surrounding muscle. Which physical therapy regimen should the nurse encourage the adolescent to implement?

7 :
A male adolescent comes to the clinic reporting severe testicular pain that started during a high school football practice. The nurse notes significant redness and swelling of the scrotum. What should the nurse do next?

8 :
The nurse is teaching a school-age child with left femoral osteomyelitis and the child's parent before discharge. What instruction should the nurse give related to the initial phase of treatment?

9 :
The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. What additional finding should the nurse expect to observe?