Question

During her sports physical examination, 15-year-old female requests oral contraceptives. She explains that she is sexually active and does not want her parents to know. Which action should the nurse take?

Answer 1

Correct Answers:

Counsel the client about the risks and benefits of using oral contraceptives.

Rationale :

🥼Nurses have a duty to provide confidential, developmentally appropriate education to adolescents seeking reproductive care.

📘In many jurisdictions, adolescents have the legal right to receive contraceptive services without parental consent.

🗣️By counseling the client on risks and benefits, the nurse respects the adolescent’s autonomy and right to informed choice.

📋This response supports evidence-based nursing practice in adolescent sexual health while preserving confidentiality.

💡It ensures the client is empowered with accurate, comprehensive information to make responsible health decisions.

📌Core Message

Nurses must provide confidential, informative counseling to adolescents requesting contraceptives.

Answer 2

Correct Answers:

The child reports no evidence of continuous headaches.

Rationale :

🧠Headaches are a classic sign of increased intracranial pressure, often signaling shunt malfunction in hydrocephalus.

😊The absence of headaches postoperatively suggests the ventriculoperitoneal shunt is draining cerebrospinal fluid effectively.

🩺While normal vitals are good, they don’t specifically confirm shunt functionality related to brain pressure regulation.

📉Monitoring for neurological symptoms like headache is a direct indicator of cerebral pressure normalization.

💬Children who can communicate symptom relief help validate the success of neurosurgical intervention.

📌Core Message

Absence of headaches post-VP shunt indicates effective pressure reduction and normal function.

Answer 3

Correct Answers:

The TSH is high because of the low production of T4 by the thyroid.

Rationale :

🔁In congenital hypothyroidism, the thyroid fails to produce adequate T4, leading to feedback-driven elevation of TSH.

📊This hormonal imbalance reflects the hypothalamic-pituitary-thyroid axis compensating for low thyroxine levels.

🧬TSH increases in an attempt to stimulate the underperforming thyroid gland, which is characteristic of primary hypothyroidism.

👶Early detection of this imbalance is critical in infants to prevent developmental delays and cognitive impairment.

📋This finding is consistent with a typical pattern of primary congenital hypothyroidism requiring prompt treatment.

📌Core Message

High TSH and low T4 in infants indicates primary hypothyroidism due to underactive thyroid function.

Answer 4

Correct Answers:

Give the mother positive feedback about the way she administered the medication.

Rationale :

🍊Iron absorption is enhanced by vitamin C, and pairing ferrous sulfate with orange juice is an ideal method.

💉Administering the iron separately and then following with juice is an effective strategy for pediatric compliance and absorption.

👍Positive reinforcement promotes continued adherence to proper medication practices.

🧒This approach also avoids mixing iron directly into liquids, which can affect taste or cause staining.

📚Reinforcing correct technique encourages long-term success in iron supplementation.

📌Core Message

Giving iron with orange juice is best practice and should be positively reinforced by the nurse.

Answer 5

Correct Answers:

Hypotension and tachycardia.

Rationale :

💓Aortic stenosis can cause left ventricular outflow obstruction, leading to reduced cardiac output.

💁‍♂️The presence of bilateral crackles signals pulmonary congestion, a result of left-sided heart failure.

📉This hemodynamic compromise often leads to hypotension and compensatory tachycardia in infants.

🩺These signs reflect the heart’s inability to meet systemic demands, which is critical in early heart disease detection.

🔍Identifying these systemic effects aids in timely management of compensated or decompensated heart failure.

📌Core Message

In aortic stenosis, hypotension and tachycardia signal reduced cardiac output and heart failure.

Answer 6

Correct Answers:

1.8

Rationale :

📐Dosage calculation: 0.3 mg/kg × 30 kg = 9 mg required.

💉With a concentration of 5 mg/mL, use formula: 9 ÷ 5 = 1.8 mL.

✅Administering the correct dose ensures effective seizure control without risk of overdose.

📊Precision is vital in pediatric medication, especially for high-risk drugs like diazepam.

⚠️Always confirm weight-based dosing with double-check protocols for safety.

📌Core Message

Pediatric dosing requires accurate calculations based on weight and drug concentration.

Answer 7

Correct Answers:

New onset bedwetting.

Rationale :

💧Enuresis (bedwetting) in a previously continent child may indicate a urinary tract infection (UTI).

🚽Infection may lead to bladder irritation or incomplete voiding, triggering urinary accidents during sleep.

🧒In preschoolers, this sign often appears before classic dysuria or urgency is verbalized.

🩺Recognizing behavioral changes in toileting is key in early pediatric UTI detection.

📋This symptom supports the existing flank pain and fever, further pointing toward lower or upper UTI.

📌Core Message

New-onset bedwetting in children may signal a UTI, especially with systemic signs.

Answer 8

Correct Answers:

Offer a pacifier for non-nutritive sucking.

Rationale :

👶Non-nutritive sucking supports oral-motor development and provides comfort during feeding restrictions.

💁‍♂️This action mimics normal feeding behavior, helping maintain neurodevelopmental milestones in infants on parenteral nutrition.

💤It also promotes soothing and bonding, which are critical for psychosocial development in hospitalized infants.

🎯Integrating developmental care even during complex medical recovery ensures holistic pediatric nursing practice.

📋It prepares the infant for future oral feeding and supports normal sensory-motor patterns.

📌Core Message

Non-nutritive sucking helps maintain oral-motor and emotional development in medically complex infants.

Answer 9

Correct Answers:

Select a site that is least restrictive to the infant.

Rationale :

🩹Peripheral IV insertion in infants should aim for comfort, safety, and minimal interference with movement.

🦶Using a least restrictive site preserves developmental mobility and reduces distress.

👀IV sites should be visible and accessible but not impair gross motor activity, like kicking or grasping.

👶This approach ensures safe infusion delivery while allowing normal exploration and self-soothing.

🧸Nurses must balance technical access with age-appropriate freedom and comfort.

📌Core Message

IV sites in infants should be least restrictive to promote comfort and natural movement.

Answer 10

Correct Answers:

Osteosarcoma

Rationale :

🦴Osteosarcoma commonly affects adolescents during growth spurts, especially near long bones like the femur.

🌙Night pain and localized swelling without trauma are classic red flags of malignant bone tumors.

📸Imaging revealing radial ossification in soft tissue strongly suggests a malignant bone lesion, not growing pains.

🔬This presentation necessitates urgent referral for biopsy, staging, and oncology consultation.

🧑‍⚕️Early recognition is critical for managing aggressive pediatric cancers like osteosarcoma.

📌Core Message

In adolescents, localized bone pain with imaging abnormalities indicates possible osteosarcoma.

HESI RN Pediatric N158

No.

1 :
During her sports physical examination, 15-year-old female requests oral contraceptives. She explains that she is sexually active and does not want her parents to know. Which action should the nurse take?

2 :
The nurse is monitoring a child with hydrocephalus who received a repeat ventriculoperitoneal (VP) shunt yesterday. Which assessment finding indicates to the nurse that the shunt is functioning normally?

3 :
A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). Which is the best explanation for this finding?

4 :
The nurse observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces (60 mL) of orange juice. What should the nurse do next?

5 :
The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. Which additional finding should the nurse expect to obtain?

7 :
The nurse is assessing a preschool-aged child who presents with flank pain, dysuria, and low-grade fever. To determine a possible urinary tract infection, which additional information should the nurse gather from the parent?

9 :
When starting a peripheral intravenous (IV) infusion on an infant, which intervention should the nurse implement?

HESI RN Pediatric N158

No.

1 : During her sports physical examination, 15-year-old female requests oral contraceptives. She explains that she is sexually active and does not want her parents to know. Which action should the nurse take?

2 : The nurse is monitoring a child with hydrocephalus who received a repeat ventriculoperitoneal (VP) shunt yesterday. Which assessment finding indicates to the nurse that the shunt is functioning normally?

3 : A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). Which is the best explanation for this finding?

4 : The nurse observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces (60 mL) of orange juice. What should the nurse do next?

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

7 : The nurse is assessing a preschool-aged child who presents with flank pain, dysuria, and low-grade fever. To determine a possible urinary tract infection, which additional information should the nurse gather from the parent?

9 : When starting a peripheral intravenous (IV) infusion on an infant, which intervention should the nurse implement?

1 :
During her sports physical examination, 15-year-old female requests oral contraceptives. She explains that she is sexually active and does not want her parents to know. Which action should the nurse take?

2 :
The nurse is monitoring a child with hydrocephalus who received a repeat ventriculoperitoneal (VP) shunt yesterday. Which assessment finding indicates to the nurse that the shunt is functioning normally?

3 :
A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid stimulating hormone (TSH). Which is the best explanation for this finding?

4 :
The nurse observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces (60 mL) of orange juice. What should the nurse do next?

5 :
The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. Which additional finding should the nurse expect to obtain?

7 :
The nurse is assessing a preschool-aged child who presents with flank pain, dysuria, and low-grade fever. To determine a possible urinary tract infection, which additional information should the nurse gather from the parent?

9 :
When starting a peripheral intravenous (IV) infusion on an infant, which intervention should the nurse implement?