Pediatric Nursing Notes

Name:___________________________________________________________________ Date:____________ Jaime is a newborn with a bilateral cleft lip and cleft palate. 1. After the physician talks with Jaime’s mother, she seems quite composed and asks to see the baby. To assess the mother’s reaction, the nurse should: a. Bring the baby to her immediately b. Tell her exactly what the baby looks like before bringing him to her c. Encourage her to express and explore her feelings, bring the baby to her and stay with her during this time d. Show her some pictures and give her some literature on harelip and cleft palate and discuss the treatment with her before bringing the baby to her 2. Jaime’s parents are young but seem very concerned and willing to learn about his care. Which of the following would be inappropriate to include in the teaching plans for the parents? a. Remove the nipple frequently when feeding Jaime b. Encourage mother to breastfeed c. Jaime’s security needs can be met other than by sucking d. Jaime’s mental functioning should be normal 3. When Jaime is 2 ½ months old, he is hospitalized for repair of his cleft lip. Pre-operatively, which of the following nursing actions is most important for Jaime? a. Burp him frequently during feeding b. Offer him small, frequent feedings so as not to tire him c. Hold him in a low or flat position to facilitate swallowing d. Offer thickened bottle feeding to increase his intake 4. When Jaime is 13 months old, he is admitted for repair of his cleft palate. What is the best reason for the palate to be repaired at this stage? a. To give Jaime a chance to develop basic speech pattern b. To prevent damaging tooth buds A 6 year old is admitted to the hospital for heart surgery to repair Tetralogy of Fallot. The nurse observes that the child is cyanotic at admission. 5. The nurse judges that the parents understand this disorder when they explain that one of the underlying their child’s cyanosis: a. Constriction of the aorta b. Stenosis of the mitral valve c. Stenosis of the pulmonary artery d. The aorta receiving blood directly front the vena cava 6. When teaching the parents about the echocardiogram that their child will undergo, the nurse should explain that the primary reason for this procedure is to determine: a. Cardiac structure b. Pressure of the blood in the heart c. The amount of blood entering the heart d. Various sounds made by each heartbeat 7. When planning for this client before corrective heart surgery, the nurse should choose which of the following as the priority nursing diagnosis? a. Ineffective family coping b. Pain c. Knowledge deficit d. Impaired gas exchange 8. The nurse plans to teach the parents about digoxin prescribed for their child. Which of the following would the nurse tell the parents? a. Digoxin should be given with at least a full of water b. Digoxin is absorbed better when taken 1 hour before eating c. Signs of digoxin toxicity include increased heart rate and loss of appetite d. If the child vomits 30 minutes after taking medication, the dose should be repeated 9. The parents express concern that their child wants to be held more frequently than usual postoperatively. Which of the following best describes this behavioral response to stress? a. Repression b. Depression

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c. Regression d. Discomfort 10. The mother asks the nurse why her child has clubbed fingers. The nurse should explain that the clubbing is due to: a. Anemia b. Peripheral hypoxia c. Delayed physical growth d. Destruction of bone marrow Billy, 12 months old, has an elevated temperature for 48 hours. There is evidence of nuchal rigidity, increased lethargy and nausea and vomiting. He is also dehydrated. Meningitis is suspected. 11. Which of the following observations would probably alert the nurse to Billy’s dehydrated state? a. Moist mucus membranes b. Depressed anterior fontanel c. Urine specific gravity of 1.007 d. 5% weight gain 12. Billy’s physician will most likely need which of the following? a. Thoracentesis tray b. Lumbar puncture tray c. NGT d. Foley catheter 13. Billy’s doctor ordered 5% dextrose in 0.33% normal saline with 20 meq of KCl to infuse at 32 ml/hr. Which of the following should be brought to the physician’s attention? a. Billy has not voided in 4 hours b. Billy has had 3 liquid green stools c. Billy has vomited 50 ml of mucous d. Billy is fussy and irritable when moved 14. During the acute stage of Billy’s illness, which of the following nursing actions should receive the highest priority? a. Give frequent tepid sponge bath b. Perform treatment as quickly as possible c. Reduce environmental stimuli d. Monitor vital signs every 5-10 mins Teresa 7-lb, 10 oz (3,500g) baby, was just delivered vaginally in the labor and delivery area. She has Apgar scores of 8 at 1 minute and 9 at 5 minutes. She has an elongated head and circumoral cyanosis. After allowing Teresa to remain with her parents in the labor and delivery area for 1 hour, the nurse transfers her to the neonatal nursery. 15. Before conducting a routine neonatal discharge screening on Teresa for phenylketonuria, the nurse should: a. Check Teresa’s chart to ensure that her mother has signed a consent form b. Assess the financial, social, and emotional status of Teresa’s parents c. Determine if Teresa has been on formula for at least 48 hours d. Ensure that Teresa’s hemoglobin level is within the normal range 16. Which of the following is the most important concept associated with all high-risk newborns? a. Support the high-risk newborns’ cardiopulmonary adaptation by maintaining an adequate airway b. Identify complications with early intervention in the high risk newborn to reduce morbidity and mortality c. Assess the high-risk newborn for any physical complications that will assist the parents with bonding d. Support the mother and significant others in their quest toward adaptation to the high-risk newborn 17. While assessing a child with pyloric stenosis, the nurse is likely to note which of the following? a. Regurgitation b. Steatorrhea

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c. Projectile vomiting d. “Currant jelly” stools 18. Discharge teaching for a child with celiac disease would include instructions about avoiding which of the following? a. Rice b. Milk c. Wheat d. Chicken 19. Which of the following should the nurse do first after noting that a child with Hirschsprung disease has a fever and watery explosive diarrhea? a. Notify the physician immediately b. Administer antidiarrheal medications c. Monitor child every 30 minutes d. Nothing, this is characteristic of Hirshsprung disease Melanie has given birth to her fourth baby at 39 weeks gestation. The newborn has been diagnosed with a congenital diaphragmatic hernia and requires immediate surgery. 20. In assessing Melanie’s newborn, the nurse will observe which or the following? a. A sunken abdomen with prominent bowel sounds b. Improved Apgar score at 10 minutes c. Increased cardiac output d. Circumoral pallor but pink extremities 21. Melanie is concerned about her newborn’s pain after surgery. The nurse’s best response is: a. “Babies don’t feel pain; medication doesn’t need to be given after surgery.” b. “Babies don’t remember painful experiences; medication for pain may cause respiratory problems.” c. “Nonpharmacologic pain relief measures will be taken.” d. “Babies do feel pain; your baby will receive pain medication after surgery.” 22. When teaching parents about unknown antecedent infections in acute glomerulonephritis, which of the following should the nurse cover? a. Herpes simplex b. Scabies c. Varicella d. Impetigo 23. Which of the following should be avoided if the child has hypospadias? a. Circumcision b. Catheterization c. Surgery d. Intravenous pyelography 24. The primary reason for surgical repair of a myelomeningocele is to do which of the following? a. Correct the neurologic defect b. Prevent hydrocephalus c. Prevent seizure disorders d. Decrease the risk of infection 25. Signs of mild mental retardation would include which of the following? a. Lateness in walking b. Mental age of a toddler c. Noticeable developmental delays d. Few communication skills 26. Which of the following assessment findings in a term neonate would cause the nurse to notify the pediatrician? a. Absence of tears b. Unequally sized corneas c. Papillary constriction to bright light d. Red circle on pupils with ophthalmoscopic examination

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27. While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate’s urinary meatus appears to be located on the ventral surface of the penis. The physician is notified because the nurse suspects which of the following? a. Phimosis b. Hydrocele c. Epispadias d. Hypospadias 28. Which of the following would the nurse expect to assess in a child with Down’s syndrome? a. Large nose b. Small tongue c. Oblique palpebral fissures d. Low arched palate 29. Which of the following statements by a 14 year old girl who wears a brace for structural scoliosis indicates effective use of the brace? a. “I wonder if I can take the brace off when I go to the homecoming dance.” b. “I’ll look forward to taking this off to take my bath everyday.” c. “I’m sure am glad that I only have to wear this awful thing at night.” d. “I’m really glad that I can take this thing off whenever I get tired.” 30. When assessing a newborn for developmental dysplasia of the hip, the nurse would expect to assess which of the following? a. Symmetrical gluteal folds b. Trendelenburg sign c. Ortolani’s sign d. Characteristic limp 31. Which of the following is the priority nursing action for a child immediately following the application of a spica cast? a. Perform neuromuscular checks b. Elevate the cast c. Cover the perineal area d. Keep the cast clean and dry 32. Which of the following types of immunity does an infant receive when given a DPT injection? a. Natural, active b. Natural, passive c. Artificial, active d. Artificial, passive Susan, is a newborn with Down’s syndrome. Her parent’s have been told of the diagnosis and are in the process of trying to adjust to this. 33. Which of the following is most appropriate to include when counseling the parents of Susan? a. Susan’s development potential is greatest during infancy b. Susan will be severely retarded c. Susan will be spastic, so poisoning should be discussed d. Susan will be as susceptible to colds as her brother – increased susceptibility 34. Which of the following is an incorrect statement regarding Down’s syndrome? a. It is associated with higher incidence of congenital heart disease b. It is associated with higher incidence of GI defects – duodenal atresia or stenosis c. It is associated with higher incidence of leukemia d. It is inherited as an autosomal recessive trait 35. Which of the following measures is of primary importance for parents with a young, mentally retarded child at home? a. Limit the amount of environmental stimulation the child is exposed to b. Have the same parent teach the child new skills at all times c. Teach the child socially acceptable behaviors so she can join the family outings d. Maintains consistent routine for daily activities

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Magdalena is at 36 weeks gestation and has been diagnosed as positive for the human immunodeficiency virus. She has had a healthy pregnancy to date but has many questions about how her health problems will affect her newborn. 36. Magdalena asks the nurse if she can breastfeed her baby. Which of the following statements is the basis for the nurse’s response? a. Because Magdalena probably won’t live to raise this child, breastfeeding will provide closeness and bonding between mother and child. b. Because the baby is likely to be positive for the HIV, breastfeeding will provide immunity for other infections c. Because Magdalena doesn’t have symptoms of AIDS, she can breastfeed d. Because HIV may be transmitted through her breastmilk, breastfeeding isn’t recommended for Magdalena 37. Magdalena has delivered a baby girl at 39 weeks gestation. At 4 hours of age, the newborn has shallow respirations at 54 bpm with periods of apnea lasting 5 to 7 seconds. The nurse’s priority action would be to: a. Continue routine monitoring b. Notify the doctor immediately c. Request an order to administer oxygen d. Prepare equipment for a respiratory arrest 38. Magdalena’s newborn is jaundiced because of an ABO blood group incompatibility and is receiving phototherapy. Which of the following nursing interventions is most appropriate for her newborn? a. Reposition the infant every 4 hours b. Limit the infant’s oral intake to 1 oz every 4 hours c. Remove the eye patches every 24 hours to assess for conjunctivitis d. Turn the phototherapy unit off when drawing blood for bilirubin levels 39. Before discharging Magdalena’s newborn on the 2nd day of life, the nurse completes her discharge examination. Which of the following findings would the nurse report to the doctor? a. A. black, dry umbilical cord b. A dark greenish-black stool c. Petechiae covering the chest and abdomen d. Bluish purple discoloration in the lumbosacral area Carlo, age 8, comes in to the physician’s clinic with a sore throat, enlarged lymph nodes, elevated temperature and malaise. He has history of frequent streptococcal throat infection. 40. Carlo has bacterial pharyngitis and is put on a regimen of oral penicillin, which of the following instructions of Carlo’s parents is most important at this time? a. Have him gargle with hot saline solution as needed b. Give Carlo the medicine for 10 days or until it is consumed c. Feed him soft diet until he feels better d. Ensure he gets a lot of Vit C foods 41. Carlo returns in 2 months for a tonsillectomy. Preparations for hospitalization include books for him to read. His mother is advised to select a book with which of the following characteristics? a. Small, paperback b. Large-size print c. Regular size print d. Large, with stiffened pages 42. After surgery, what assessment data may indicate that Carlo is hemorrhaging? a. Tachycardia, hypertension, hemoptysis b. Bradycardia, hypotension, increase swallowing c. Tachycardia, hypotension, increase swallowing d. Tachycardia, hypotension, decreased swallowing 43. Carlo’s nurse prepares the family for his discharge. Which of the following instructions should be emphasized? a. Return to school in 1-2 weeks b. No vigorous activities for 3-4 weeks c. Saline gargles as necessary for control d. Delayed hemorrhage may occur on the third post-op day

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10-year-old Tanya is admitted to the hospital with a medical diagnosis of rheumatic fever. She relates a history of sore throat about a month ago. She is placed on a bed rest with BRP’s. 44. Which of the following nursing assessment would be given the highest priority when assessing Tanya? a. Her response of being hospitalized b. The presence of a macular rash on her trunk c. Her sleeping or resting apical pulse d. The presence of polyarthritis and pain in her joints 45. Tanya exhibits manifestation of Sydanham’s chorea. Which of the following is NOT a manifestation of this condition? a. Intellectual impairment b. Muscle weakness c. Purposeless tremors d. Emotional lability 46. Which of the following nursing plans should receive the highest priority during Tanya’s hospitalization? a. Minimize cardiac damage by keeping Tanya on bed rest b. Relieve pain by administering prescribed analgesic c. Help Tanya cope with hospitalization by providing age-appropriate activities d. Prevent injury by padding the bed side rails 47. Which activity is most appropriate for Tanya during the acute phase of her illness? a. Playing basketball b. Visiting other children in the unit c. Keeping a written diary d. Listening to the records of her favorite groups 48. Three of the following lab results are crucial indicators of Tanya’s progress. Which one does not? a. Antistreptolysin “O” titer b. C-reactive protein c. Protein in the urine d. Erythrocyte sedimentation rate 49. Tanya is discharged after 3 weeks of hospitalization. Which of the following statements best indicates that Tanya’s parents have understood the discharge teaching? a. “Tanya should lead a sedentary lifestyle for at least a year.” b. “Tanya must take daily antibiotics for an extended period of time to prevent recurrence of rheumatic fever.” c. “Tanya should not return to her fifth-grade classroom but should have a home teacher the rest of the year.” d. “Tanya may have permanent neurologic sequela as a result of the Sydenham’s chorea.” 14-year-old Borat has hemophilia. He is seen at the clinic for a periodic check-up. 50. When obtaining a history from Borat, which of the following reported manifestations would be the greatest cause for concern? a. Epistaxis b. Pallor c. Easy bruising d. Hemarthrosis 51. His father tells the nurse that Borat loves football so much. He wants to try out for his junior high football team. His parents are having a hard time telling him that it is impossible. Which of the following alternatives is the best suggestion for Borat? a. Allow him to try out for the team as long as he wears a helmet and elbow and knee pads all the time b. Start a collection of football memorabilia c. Develop an interest in swimming or table tennis instead d. Try to become equipment manager for his junior high team

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52. Borat is admitted to the hospital with an acute bleeding episode in his right elbow, which cannot be controlled at home. Which of the following will not be use to control bleeding? a. Plasma b. Plasma concentrate c. Packed cells d. Cryoprecipitate 53. Borat is recovering and will be discharged tomorrow. His father expresses concern about his failure as a family man. The nurse ascertains that Borat’s father is anxious to know if Borat can have children who do not have hemophilia. Assuming that Borat’s future spouse is not a carrier, which explanation is most accurate? a. All his children will be carriers b. His son will have the disease and his children daughters will be carriers c. There is a 50% chance that each of his children will have hemophilia d. His sons will be normal and his daughters will be carriers 54. Which of the following is the best indicator of a successful outcome of Borat’s long-term treatment? a. Bleeding episodes are prevented or treated early to minimize sequelae b. Borat is able to cope with his peers academically c. Borat’s weight is maintained within age appropriate ranges d. Borat chooses a realistic career goal 9-month-old Torio has been admitted in the pediatric unit with vomiting, colicky abdominal pain, and abdominal distention. A tentative diagnosis of intussuception is made. 55. When assessing Torio, which type of stool indicates a worsening of Torio’s condition? a. Fatty, bulky, foul-smelling b. Dark, red, jelly-like c. Ribbon-like dark green d. Clay colored 56. Torio is not likely to exhibit which of the following behaviors? a. Loud crying when his parents leave him b. Fear of strangers c. Searching for hidden objects d. Saying at least 3 words besides “dada” and “mama” 57. Torio is scheduled for surgery. His parents are anxious and ask what will be done in surgery. Which explanations should be given? a. The sigmoid colon will be resected with pull-through anastomosis b. The obstruction will be corrected by manual reduction c. The affected portion of the intestines will be resected with permanent colostomy created d. The ileum will be resected and a permanent ileostomy created 58. Torio’s parents ask what is wrong with his intestines. Which of the following statements best describe Torio’s condition? a. A telescoping of one part of the bowel into a more distal part b. Malrotation of the intestines c. Atresia of the intestinal tract d. Absence of parasympathetic ganglion cells 59. Preoperatively, the priority-nursing goal for Torio is to: a. Maintain Torio’s attachment to his parents b. Meet Torio’s need for sucking and comfort while he is NPO c. Maintain adequate hydration d. Promote adequate rest and sleep 60. Following surgery, Torio returns to the unit. He is fussy and seems to be in discomfort. The nurse palpates his abdomen and notes some distention. Which action should be implemented first? a. Call the surgeon to report this observation b. Insert a rectal tube c. Sit Torio upright and pat his back d. Check the NGT for patency

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61. What is the potential greatest threat to Torio’s continued development while he is hospitalized? a. Developing mistrust towards the nursing staff b. Separation from his parents c. Restricted mobility d. Disruption in his sleeping and eating routines

Angel, 4 years old, is brought to the clinic with a high fever. She has been irritable for several days and is clinging to 2 dolls and her mother says she refuses to eat. While performing an initial assessment, the nurse makes several observations that may indicate that Angel is a victim of child abuse. 62. Children are most frequently abused by: a. Babysitter b. Relative c. Teacher d. Casual acquaintances 63. The child least likely at risk for being abused is one whose family: a. Moves frequently b. Owns their own home c. Has experience divorce d. Has problems with chronic illness 64. Which test is least likely to indicate that Angel has been sexually abused? a. A Pap smear b. Urine culture c. Throat culture d. Vaginal culture 65. When interviewing a child suspected of being sexually abused, the nurse should: a. Ask leading questions b. Have the parents consent c. Have a security guard present d. Use the child’s words to describe body parts 66. Children who survive physical abuse are least likely to become: a. Depressed b. Drug abusers c. Abusive parents d. Academic achievers 67. Playing with her dolls while in the examination room, Angel was seen engaging in explicit sexual behavior. The nurse should know that: a. Angel is mimicking behavior seen on TV b. Angel is acting out a personal experience c. Such play is a healthy expression of sexual development d. Angel needs to be directed to a more appropriate play 68. When abuse is suspected, the least appropriate nursing action is to: a. Take a wait-and-see position b. Call a local social service agency for help c. Prevent the child’s return to a dangerous environment d. Confront the parent with security present 69. The nurse is planning nursing interventions for parents who abuse their children. It is important for the recall that these parents: a. Plans ahead as to when and how to abuse their children b. Ask for help generally only after feeling overwhelmed with the problem c. Usually feel no guilt concerning the abuse d. Are always a product of child abuse environment 70. When planning a client education program for sickle cell disease, the nurse should include which of the following topics? a. Proper handwashing and infection avoidance b. A high-iron, high-protein diet

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c. Fluid restriction to 1 liter per day d. Aerobic exercises to increase oxygenation

71. Which of the following is the most common form of childhood cancer? a. Lymphoma b. Brain tumors c. Leukemia d. Osteosarcoma 72. The nurse would prepare the parents of a child with suspected leukemia for which of the following tests that would confirm this diagnosis? a. Maternal drug use b. Bone marrow aspiration c. Complete blood count d. Blood culture 73. The nurse is caring for a neonate with erythroblastosis fetalis. The nurse knows that this disease results from: a. Maternal drug use b. Prematurity c. Destruction of red blood cells d. Gestational diabetes 74. Rh incompatibility results when: a. The neonate’s blood group is Rh-positive and the mother’s is Rh-positive b. The neonate’s blood group is Rh-negative and the mother’s is Rh-negative c. The neonate’s blood group is Rh-positive and the mother’s is Rh-positive d. The neonate’s blood group is Rh-negative and the mother’s is Rh-negative 75. When administering an antipyretic to a child, the nurse knows that aspirin is contraindicated for children with viral infections because of the possibility of developing which of the following: a. Reye’s syndrome b. Reflux syndrome c. Raynaud’s disease d. Reiter’s syndrome 76. Which of the following tests is most helpful in diagnosing hemophilia? a. Bleeding time b. Partial prothromboplastin time c. Platelet count d. Complete blood count 77. The nurse explains to the mother of a neonate diagnosed with erthroblastosis fetalis that the exchange transfusion is necessary to prevent damage primarily to which of the following organs in the neonate? a. Kidneys b. Brain c. Lungs d. Liver 78. A parent asks the nurse about head lice infestation during a visit to the clinic. Which of the following symptoms would the nurse tell the parent is most common in a child infected with head lice? a. Itching of the scalp b. Scaling of the scalp c. Serous weeping on the scalp surface d. Pinpoint hemorrhagic spots on the scalp surface 79. In a child with asthma, B-adrenergic agonist agents, such as albuterol, are administered primarily to do which of the following? a. Decrease postnasal drip b. Dilate bronchioles

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c. Reduce airway inflammation d. Reduce secondary infections

80. Which of the following statements by the family of a child with asthma indicates a need for additional home care teaching? a. “We need to identify what things trigger these attacks.” b. “He is to use his bronchodilator inhaler before the steroid inhaler.” c. “We’ll make sure that he avoids exercise to prevent attacks.” d. “He should increase his fluid intake regularly to thin mucous secretions.” 81. When developing a plan of care for the child diagnosed with cystic fibrosis (CF), which of the following must the nurse keep in mind? a. CF is an autosomal dominant hereditary disorder b. Pulmonary secretions are abnormally thick c. Obstruction of the endocrine glands occurs d. Elevated levels of potassium are found in the sweat 82. In children with sickle cell disease, tissue damage results from which of the following? a. A general inflammatory response due to an auto immune reaction to hypoxia b. Air hunger and respiratory alkalosis due to deoxygenated red blood cells c. Local tissue damage with ischemia and necrosis due to obstructed circulation d. Hypersensitivity of the central nervous system due to elevated serum bilirubin 83. Which of the following would the nurse include in the plan of care for a child with juvenile rheumatoid arthritis? a. Administration of corticosteroids to decrease joint damage b. Prevention of contractures by keeping extremities in a flexed position c. Vigorous range of motion exercises with affected joints d. Application of heat to minimize pain and stiffness 84. Which of the following disorders leads to cyanosis from deoxygenated blood entering the systemic arterial circulation? a. Patent ductus arteriosus b. Tetralogy of Fallot c. Coarctation of the aorta d. Aortic stenosis 85. While assessing a child with coarctation of the aorta, the nurse would expect to fine which of the following? a. Absent or diminished femoral pulse b. Tet spells c. Squatting position d. Severe cyanosis at birth 86. Which of the following nursing interventions would be appropriate to promote optimal nutrition in an infant with congestive heart failure? a. Offering formula that is high in sodium and calories b. Providing large feedings evenly spaced every 4 hours c. Replacing regular nipples with easy-to-suck ones d. Allowing the infant to feed for at least 1 hour 87. When developing a teaching plan for the parents of a child with pulmonic stenosis, the nurse would keep in mind that this disorder involves which of the following? a. Return of blood to the heart entry into the left atrium b. Obstruction of blood flow from the right ventricle c. Obstruction of blood from the left ventricle d. A single vessel arising from both ventricles 88. Which of the following symptoms would the nurse expect to observe in a newborn diagnosed with respiratory distress syndrome? a. Inspiratory grunting b. Expiratory grunting c. Inspiratory stridor

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d. Expiratory wheezing

89. Which of the following respiratory conditions is always considered a medical emergency? a. Laryngotracheobronchitis (LTB) b. Epiglottitis c. Asthma d. Cystic fibrosis 90. The nurse is careful to cover the eyes and genitals of a newborn undergoing phototherapy. Covering the eyes prevents retinal damage; whereas covering the genitals prevents: a. Priapism b. Testicular ulceration c. Scrotal damage d. Prostate gland damage 91. Which nursing action is also necessary while a newborn is undergoing phototherapy? a. Turning him frequently b. Reducing his fluid intake c. Checking his urine glucose level d. Decreasing environmental stimuli 92. Which assessment finding indicates that phototherapy has been effective for a newborn? a. Erythema of the body surface exposed to the light b. Bronze baby syndrome c. Increased conjugated bilirubin levels d. Elimination of green urine and greenish, loose stools 93. Which condition results from deposits of bilirubin in the neonate’s brain, especially in the brain stem and basal ganglia? a. Keratosis b. Kernicterus c. Athetosis d. Hydrops fetalis 94. A nurse prepares to administer digoxin (Lanoxin) to a 3-year-old child with a diagnosis of congestive heart failure. The nurse notes that the apical rate is 110 beats per minute. Based on this finding, which nursing action is most appropriate? a. Administer the digoxin b. Recheck the apical rate in 15 minutes c. Notify the physician d. Hold the medication 95. A nurse is performing an admission assessment on a 6-month-old infant with a diagnosis of hydrocephalus. The nurse assesses for the major sign associated with hydrocephalus when the nurse: a. Tests the urine for protein b. Takes the apical pulse c. Palpates the anterior fontanel d. Takes the blood pressure 96. A nurse has provided discharge instructions to the parents of an infant who had a ventriculoperitoneal shunt procedure performed for the treatment of hydrocephalus. Which statement if made by the parents indicates an accurate understanding of the presence of a shunt complication? a. “If my infant has a high-pitched cry, I should call the doctor.’ b. I should position my infant on the side with the shunt when sleeping.” c. “My infant will pass urine more often now that the shunt is in place.” d. “I should call my doctor if my infant refuses baby food.” 97. A nurse is performing an admission assessment on a newborn infant with a diagnosis of spina bifida (meningomyelocele). The nurse assesses for a major symptom associated with this type of spina bifida when the nurse: a. Checks the capillary refill of the nail beds of the upper extremities

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b. Tests the urine for blood c. Palpates the abdomen for masses d. Checks for responses to painful stimuli on the lower extremities 98. A nurse is caring for a newborn infant with spina bifida (meningomyelocele) who is scheduled for surgical closure of the sac. In the preoperative period the priority nursing action would be to monitor the: a. Blood pressure b. Moisture of the normal saline dressing covering the sac c. Specific gravity of the urine d. Anterior fontanel for depression 99. Later on the day, the nurse notices that Baby boy Lopez appears jaundiced. The latest laboratory results indicate the he has a serum bilirubin level of 12 mg/dl. The physician prescribes phototherapy. Considering the mother has type B positive blood, Baby boy Lopez’s condition probably is the result of: a. Rh incompatibility b. ABO incompatibility c. Impaired bilirubin conjugation d. Excessive fetal hemoglobin 100. Which of the following represents an effective nursing intervention to reduce cardiac demands and decrease cardiac workload? a. Scheduling care to provide for uninterrupted rest periods b. Developing and implementing a consistent plan of care c. Feeding the infant over long periods of time d. Allowing the infant to have her way to avoid conflict

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