PEDIATRIC NURSING

1. The nurse is testing reflexes in a four-month-old infant as part of the neurologic assessment. Which of the following findings would indicate an abnormal reflex pattern and an area of concern in a four-month-old infant?

		A		Closes hand tightly when palm is touched.
		B		Begins strong sucking movements when mouth area is stimulated.
		C		Hyperextends toes in response to stroking sole of foot upward.
		D		Does not extend and abduct extremities in response to loud noise.

Answer Rationale

A.	The palmar grasp is present at birth. The palmar grasp lessens by age three months and is no longer reflexive. The infant is able to close hand voluntarily.
B.	The sucking reflex is present at birth and persists throughout infancy, even with and without stimulation, such as seen during sleep.
C.	The Babinski reflex is present at birth. The Babinski reflex disappears after one year of age.
D.	The startle or Moro reflex is present at birth. This reflex is strongest during the first two months of life and disappears after three to four months of age.

2. The mother of a three-month-old infant asks the nurse when she can start feeding her baby solid food. Which of the following should the nurse include in teaching this mother about the nutritional needs of infants?

		A		Infant cereal can be introduced by spoon when the extrusion reflex fades.
		B		Solid foods should be given as soon as the infant's first tooth erupts.
		C		Pureed food can be offered when the infant has tripled his birth weight.
		D		Infant formula or breast milk provides adequate nutrients for the first year.

Answer Rationale

A.	Infant cereal is generally introduced first because of its high iron content. The infant is able to accept spoon feeding at around four to five months when the tongue thrust or extrusion reflex fades.
B.	Solid food can be offered even if the baby does not have any teeth. The first primary teeth usually erupt at approximately six to eight months.
C.	The infant usually triples his birth weight by the age of one year. The infant is capable of eating solid foods before this time. Doubling of birth weight is one of the readiness indicators to begin solid foods.
D.	Breast milk or commercial iron-fortified formula is recommended for the first year of life. Whole milk should not be introduced to infants until after one year of age. Solid foods should be offered to assist the infant in coordination and motor development and as well as essential nutrients.

3. The nurse is assessing a six-month-old infant during a well child visit. The nurse makes all of the following observations. Which of the following assessments made by the nurse is an area of concern indicating a need for further evaluation? 

		A		Absence of Moro reflex.
		B		Closed posterior fontanel.
		C		Three pound weight gain in two months.
		D		Moderate head lag when pulled to sitting position.

Answer Rationale A. The Moro reflex is present at birth. The Moro reflex is strongest during the first two months of life and disappears after three to four months. B. The posterior fontanel is closed by two months of age. C. The infant gains 1½-2 pounds per month for the first five months of life. A three pound weight gain in the last two months is a normal weight gain. D. By four to six months, head control is well established. There should be no head lag when infant is pulled to a sitting position by the age of six months.

4. The nurse is giving anticipatory guidance regarding safety and injury prevention to the parents of an 18-month-old toddler. Which of the following actions by the parents indicates understanding of the safety needs of a toddler?

			A	Supervise the child in outdoor, fenced play areas.
			B	Teach the child swimming and water safety.
			C	Use automobile booster seat with lap belt.
			D	Allow child to cross the street with four-year-old sibling.

Answer Rationale

A.	The child has great curiosity and has the mobility to explore. Toddlers need to be supervised in play areas. Play areas with soft ground cover and safe equipment need to be selected.
B.	Swimming and water safety lessons are possible at this age; however, they are not a substitute for protection. The toddler is helpless in water and unaware of danger.
C.	Boosters are not restraint systems like the convertible devices because they depend on the vehicle belts to hold the child and booster in place. The rule of four serves as a guide: if the child weighs 40 pounds or is 40 inches or is four years old, then the child restraint can be replaced by the car's regular restraint system.
D.	The four-year-old child does not have the cognitive ability to keep himself safe or to protect the 18-month-old child. These children are often unable to recognize danger.

5. The parents of an eight-year-old child bring the child into the clinic for a school physical. The nurse makes all of the following assessments. Which assessment finding is an area of concern and needs further investigation?

		A		Complains of a stomach ache on test days at school.
		B			Has many evening rituals and resists going to bed at night.
		C			Refers to self as being too dumb and too small during the exam.
		D			Has lost three deciduous teeth and has the central and lateral incisors.

Answer Rationale

A.	The school-age child often experiences stress related to school in physical complaints. The school-age child is afraid of getting poor grades and afraid of failing.
B.	Bedtime resistance is a common characteristic during the middle school-age years. For some children it is related to normal fears of their age. These children use delay tactics to avoid going to bed.
C.	The school-age years are very important in the development of a healthy self-esteem. These statements by the eight-year-old child indicate a risk for development of a sense of inferiority and need further assessment.
D.	This is a normal pattern of permanent teeth eruption. Eruption of permanent teeth begins at approximately six years of age. The eruption of the secondary teeth follow the same order as the primary teeth and follow shedding of the deciduous teeth.

6. The nurse is performing a neurologic assessment on an eight-year-old child. As part of this neurologic assessment the nurse is assessing how the child thinks. Which of the following abilities best illustrates that the child is developing concrete operational thought?

		A		Able to make change from a dollar bill.
		B		Describes a ball as both red and round.
		C		Tells time in terms of after breakfast and before lunch.
		D		Able to substitute letters for numbers in simple problems.

Answer Rationale

A.	This ability illustrates the concept of conservation, which is one of the major cognitive tasks of school-age children.
B.	The ability to understand two characteristics of an object is attained during the preschool period and is an example of preoperational thought.
D.	This is an example of egocentric thought. The child understands time in terms of how it relates to himself. Egocentrism is a characteristic of the preschool child.
E.	This is an example of formal operations or abstract thinking in using letters to represent numbers as used in the math concepts of algebra. School-age children can serialize and use combinational skills to manipulate numbers and to learn the skills of addition, subtraction, multiplication, and division.

7. A two-month-old infant is in the clinic for a well baby visit. Which of the following immunizations can the nurse expect to administer?

	A			TD, Varicella, IPV.
	B			DTaP, Pneumovax.
	C			DTaP, MMR, Menomune.
	D			DTaP, Hib, OPV, HBV.

Answer Rationale

A.	The tetanus, diphtheria is given between the ages of 14-16 years, the varicella or chickenpox has no current recommendation by CDC, and inactivated poliovirus vaccine (IPV) is given for immunocompromised children.
B.	The DTP is given; however, the pneumovax is given to children two years and older who have sickle cell disease, asplenia, nephrotic syndrome, HIV infection, and Hodgkin's disease before beginning cytoreduction therapy.
C.	The diphtheria, tetanus, and acellular pertussis is given as the third dose of the DTP. The MMR is given after the infant's first birthday. The Menomune is recommended for children two years and older with terminal complement deficiencies and anatomic or functional asplenia.
D.	Helthy infants at two months of age receive diphtheria, tetanus and pertussis (DTP); hemophilus influenza (Hib); oral polio vaccine (OPV); and hepatitis B virus (HBV).

8. The nurse is discussing the risk of sudden infant death syndrome (SIDS) in infants with the parents whose second baby died of SIDS six months ago. The parents express fear that other children will die from SIDS since they have already had one baby die. Which of the following statements made by the parents indicate their understanding of the relationship of future children and the risk of SIDS?

	A			"Any new baby will be on home monitoring for one year to prevent SIDS.''
	B			"There is a 99% chance that we will not have another baby die of SIDS.''
	C			"Genetic testing is available to determine the likelihood of another baby dying from SIDS.''
	D			"There is medicine that can be used to stimulate the heart rate while the baby is sleeping.''

Answer Rationale

A.	Home monitoring is not recommended for subsequent siblings. Home infant monitoring does not prevent SIDS.
B.	Whether subsequent siblings of the SIDS infant are at risk is unclear. Even if the increased risk is correct, families have a 99% chance that their subsequent child will not die of SIDS.
C.	No genetic link has been identified as a causative risk factor in SIDS.
D.	Theophylline is used in neonatal apnea as a cardiac stimulant to reduce bradycardiac events. There is no medication to prevent or reduce the risk of SIDS.

9. A ten-day-old baby is admitted with 5% dehydration. The nurse notes which of the following signs?

		A		Tachycardia.
		B		Bradycardia.
		C		Hypothermia.
		D		Hyperthermia.

Answer Rationale

A.	Tachycardia is associated with dehydration.
B.	Bradycardia is not noted until the patient is greater than 25% dehydrated.
C.	Hypothermia is not associated with dehydration.
D.	Hyperthermia is not always associated with dehydration.

1O. The nurse is asked why infants are more prone to fluid imbalances than adults. The response is

		A		adults have a greater body surface area.
		B		adults have a greater metabolic rate.
		C		infants have functionally immature kidneys.
		D		infants ingest a lesser amount of fluid per kilogram.

Answer Rationale

A.	Infants have a greater BSA that allows larger quantities of fluid to be lost through the skin.
B.	Infants have a greater metabolic rate related to their larger BSA.
C.	Infant kidneys are unable to concentrate or dilute urine, to conserve or secrete sodium, or to acidify urine.
D.	Infants excrete a greater amount of fluid per kilogram of body weight than do older children or adults.

11. The community health nurse is making a newborn follow-up home visit. During the visit the two-year-old sibling has a temper tantrum. The parent asks the nurse for guidance in dealing with the toddler's temper tantrums. Which of the following is the most appropriate nursing action?

	A			Help the child understand the rules.
	B			Leave the child alone in his bedroom.
	C			Suggest that the parent ignore the child's behavior.
	D			Explain that the toddler is jealous of the new baby.

Answer Rationale

A.	Reasoning is an ineffective discipline technique to use for toddlers related to their limited cognitive ability.
B.	Using the bedroom as a punishment should be avoided. The bedroom is often a stimulating environment. The bedroom should be a safe and secure place.
C.	The best approach toward extinguishing attention-seeking behavior is to ignore it as long as the behavior is not inflicting injury.
D.	The toddler may be jealous of the new baby; however, the parent is asking for guidance in dealing with the temper tantrum at this time.

12. The parent of a three-year-old child brings the child to the clinic for a well child checkup. The history and assessment reveals the following findings. Which of these assessment findings made by the nurse is an area of concern and requires further investigation?

	A			Unable to ride a tricycle.
	B			Has ability to hop on one foot.
	C			Uses gestures to indicate wants.
	D			Weight gain of four pounds in last year.

Answer Rationale

A.	While a child of three years of age is expected to have the gross motor ability to ride a tricycle, this finding would not be an area of concern and need for referral or further investigation.
B.	The child is expected to have the gross motor ability to hop on one foot by the age of four years. This ability is still considered normal.
C.	This behavior indicates a delay in language and speech development. The child may not be able to hear. The child should have a vocabulary of about 900 words and use complete sentences of three to four words.
D.	Usual weight gain at the age of three years is four to six pounds per year. A four pound weight gain in one year is normal.

13. The parents of a four-year-old child tell the nurse that the child has an invisible friend named "Felix.'' The child blames "Felix'' for any misbehavior and is often heard scolding "Felix,'' calling him a "bad boy.'' The nurse understands that the best interpretation of this behavior is which of the following?

	A			A delay in moral development.
	B			Impaired parent-child relationship.
	C			A way for the child to assume control.
	D			Inconsistent parental discipline strategies.

Answer Rationale

A.	This is expected moral development for this age group. In the punishment and obedience orientation (ages two to four), children judge an action as good or bad depending on rewards or punishment.
B.	There are no data to support that there is an alteration in the parent-child relationship. The active imagination of the preschool child support the appearance of imaginary friends.
C.	Imaginary friends are a normal part of development for many preschool children. These imaginary friends often have many faults. The child plays the role of the parent with the imaginary friend. This becomes a way of assuming control and authority in a safe situation.
D.	There are no data to support that the parents are inconsistent in discipline strategies or have unrealistic behavioral expectations of this four-year-old child.

14. The nurse is caring for a five-year-old child who is in the terminal stages of acute leukemia. The child refuses to go to sleep and is afraid that his parents will leave. The nurse recognizes that the child suspects he is dying and is afraid. Which of the following questions about death is most likely to be made by a five-year-old child?

	A			"What does it feel like when you die?''
	B			"Who will take care of me when I die?''
	C			"What will my friends do when I die?''
	D			"Why do children die if they're not old?''

Answer Rationale

A.	This is an expected response of a school-age child who wants to know concretely what it feels like to experience death. School-age children often ask if it hurts when you die.
B.	The greatest fear of preschool children is being left alone and abandoned. Preschool children still think as though they are alive and need to be taken care of.
C.	This is an expected response of a school-age child who is interested in peer relationships and has lost some of their egocentric thinking. School-age children can think of how something will affect others.
D.	This is an expected response of a school-age child. School-age children know that everyone dies; however, they think death happens to old people and not people they know or love.

15. The nurse is caring for a 10-year-old child during the acute phase of rheumatic fever. Bedrest is part of the child's plan of care. Which of the following diversional activities is developmentally appropriate and meets the health needs of this child in the acute phase of rheumatic fever?

	A			Using hand-held computer video games.
	B			Sorting and organizing baseball cards in a notebook.
	C			Playing basketball with a hoop suspended from the bed.
	D			Using art supplies to make drawings about the hospital experience.

Answer Rationale

A.	The disease process of rheumatic fever may prevent the child from having the fine motor skill to utilize the hand-held computer game and increase the child's frustration.
B.	The middle childhood years are times for collections. The collections of middle to late school-age children become orderly, selective, and neatly organized in scrapbooks. This quiet activity supports the development of industry and concrete operational thought as well as the physical restrictions related to the rheumatic fever.
C.	The basketball hoop demands high level of physical energy for the child and although it provides an important physical outlet for the school-age child, the activity increases the workload of the heart during the acute phase of rheumatic fever.
D.	The disease process of rheumatic fever including the effects on the central nervous system interferes with the child's fine motor ability. Drawing with art supplies may be too difficult for the child during the acute stage.

16. A 10-month-old weighs 10 kg and has voided 100 ml in the past four hours. The nurse determines normal urine output based on the fact that normal urine output is

	A			1-2 ml/kg/hour.
	B			3-5 ml/kg/hour.
	C			7-9 ml/kg/hour.
	D			10 ml/kg/hour.

Answer Rationale

A.	Normal urine output is 1-2 ml/kg/hour.
B.	Normal urine output is 1-2 ml/kg/hour.
C.	Normal urine output is 1-2 mg/kg/hour.
D.	Normal urine output is 1-2 ml/kg/hour.

17. A three-month-old is NPO for surgery. The nurse attempts to comfort him by

	A			administering acetaminophen.
	B			encouraging parents to leave so the child can rest.
	C			offering pacifier.
	D			giving 10 cc Pedialyte.

Answer Rationale

A.	There is no basis to administer any meds.
B.	The nurse should encourage family to stay.
C.	Non-nutritive sucking will help console and pacify him.
D.	Patient is NPO.

18. An 11-year-old is admitted for treatment of lead poisoning. The nurse includes which of the following in the plan of care?

	A			Oxygen.
	B			Strict intake and output.
	C			Heme-occult stool testing.
	D			Calorie counts.

Answer Rationale

A.	Oxygen is not indicated for treatment of lead poisoning.
B.	CaNaEDTA (treatment for lead poisoning) is nephrotoxic andPlPh/10Apstrict intake and output records need to be kept.
C.	This is not indicated for treatment of lead poisoning.
D.	This is not indicated for treatment of lead poisoning.

19. A two-month-old is admitted with diarrhea. What is the best room assignment for the nurse to make?

	A			Semi-private room with no roommate.
	B			Private room with no bathroom.
	C			Semi-private room with 10-year-old who has acute lymphocytic   leukemia.
	D			Open ward.

Answer Rationale

A.	Diarrhea is considered infectious until proven otherwise. There is a potential for infection of a roommate.
B.	A bathroom is irrelevant with an infant in diapers. A private room is necessary.
C.	Immunocompromised patients should also be in a private room.
D.	Infant diarrhea is considered infectious until proven otherwise so this is an inappropriate assignment.

20. The nurse is discussing safety measures to prevent poisoning with the mother of a one-year-old. The nurse knows the mother understands safety precautions when she states,

	A			"I have child protection locks on my cabinet under the sink.''
	B			"My child is not potty-trained, so the bathroom is safe.''
	C			"I keep all poisons and cleaners above the fridge.''
	D			"I don't think I have any poisons in my house.''

Answer Rationale

A.	Child protection locks are not child-proof and all cleaners/poisons should be kept in high cabinets.
B.	Developmentally, this child will explore all surroundings, including the bathroom cabinets.
C.	All cleaners and poisons should be kept in high locked cabinets .
D.	Poisons are prevalent in many household products including cleaners, pool chemicals, cosmetics, and over-the-counter medications.