Nursing Care of Child Exam

1. A school nurse is assessing a school-age child’s blood pressure while he is seated in a chair. The child starts to experience a tonic-clonic seizure. Which of the following actions should the nurse take first?
a) Clear the immediate area around the child of hazardous objects
b) Loosen the child’s restrictive clothing
c) Assist the child to a side-lying position on the floor
d) Apply an oxygen mask to the child
Answer: C
Explanation: Aspiration, obstruction of the airway, and physical harm from slipping out of the chair pose the biggest risks to this youngster. The kid should be promptly placed in a side-lying posture on the floor by the nurse. By keeping the child’s airway open and allowing secretions to exit the mouth, this position helps to avoid aspiration. Nursing Care of Child Exam.

2. A nurse is preparing to administer ibuprofen 5 mg per kg every 6 hours PRN for temperatures above 38.0 degrees Celsius or 100.5 degrees Fahrenheit to an infant who weighs 17.6 lb. The infant has a temperature of 38.4 degrees Celsius or 100 + 1.2 degrees Fahrenheit. Available is ibuprofen liquid 100mg/ 5 ml. How many milliliters should the nurse administer to the infant per dose? Round the answer to the nearest whole number. Use a leading zero if it applies.
Answer: 2 mL

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3. A nurse is receiving a change-of-shift Report for children. Which of the following children should the nurse assess first?
a) A toddler who has a concussion and an episode of forceful vomiting
b) An adolescent who has infective endocarditis and reports having a headache
c) An adolescent who was placed into Halo traction 1 hour ago and rates his pain at a 6 on a 0-10 scale
d) A school-age child who has acute glomerulonephritis and brown-colored urine
Answer: A
Explanation: The kid with a concussion and an episode of severe vomiting should be evaluated by the nurse initially since there is a chance that the intracranial pressure would rise and cause potentially fatal consequences. Nursing Care of Child Exam.

4. A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify the sound as which of the following? Click the audio button to listen.
a) Biots respiration
b) Chaney Stokes respiration
c) Tachypnea
d) Bradypnea
Answer: C
Explanation: The sound detected during auscultation should be recognized by the nurse as tachypnea, which is characterized by rapid, regular breathing. This breathing pattern is frequently associated with metabolic acidosis, anxiety, fever, or severe anemia. Nursing Care of Child Exam.

5. A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse?
a) Elevate the head of the child’s bed
b) Insert a large-bore IV catheter for the child
c) Determine the allergen that caused the child’s reaction
d) Administer IM epinephrine to the child
Answer: D
Explanation: Using the urgent vs. nonurgent approach to client care, the nurse decides that giving the youngster IM epinephrine is the most important course of action. Histamine release during an allergic reaction result in both vasodilation and bronchoconstriction. Since it ultimately results in less blood returning to the heart, this is an emergency.

6. A nurse is teaching the parents of a newborn about ways to prevent sudden infant death syndrome SIDS. Which of the following instructions should the nurse include?
a) Place the infant in a prone position to sleep.
b) Allow the infant to sleep on a large pillow.
c) User soft mattress in the infant’s crib.
d) Give the infant a pacifier at bedtime.
Answer: D
Explanation: The nurse should let the parent know that using a pacifier while the baby sleeps and breastfeeding are two strategies to prevent SIDS. Nursing Care of Child Exam.

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7. A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report to the
provider?
a) Nasal flaring
b) WBC 11,300
c) Diarrhea
d) Abdominal distension
Answer: D
Explanation: Nursing and using a pacifier while the baby sleeps are two ways to prevent SIDS, the nurse should inform the parent. Nursing Care of Child Exam.