PEDIATRIC NURSING Newborn Care 76. The “Unang Yakap” campaign is a call to action by the Department of Health (DOH) to implement the Essential Newborn Care (ENC) protocol. The Philippines is one of the 42 nations that account for 90% of the global under-five mortality. An estimated 82, 000 Filipino children die annually before their 5th birthday. Thus, Essential Newborn Care (ENC) made to address the aforementioned problem. More than one-third (37 percent) of these children are newborns less than 28 days old. According to their research based study, these newborns die mostly of which of the following preventable causes? a. Diarrhea, Injuries and Malaria b. Pneumonia, Measles and HIV/AIDS c. Tetanus, Diarrhea, and Congenital Defects d. Asphyxia, Sepsis/ Pneumonia and Preterm 77. The ENC protocol is a simple, concise and straightforward guideline that is backed by solid research evidence that emphasizes a core sequence of four actions that are performed step-by-step and it can be enforced immediately in all health care settings. In performing the four time-bound interventions, how long does it take to carry out? a. 30 minutes c. 90 minutes b. 60 minutes d. 120 minutes 78. Arrange the ENC step-by-step intervention: 1. Proper cord clamping and cutting 2. Immediate drying 3. Non-separation of the newborn from the mother for early breastfeeding initiation and rooming-in 4. Uninterrupted skin-to-skin contact 5. Eye care and Vitamin K administration a. 4-3-1-2-5 b. 2-4-1-3-5 c. 4-2-1-5-3 d. 2-4-3-1-5
a. Aspiration of the trapped blood under the periosteum. b. Explanation to the parents about the cause and prognosis. c. Gentle rubbing in a circular motion to decrease size d. Application of cold to reduce size. 86. A nurse notices a group of infants brought by their parents in the well-baby clinic for routine check-up. Which of the following will require the nurse for further assessment? a. A 4-month-old infant with absent rooting reflex b. An 8-month-old infant who can sit well unsupported c. A 10-month-old infant who looks for a toy hidden by the mother behind a chair d. A 7-month-old infant who assumes asymmetric tonic neck reflex position intermittently RATIONALE: D. Tonic neck reflex should disappear at 3-4 mos together with the rooting, and moro reflex. 87. Which of the following laboratory values would the nurse interpret as associated with cold stress in a 1-day-old preterm neonate? a. Bilirubin level of 13 mg/dL. c. Hematocrit of 65%. b. Glucose level of 15 mg/dL. d. Hemoglobin level of 23.5 g/dl Answer: B. Hypothermia could lead to hypoglycemia as the newborn compensates to produce heat. 88. While assessing a post-term neonate, the nurse explains to the mother that post-term neonates typically exhibit which of the following? a. Soft, oily skin c. Positive scarf sign b. Little vernix caseosa d. Abundant lanugo RATIONALE: B. Typical physical characteristics of post-term neonates, those born after the 42nd week of gestation, include a long, thin body; abundant scalp hair; absence of vernix caseosa; dry, thin, cracked, or peeling skin; long, thin nails; abundant sole creases; and an absence of lanugo. At birth, these neonates tend to look as though they were 1 to 3 weeks old. 89. When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse would expect to do which of the following? a. Turn the neonate every 6 hours. b. Encourage the mother to discontinue breast-feeding. c. Notify the physician if the skin becomes bronze in color. d. Check the vital signs every 2 to 4 hours. RATIONALE: D. vital signs are checked every 2 to 4 hours because hyperthermia can occur due to the phototherapy lights. (A)The infant should be turned every 2 to 4 hours to expose all body surfaces to the lights, thus promoting the breakdown of bilirubin. (B)Breast-feeding generally does not need to be discontinued. However, the infant needs adequate fluid intake to maintain hydration because the heated phototherapy lights may increase fluid losses. Offering water to the neonate after breastfeeding would be appropriate. (C)The skin of the neonate may become bronze as a result of phototherapy. This benign condition has no adverse effects and disappears when therapy is discontinued. Growth and Development 90. In assessing a child‟s growth and development, the nurse is guided by principles of growth and development. Which is not included? a. All individuals follow cephalo-caudal and proximo-distal b. Each child is unique c. Not all parts of the body grow at the same time and rate d. Rate and pattern of growth can be modified 91. A 7 month old infant has all of the following abilities. Which skill as most recently acquired? a. Development of pincer grasp c. Rolling over b. Transferring a rattle from one hand to another d. Drinks from a cup 92. A client tells the nurse, "I think my baby likes to hear me talk to him." When discussing neonates and stimulation with sound, which of the following would the nurse include as a means to elicit the best response? a. High-pitched speech with tonal variations b. Low-pitched speech with a sameness of tone c. Cooing sounds rather than words d. Repeated stimulation with loud sounds 93. As a nurse you are reviewed infant safety procedures with Katherine‟s mother. What are the most common types of accidents among infants? a. Poisoning & burns c. Aspiration & falls b. Falls & accidents d. Drowning & homicide RATIONALE: C. Aspiration. Because the site of their gratification is their mouths. In combination with their new found abilities of pincer grasp. It is then by natural that they bring objects to their mouths. Falls. Because there are increasingly becoming to move around, by crawling & cruising. 94. Which of the following action shows an appropriate understanding about preventing injury and promoting safety to an infant? a. Providing candy pacifiers as an alternative b. Slicing hotdogs into small, irregular pieces c. Place infant rear facing at front seat where the air bag is d. Place infant in a bed under tucked-in blankets
104. A 9 year-old is taken to the emergency room with right lower quadrant pain and vomiting. When preparing the child for an emergency appendectomy, what must the nurse expect to be the child's greatest fear? a. Change in body image c. Perceived loss of control b. An unfamiliar environment d. Guilt over being hospitalized RATIONALE: C: Perceived loss of control. For school age children, major fears are loss of control and separation from friends/peers. 105. An adolescent client has had surgery & has a dressing on his abdomen. Which of the following questions should the nurse expect the client to ask? a. “Will I have a scar?” b. “What complications can I expect?” c. “When can I return to school?” d. “Did the surgery go okay?”
RATIONALE: C. headache are for older children. Bulging fontanels are for infants.
114. Baby boy Paulo. A newborn in distress is admitted to the neonatal intensive care unit immediately after birth. Baby boy Paulo is diagnosed as having communicating hydrocephalus. In explaining communicating hydrocephalus to the parents, the nurse should state: a. “Too much CSF is produced within the atrium of the brain” b. “The CSF is prevented from proper absorption by a blockage in the ventricles of the brain”
c. “The part of the brain surface that normally absorbs CSF after its production is not functioning adequately” d. “There is a flow of CSF between the brain cells and the ventricles, which do not empty properly into the spinal cord” RATIONALE: C. In letter A, the brain does not have an atrium but rather a ventricle. Any obstruction is a cause of noncommunicating hydrocephalus. Impaired reabsorption or increase CSF production causes communicating hydrocephalus. 115. A client is 2 hrs post venticuloperitoneal shunt placement. How should the nurse position the client? a. head of bed elevated 30° on nonoperative side b. head of bed elevated 30° on operative side c. bed flat on operative side d. bed flat on nonoperative side 116. A 6 year old is brought to the emergency department, unconscious after having been hit by a car. Which of the following will not be included when the nurse performs a baseline neurologic exam? a. Motor function c. Visual acuity b. Vital signs d. Level of consciousness 117. A nurse assigned in a newborn nursery receives a telephone call from the delivery room and is told that a newborn with spina bifida (meningomyelocele type) will be transported to the nursery. Which of the following priority items would the nurse prepares at the newborn‟s bedside? a. A specific gravity urinometer c. A rectal thermometer b. A bottle of sterile normal saline d. A blood pressure cuff RATIONALE: B. The newborn with spina bifida is at risk for infection before the closure of the sac. A sterile normal saline dressing is placed over the sac to maintain moisture of the sac and its contents. This prevents tearing or breakdown of the skin integrity at the site. (pg. 413, #18, Saunders). 118. The nurse carefully monitors the intake and output of a child with meningomyelocele. The primary rationale for this nursing intervention is that infants with meningomyelocele: a. Often have malformation of the kidneys b. Have impaired bowel and bladder functioning c. Are susceptible to rapid changes in fluid balance because of the sac formation reaching the adrenal gland d. Have difficulty ingesting fluids because of a poor sucking reflex 119. A nurse explains that a child with athetoid cerebral palsy most probably will demonstrate: a. Exaggerated hyperactive reflexes b. Normal intelligence level c. Slow, wormlike writing movements d. Unsteady gait and clumsy, uncoordinated upper extremity function Children with CARDIOVASCULAR PROBLEMS 120. At 2 days of age, a murmur is heard over the right and left auricles of the newborn‟s heart. This may represent: a. Patent umbilical cord c. Patent ductus arteriosus b. Patent foramen ovale d. Patent ductus venosus 121. A Clinical Instructor asked her student nurse about the defects associated with Tetralogy of Fallot, the student nurse would answer by including which of the following defect in her response? a. Coarctation of the aorta, Aortic Valve stenosis, PDA, & mitral valve stenosis b. VSD, Coarctation of the aorta, PDA & Tricuspid valve atresia c. Aorta exits from from the right ventricle, pulmonary artery exits from the left ventricle & two non communicating circulations d. Pulmonary Stenosis, Ventricular Septal Defect, Overriding Aorta, Right ventricular hyperthropy Answer: d. Pulmonary Stenosis, Ventricular Septal Defect, Overriding Aorta, Right ventricular hyperthropy 122. An infant, Monay, is confined in the Neonatal Intensive Care Unit (NICU) with a diagnosis of Tetralogy of Fallot (TOF). Which of the ff. signs when manifested by the young infant support the diagnosis of TOF? 1. Clubbing of fingers and toes 3. Squatting 2. Acyanosis 4. Anemia a. 1,2,3,4 c. 1 only b. 1,2,3 d. 1, 4 only RATIONALE: C. An infant does not know how to squat by itself. Squatting is not seen, rather the nurse will position the infant in a knee chest position to compensate. 123. On admission for heart surgery to repair tetralogy of Fallot, the nurse observes that a 6-year-old child is cyanotic. The nurse judges that the parents understand this disorder when they explain that one of the underlying causes of their child's cyanosis is related to which of the following? a. Constriction of the aorta b. Stenosis of the mitral valve c. Narrowing of blood vessel towards the lungs d. Aorta receiving blood directly from the vena cava 124. After the health teaching of the nurse, which of the following actions by the mother is appropriate to promote optimal nutrition in an infant with heart failure? a. Offering formula that is high in sodium & Calories b. Providing large feedings evenly spaced every 4 hours c. Replacing regular nipples with soft & easy to suck ones d. Allowing the infant to feed for at least one hour
125. You have just admitted a child who is diagnosed with Kawasaki Disease, you know that in this disease, the child is prone to develop which of the following condition? a. Aneurysm formation c. Sepsis b. Mitral valve disease d. Meningitis Answer: a. Aneurysm formation. Without treatment, 20 - 25% can develop aneurysm formation. aka mucocutaneous lymph node syndrome & is an acute systematic inflammatory illness Children with RESPIRATORY PROBLEMS 126. In the initial assessment, which of the following would the nurse expect as a typical sign of esophageal atresia and tracheoesophageal fistula (TEF)? a. Continuous drooling. c. Bloody emesis b. Diaphragmatic breathing. d. Large amounts of frothy meconium RATIONALE: A. Esophageal atresia and TEF may occur together or separately. Esophageal atresia prevents the passage of swallowed mucus and saliva into the stomach. After fluid has accumulated in the pouch, it flows from the mouth. The infant then drools continuously. The lack of swallowed amniotic fluid prevents the accumulation of normal meconium; lack of stool results. (B)Diaphragmatic breathing is not associated with TEF. (C)Bloody emesis may occur with upper gastrointestinal bleeding or irritation. (D)Meconium stool is usually passed within the first 24 hours after birth. It is dark and pasty, not frothy. For the infant with esophageal atresia and TEF, no stool would be passed. 127. A mother calls the ER department and reports that her 6-year-old child has awakened with a complaint of sore throat & pain on swallowing. She reports that the child was fine when going to bed. The child has a fever of 39.2OC, or 102.5OF, orally and is restless, having difficulty breathing, and appears quite sick. Which of the following questions is a priority for the nurse to ask to triage this client? a. “Did you give the child an antipyretic?” b. “Has the child been drooling?” c. “Has the child been exposed to strep throat?” d. “Is the child up to date on immunization?” RATIONALE: B. Suggestive of epiglottitis, which is a medical emergency. Confirming that the child is drooling would be additional data to support the nurse‟s suspicions and assist to d irect the parent and child to an emergency department for evaluation and treatment. (pg. 615, #12, NSNA). 128. When planning for the comfort of a preschooler in a mist tent(croupette), which of the following toys would be appropriate for the child to play with while in the tent? a. Friction cars c. Stuffed teddy bear b. Soft plastic doll d. TV game remote 129. The nurse is caring for a 5-year-old child diagnosed with laryngotracheobronchitis who is otherwise in good health. The child‟s mother verbalizes to the nurse that she is very upset that the physician did not prescribe antibiotics. The nurse‟s response would be based on the understanding that laryngotracheobronchitis is a. A minor bacterial illness & antibiotics are not recommended because of the risk of developing bacterial resistance b. Most appropriately controlled by cough syrup administered every four hours c. Treated by antihistamines, not antibiotics d. Usually viral in a child under 5 years and not affected by antibiotic therapy RATIONALE: D. Laryngotracheobronchitis (croup) is usually caused by a virus, especially in young children. Antibiotics are ineffective against viral illness. pg. 616, #18, NSNA). 130. The mother of a 15-month-old child who is coughing and having trouble breathing telephones the clinic to ask advice because she suspects that her child has croup. Which of the following instructions would be most appropriate? a. Administer acetaminophen (Tylenol) every 4 hours b. Take the child into the bathroom and run the hot water c. Give over-the-counter cough syrup every 6 hours d. Get the child to take as much fluid as possible 131. A 3-year-old child with cystic fibrosis is admitted to the hospital with bronchopneumonia. Which of the following signs and symptoms would be most helpful in providing supportive diagnostic data for this child's condition? a. Weight loss and stringy stools c. Constipation and vomiting b. Cough and fever d. Dysuria and rash RATIONALE: B. As a result of the infectious process and mucus accumulation, classic signs of pneumonia include fever and cough. (A)Weight loss may occur in a child with cystic fibrosis because of the energy expenditure needed to fight the infection. Typically stools are large, bulky, and greasy. (C)Constipation is not a common manifestation of pneumonia. However, vomiting may occur, especially if the child is coughing frequently and has a lot of mucus. (D)Dysuria and rash are not associated with pneumonia. Children with GASTROINTESTINAL PROBLEMS 132. Which of the following interventions is a priority for the nurse to implement in the postoperative care of a child with a cleft lip repair? a. Encourage the parents to limit their visits to allow the child to rest b. Restrain the child‟s arms with blankets to prevent the rubbing the suture line c. Place the child prone to facilitate drainage d. Assess for edema of the tongue, lips and mucus membranes RATIONALE: D. Trauma to the mucous membranes of the mouth that occurs with a cleft lip repair causes edema, leading to the respiratory distress and potential closing of the airway. (pg. 649, #5, NSNA). 133. Which of the following methods would the nurse use to feed an infant after surgical repair of cleft lip? a. Gastric gavage b. A plastic cup
144. While assessing a child in a hip spica cast, which of the following assessment findings would alert the nurse to suspect a possible infection under the cast? a. Cold toes c. Hot spots on the cast b. Absent pedal pulses d. Cyanotic extremities RATIONALE: C. „‟Hot spots‟‟ on the cast or areas of warmth that radiate from inflamed tissue below the cast, usually signify infection. The other options are indicative of neurovascular compromise 145. Pokwang is a 6-month-old Fil-American girl who is admitted to the pediatric ward due to corrective serial coating of her congenital clubfoot. The type of clubfoot Pokwang has is talipes Calcaneovalgus. Which TWO of the following clinical manifestations are observed by the nurse? I. The foot and ankle deviate toward the midline of III. Foot is dorsiflexed at the ankle the body IV. Foot and ankle bend away from the midline of the II. There is plantar flexion of the forefoot body a. ll and lV b. ll and lll c. l and ll d. lll and lV
RATIONALE: B. Acne is a disorder of the pilosebaceous follicles (hair follicles and sebaceous gland complex). During adolescence, the secretions of the sebaceous glands increase, altering the follicular lining and causing occlusion of the ducts with accumulated sebum. Bacteria in the follicle then cause an infection. Frequent washing of affected areas with soap and water is recommended to act as a mild peeling agent and reduce secondary infection. (A)Witch hazel is an astringent that can be used after thoroughly cleansing the skin. (C)Hydrogen peroxide is a poor cleansing agent for skin with acne. (D)Lotions and creams aggravate the condition by adding more oily substances to the already oily skin. 150. The allergist prescribes Hydrocortisone 1% (Hytone) cream for topical application twice a day to areas with atopic dermatitis. The nurse instructs general skin care, cream application & infection control measures. Which instruction is most important to stress to the parents? a. Spread a thick film the prescribed cream on the affected areas daily & wash the affected areas once a week. b. Gently abrade the skin before applying the cream to enhance absorption c. Limit the use of the soap & water; use an emollient cream at least four times a day d. Wash the affected areas frequently & use moisturizing cream sparingly RATIONALE: C. Limit the use of the soap & water; use an emollient cream at least four times a day (A) Creams ( especially corticosteroids )should be applied in a thin film. Excessive application may lead to systemic absorption & may produce Cushing‟s syndrome(DISCUSS!) (B) Abrading the skin can increase the risk of infection (D) Excessive washing removes moisture