21108577 Nclex 100 Questions and Answers With Rationale Pediatric Nursing2

8/12/2019 21108577 Nclex 100 Questions and Answers With Rationale Pediatric Nursing2

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1. A child with leukemia is beingdischarged after beginningchemotherapy. Which of the followinginstructions will the nurse include whenteaching the parents of this child?

a) provide a diet low in protein and highcarbohydrates

b) b) avoid fresh vegetables that are not cooked orpeeled

c) c) notify the doctor if the child's temperatureexceeds 101 F (39C)

d) d) increase the use of humidifiers throughoutthe house



Answer Bfresh fruits and vegetables harbor

microorganisms, which can cause infectionsin immune-compromised child. Fruits and

vegetables should either be peeled orcooked. The physician should be notifiedof a temperature above 100F, a diet low inprotein is not indicated, and humidifiersharbor fungi in the water containers.



2. A client with hemophilia has a very

swollen knee after falling from bicycleriding. Which of the following is the firstnursing action?

a) initiate an IV site to begin administration ofcryoprecipitate

b) type and cross-match for possibletransfusion

c) monitor the client's vital signs for the first5 minutes

d) apply ice pack and compression dressings tothe knee



Answer D

rest, ice, compression, and elevation (RICE)are the immediate treatments to reduce theswelling and bleeding into the joint. Theseare the priority actions for bleeding into the

joint of a client with hemophilia.



3. A client and her husband are positivefor the sickle cell trait. The client asks thenurse about chances of her children havingsickle cell disease. Which of the following isappropriate response by the nurse?

a) one of her children will have sickle cell disease

b) only the male children will be affected

c) each pregnancy carries a 25% chance of the

child being affectedd) if she had four children, one of them would

have the disease



Answer C

In autosomal recessive traits, both parentsare carriers. There is a 25% chance with eachpregnancy that a child will have the disease.



Answer C

reading a book is restful activity and can keepthe child from becoming bored. Choices a, b, andd require too much energy for a child withanemia and can increase oxygen demands on thebody.



5. A 16 month old child diagnosed with

Kawasaki Disease (KD) is very irritable,refuses to eat, and exhibits peeling skinon the hands and feet. Which of thefollowing would the nurse interpret as

the priority?

a) applying lotions to the hands and feet

b) offering foods the toddler likes

c) placing the toddler in a quiet environment

d) encouraging the parents to get some rest



Answer C One of the characteristics of children with KDis irritability. They are often inconsolable.Placing the child in a quiet environment may

help quiet the child and reduce the workload ofthe heart. The child's irritability takes priorityover peeling of the skin.



6.Which of the following should the nursedo first after noting that a child withHirschsprung disease has a fever andwatery explosive diarrhea?

a. Notify the physician immediately

b. Administer antidiarrheal medications

c. Monitor child ever 30 minutes

d. Nothing, this is characteristic ofHirschsprung disease



Answer A.For the child with Hirschsprung disease, fever andexplosive diarrhea indicate enterocolitis, a life-threatening situation. Therefore, the physician

should be notified immediately. Generally, becauseof the intestinal obstruction and inadequatepropulsive intestinal movement, antidiarrheals arenot used to treat Hirschsprung disease. The child is

acutely ill and requires intervention, with monitoringmore frequently than every 30 minutes.Hirschsprung disease typically presents withchronic constipation.



7. A newborn’s failure to pass meconium

within the first 24 hours after birthmay indicate which of the following?

a. Hirschsprung disease

b. Celiac disease

c. Intussusception

d. Abdominal wall defect



Answer A Failure to pass meconium within the first 24 hoursafter birth may be an indication of Hirschsprungdisease, a congenital anomaly resulting in mechanical

obstruction due to inadequate motility in anintestinal segment. Failure to pass meconium is notassociated with celiac disease, intussusception, orabdominal wall defect.



8. When assessing a child for possible

intussusception, which of the followingwould be least likely to provide valuableinformation?

a. Stool inspectionb. Pain pattern

c. Family history

d. Abdominal palpation



Answer C.Because intussusception is not believed to have afamilial tendency, obtaining a family history wouldprovide the least amount of information. Stool

inspection, pain pattern, and abdominal palpationwould reveal possible indicators of intussusception.Current, jelly-like stools containing blood andmucus are an indication of intussusception. Acute,

episodic abdominal pain is characteristics ofintussusception. A sausage-shaped mass may bepalpated in the right upper quadrant.



9. After teaching the parents of apreschooler who has undergone T and A

(Tonsillectomy and Adenoidectomy) aboutappropriate foods to give the child afterdischarge, which of the following, if statedby the parents as appropriate foods,

indicates successful teaching?

a) meatloaf and uncooked carrots

b) pork and noodle casserole

c) cream of chicken soup and orangesherbet

d) hot dog and potato chips



10. A child diagnosed with tetralogy offallot becomes upset, crying and thrashingaround when a blood specimen is obtained.The child's color becomes blue andrespiratory rate increases to 44 bpm.Which of the following actions would the

nurse do first?a) obtain an order for sedation for the

childb) assess for an irregular heart rate and

rhythmc) explain to the child that it will onlyhurt for a short timed) place the child in knee-to-chestposition



Answer D the child is experiencing a "tet spell" or hypoxic episode.Therefore the nurse should place the child in a knee-to-

chest position. Flexing the legs reduces venous flow ofblood from lower extremities and reduces the volume ofblood being shunted through the interventricular septaldefect and the overriding aorta in the child withtetralogy of fallot. As a result, the blood then enteringthe systemic circulation has higher oxygen content, anddyspnea is reduced. Flexing the legs also increasesvascular resistance and pressure in the left ventricle. Aninfant often assumes a knee-to-chest position to relieve

dyspnea. If this position is ineffective, then the childmay need sedative. Once the child is in this position, thenurse may assess for an irregular heart rate and rhythm.Explaining to the child that it will only hurt for a short

time does nothing to alleviate hypoxia.



11. Which of the following would the nurse

perform to help alleviate a child's joint painassociated with rheumatic fever?

a) maintaining the joints in an extended position

b) applying gentle traction to the child'saffected joints

c) supporting proper alignment with rolled pillows

d) using a bed cradle to avoid the weight of bedlines on the joints



Answer D

for a child with arthritis associated with rheumatic

fever, the joints are usually so tender that even theweight of bed linens can cause pain. Use of the bedcradle is recommended to help remove the weight ofthe linens on painful joints. Joints need to be

maintained in good alignment, not positioned inextension, to ensure that they remain functional.Applying gentle traction to the joints is notrecommended because traction is usually used torelieve muscle spasms, not typically associated withrheumatic fever. Supporting the body in goodalignment and changing the client's position arerecommended, but these measures are not likely torelieve pain.



12. Which of the following health teachingsregarding sickle cell crisis should beincluded by the nurse?

a) it results from altered metabolism anddehydration

b) tissue hypoxia and vascular occlusion causethe primary problems

c) increased bilirubin levels will cause

hypertensiond) there are decreased clotting factors with an

increase in white blood cells



Answer B tissue hypoxia occurs as a result of the

decreased oxygen-carrying capacity of the redblood cells. The sickled cells begin to clump

together, which leads to vascular occlusion.



13. Which of the following should the

nurse expect to note as a frequentcomplication for a child with congenitalheart disease?

a. Susceptibility to respiratoryinfection

b. Bleeding tendencies

c. Frequent vomiting and diarrhea

d. Seizure disorder



Answer AChildren with congenital heart disease aremore prone to respiratory infections.Bleeding tendencies, frequent vomiting, and

diarrhea and seizure disorders are notassociated with congenital heart disease.



14. While assessing a newborn with cleft lip,

the nurse would be alert that which of thefollowing will most likely be compromised?

a. Sucking ability

b. Respiratory status

c. Locomotion

d. GI function



Answer A.Because of the defect, the child will be unable to

from the mouth adequately around nipple, therebyrequiring special devices to allow for feeding and

sucking gratification. Respiratory status may becompromised if the child is fed improperly or duringpostoperative period, Locomotion would be aproblem for the older infant because of the use of

restraints. GI functioning is not compromised in thechild with a cleft lip.



15. When providing postoperative care for the

child with a cleft palate, the nurse shouldposition the child in which of the followingpositions?

a. Supine

b. Prone

c. In an infant seat

d. On the side



Answer B.

Postoperatively children with cleft palate shouldbe placed on their abdomens to facilitate drainage.If the child is placed in the supine position, he or

she may aspirate. Using an infant seat does notfacilitate drainage. Side-lying does not facilitatedrainage as well as the prone position



21. When assessing a 12 year old child withWilm's tumor, the nurse should keep in mindthat it most important to avoid which of thefollowing?

a) measuring the child's chestcircumference

b) palpating the child's abdomen

c) placing the child in an uprignt position

d) measuring the child's occipitofrontalcircumference



Answer B The abdomen of the child with Wilm's tumorshould not be palpated because of the dangerof disseminating tumor cells. The child with

Wilm's tumor should always be handled gentlyand carefully



23. A 4 year old with hydrocephalus isscheduled to have a ventroperitoneal shunt inthe right side of the head. When developingthe child's postoperative plan of care, thenurse would expect to place the preschooler inwhich of the following positions immediately

after surgery? a) on the right side, with the foot of the bed

elevated

b) on the left side, with the head of the bedelevated

c) prone with the head of the bed elevated

d) supine, with the head of the bed flat



Answer D

For at least the first 24 hours after insertionof a ventriculoperitoneal shunt, the child ispositioned supine with the head of the bed flatto prevent too rapid decrease in CSF pressure. Arapid reduction in the size of the ventricles cancause subdural hematoma. Positioning on theoperative site is to be avoided because it placespressure on the shunt valve, possibly blockingdesired drainage of CSF. With continued

increased ICP, the child would be positioned withthe head of bed elevated to allow gravity to aiddrainage.



24. After talking with the parents of a childwith Down Syndrome, which of the following

would the nurse identify as an appropriategoal of care of the child?

a) encouraging self-care skills in the child

b) teaching the child something new each day

c) encouraging more lenient behavior limitsfor the child

d) achieving age-appropriate social skills



Answer A

The goal in working with mentally challenged childrenis to train them to be as independent as possible,focusing on the developmental skills. The child may notbe capable of learning something new every day butneeds to repeat what has been taught previously. Ratherthan encouraging more lenient behavior limits, theparents need to be strict and consistent when settinglimits for the child. Most children with Down syndromeare unable to achieve age-appropriate social skills due to

their mental retardation. Rather, they taught sociallyappropriate behaviors.



25. When teaching an adolescent with aseizure disorder who is receiving Valproic

acid (Depakene), which of the followingwould the nurse instruct the client to reportthe health care provider?

a) three episodes of diarrheab) loss of appetite

c) jaundice

d) sore throat



Answer C A toxic effect of valproic acid (Depakene) is liver

toxicity, which may manifest with jaundice andabdominal pain. If jaundice occurs, the client needs

to notify the health care provider as soon aspossible.



26. A hospitalized preschooler with meningitiswho is to be discharged becomes angry when

the discharge is delayed. Which of thefollowing play activities would be mostappropriate at this time?

a) reading the child a storyb) painting with water colors

c) pounding on a pegboard

d) stacking a tower of blocks



Answer C

The child is angry and needs a positive outlet forexpression of feelings. An emotionally tense childwith pent-up hostilities needs a physical activitythat will release energy and frustration. Pounding on

a pegboard offers the opportunity.Listening to a story does not allow child to expressemotions. It also places the child in a passive roleand does not allow the child to deal with feelings in

a healthy and positive way. Activities such aspaintings and stacking a tower of blocks requireconcentration and fine movements, which could addto frustration.



27. The parents of a child tell the nurse they feelguilty because their child almost drowned. Which of

the following remarks by the nurse would be mostappropriate?

a) I can understand why you feel guilty, butthese things happen

b) tell me a bit more about your feelings ofguilt

c) you should not have taken your eyes off

your childd) you really shouldn't fell guilty; you're lucky

because your child will be alright



Answer BGuilt is a common parental response. The

parents need to be allowed to express theirfeelings openly in a nonthreatening,

nonjudgmental atmosphere.



29. When assessing the development of a 15

month old child with cerebral palsy, which of thefollowing milestones would the nurse expect atoddler of this age to have achieved?

a) walking up stepsb) using a spoon

c) copying a circle

d) putting a block in cup



Answer D

Delay in achieving developmental milestones is acharacteristic of children with cerebral palsy. A 15month old child can put a block in a cup. Walking upsteps typically is accomplished at 18 to 24 months.

A child usually is able to use a spoon at 18 months.The ability to copy a circle is achieved atapproximately 3 to 4 years of age.



31. Which of the following foods wouldthe nurse encourage the mother to offerto her child with iron-deficiency anemia?

a) rice cereal, whole milk, and yellow vegetables

b) potato, peas, and chickenc) macaroni, cheese and ham

d) pudding, green vegetables and rice



Answer B potato, peas, chicken, green vegetables, and

rice cereal contain significant amounts of ironand therefore would be recommended. Milk and

yellow vegetables are not good iron sources.Rice, by itself also is not a good source of iron.



33. When teaching the mother of an infantwho has undergone surgical repair of a cleft

lip how to care for the suture line, thenurse demonstrates how to remove formulaand drainage. Which of the followingsolutions would the nurse use?

a) mouthwash

b) providone - iodine (betadine) solution

c) a mild antiseptic solutiond) half-strength hydrogen peroxide



Answer D

half-strength hydrogen peroxide is recommendedfor cleansing the suture line after cleft lip repair.The bubbling action of the hydrogen peroxide iseffective for removing debris. Normal saline also may

be used. Mouthwashes frequently contain alcoholwhich can be irritating. Povidone-iodine solution is notused because iodine contained in the solution can beabsorbed through the skin, leading to toxicity. A mild

antiseptic solution has some antibacterial propertiesbut is ineffective in removing suture-line debris.



35. When the infant returns to the unit

after imperforate anus repair, the nurseplaces the infant in which of the followingposition?

a) on the abdomen, with legs pulled up underthe body

b) on the back, with legs extended straightout

c) lying on the side with hips elevated

d) lying on the back in a position of comfort



Answer C after surgical repair for an imperforate anus, the

infant should be positioned either supine with thelegs suspended at 90-degree angle or on either side

with the hips elevated to prevent pressure on theperineum. A neonate who is placed on the abdomenpulls the legs up under the body, which puts tensionon the perineum, as does positioning the neonatewith the legs extended straight out



38. Which of the following statements isLEAST accurate concerning urinary tract

infections (UTI) in children?

A)A negative urinalysis rules out UTI in children < 2 years of age.

B)B) Children with multiple UTIs should be evaluatedfor abuse.

C) Infants younger than 3 months of age with a UTIshould be admitted for intravenous antibiotics.

D) Neonatal boys are more prone to UTIs than girls.E) Well appearing children > 3 months old with

pyelonephritis may be treated as outpatients.

Answer A



A negative urinalysis rules out UTI in children < 2 years of age.In children younger than 2-years-old, a negative urinalysis

does not rule out a urinary tract infection. Up to 50% ofchildren with UTIs can have a false negative urinalysis. Nitriteand leukocyte esterase presence in urine dipstick have thehighest combined sensitivity for UTI. In addition, if both are

positive, the false positive rate is less than 4%. Most consider young girls to be at the highest risk for UTI. This is in facttrue except for the neonatal period, when neonatal boysactually have a higher risk than girls. Children with UTIs aremanaged differently based on the age of the child. The very

young are treated conservatively, and those under 3 months ofage are generally admitted to the hospital for IV antibiotics.Pyelonephritis used to be commonly managed as an inpatient,but in well appearing children, this infection can be treated as

an outpatient with oral antibiotics.



42. A child discharged with slowcerebrospinal fluid (CSF) leak 3 days after

a head injury was sustained. What will thenurse include in the discharge plans?

a) avoid use of nonsteroidal anti-inflammatory

drugsb) turn from side to side only

c) maintain complete bed rest

d) gradually increase diet to clear liquids



45. A newborn’s failure to pass meconium

within 24 hours after birth may indicatewhich of the following?

a. Aganglionic Mega colon

b. Celiac disease

c. Intussusception

d. Abdominal wall defect



Answer A

Failure to pass meconium of Newborn during thefirst 24 hours of life may indicate Hirschsprungdisease or Congenital Aganglionic Megacolon, ananomaly resulting in mechanical obstruction due toinadequate motility in an intestinal segment. B, C,and D are not associated in the failure to passmeconium of the newborn.



47. You are in your office late one cold winter evening,seeing a pair of siblings who have a cold and cough.The mother and paternal grandmother are there. The

grandmother notes that the best way to prevent thespread of colds is by wearing a wool hat at all times.What should you say?

A.Agree and pull out a cartoon with the

trademarked hats promoting your practiceB. Wearing a face mask and eye shields is the best

methodC. Limiting exposure to other children to once

weekly would helpD.Washing hands and all toys frequently would befine

E. Isolating all children with colds is the bestmethod



49 A male infant weighing 3 kg is born via



49. A male infant weighing 3 kg is born viaspontaneous vaginal delivery at 37 weeks’gestation. His Apgar score is 6/9 at 1 and 5

minutes. The patient is in no apparent distress.Physical examination reveals no anus. What isthe most appropriate initial step in thispatient’s management?

(A)Colostomy(B) Continued observation for 24 hours(C) Intubation and mechanical ventilation

(D) Magnetic resonance imaging (MRI) ofthe abdomen and pelvis(E) Posterior sagittal anorectoplasty



Answer B Continued observation for 24 hours. The patient should be observedfor delayed passage of meconium, as this can be normal up to 48 hours

of life. If delayed beyond this period, meconium ileus, meconium plug,imperforate anus, or Hirschsprung’s disease should be considered.Evaluation of imperforate anus should include inspection for drainageof meconium through a fistula to the perineum or the urinary tractbecause this significantly alters treatment.1 Specifically, fistulaeoccur with low termination of the colon/rectum, which can be manageddefinitively with anorectoplasty. Absence of a fistula significantlyincreases the likelihood of a “high defect” imperforate anus, which canbe managed with colostomy and subsequent contrast imaging of thedistal colon/rectum, followed by definitive repair at a few months ofage. Some surgeons obtain a cross-table lateral abdominal radiograph

(not MRI) to determine where the terminal colon/rectumlies in relation to the perineum, but this approach is unnecessary and isnot widely practiced. Ultrasonography and radiography are required torule out VACTERL association, but there is no need for MRI.Intubation and mechanical ventilation are not indicated in this case.



51. A nurse has just started her roundsdelivering medication. A new patient on her

rounds is a 4 year-old boy who is non-verbal. This child does not have on anyidentification. What should the nurse do?

A: Contact the providerB: Ask the child to write their name onpaper.C: Ask a co-worker about theidentification of the child.D: Ask the father who is in the roomthe child’s name.



Answer D

In this case you are able to determine the name ofthe child by the father’s statement. You should notwithhold the medication from the child following

identification.



53. A mother has recently been informedthat her child has Down’s syndrome. You will

be assigned to care for the child at shiftchange. Which of the followingcharacteristics is not associated with Down’ssyndrome?

A: Simian crease

B: Brachycephaly

C: Oily skin

D: Hypotonicity



Answer C

The skin would be dry and not oily.



54. Who among the following pediatric clientshould be assessed first by the nurse?

a) the child with 2 episodes of soft stools during theshift

b) the child who had cough for the past three days, withclear nasal discharge and is irritable

c) the child with 2 episodes of inconsolable crying whilethe knees are drawn over the abdomen and plays

between the episodesd) the child with skin rashes on his face and trunk



Answer C

- this indicates appendicitis. The pattern of abdominalpain in appendicitis is as follows: pain occurs for 2 to 3hours, pain is relieved in 2 to 3 hours, the n pain recurs

and persists. During the time that pain subsides, it iswhen rupture of appendicitis may occur unnoticed.



55. The nurse is caring for several infants whoare 2-day old. Who among these infants should

be given highest priority by the nurse?

a) a bottlefed infant who takes 1-ounce of milk every 3 to 5hours

b) a breastfed infant who lost 0.5 ounce of his weight

c) a bottlefed infant who takes 2 to 3 ounces of milk every 2to 4 hours

d) a breastfed infant who feeds every 2 to 4 hours



Answer A

- the client experiences poor feeding (1 ounce = 30 ml)which indicates specific problems. The infant normallylooses weight during the first week of life and he/sheusually gains weight on the second week.



Answer B

Because of the structural defect, children with cleftpalate may have ineffective functioning of theirEustachian tubes creating frequent bouts of otitismedia. Most children with cleft palate remain well-

nourished and maintain adequate nutrition throughthe use of proper feeding techniques. Food particlesdo not pass through the cleft and into theEustachian tubes. There is no association betweencleft palate and congenial ear deformities.



Answer A.

For the child with Hirschsprung disease, fever andexplosive diarrhea indicate enterocolitis, a life-threatening situation. Therefore, the physicianshould be notified immediately. Generally, because

of the intestinal obstruction and inadequatepropulsive intestinal movement, antidiarrheals arenot used to treat Hirschsprung disease. The childis acutely ill and requires intervention, withmonitoring more frequently than every 30minutes. Hirschsprung disease typically presentswith chronic constipation.

62 Whi h f th f ll i ti



62. Which of the following suggestionsshould the nurse offer the parents of a

4-year-old boy who resists going to bedat night?

a. “Allow him to fall asleep in your room, then

move him to his own bed.”

b. “Tell him that you will lock him in his room if hegets out of bed one more time.”

c. “Encourage active play at bedtime to tire himout so he will fall asleep faster.”

d. “Read him a story and allow him to play quietly

in his bed until he falls asleep.”



Answer D.

Preschoolers commonly have fears of the dark, beingleft alone especially at bedtime, and ghosts, whichmay affect the child’s going to bed at night. Quietplay and time with parents is a positive bedtimeroutine that provides security and also readies thechild for sleep. The child should sleep in his own bed.Telling the child about locking him in his room willviewed by the child as a threat. Additionally, alocked door is frightening and potentially hazardous.

Vigorous activity at bedtime stirs up the child andmakes more difficult to fall asleep.



63. The nurse is caring for a 4-year oldwith cerebral palsy. Which nursing

intervention will help ready the child forrehabilitative services?

a. Patching one of the eyes to strengthen themuscles

b. Providing suckers and pinwheels to strengthentongue movement

c. Providing musical tapes to [provide auditory

trainingd. Encouraging play with a video game to improve

muscle coordination



Answer BThe nurse can help ready the child with cerebralpalsy for speech therapy by providing activitiesthat help the child develop tongue control.



Answer A

The least restrictive restraint for infant with acleft lip and cleft palate repair is elbow restraint.

69 Th i i f i f t



69. The nurse is caring for an infantfollowing a cleft lip repair. While comforting

the infant, the nurse should avoid:

a.Holding the infant

b.Offering a pacifierc. Providing a mobile

d.Offering sterile water



Answer B

The nurse should avoid giving the infant apacifier or bottle because sucking is notpermitted.



72. A child with croup is placed in a cool,high-humidity tent connected to room air.

The primary purpose of the tent is to:

a. Prevent insensible water loss

b. Provide a moist environment with oxygenat 30%

c. Prevent dehydration and reduce fever

d. Liquefy secretions and relieve laryngeal

spasm



Answer D

The primary reason for placing the child with croupunder a mist tent is to liquefy secretions andrelieve laryngeal spasm.



74. A 2-year old is hospitalized with

suspected intussusception. Which finding isassociated with intussusception?

a. “currant jelly” stools

b. Projectile vomiting

c. “ribbonlike” stools

d. Palpable mass over the flank



Answer AA child with intussusception has stools thatcontain blood and mucus, which are described as“currant jelly” stools.



75. A 4-year old is admitted with acute

leukemia. It will be most important tomonitor the child for:

a. Abdominal pain and anorexia

b. Fatigue and bruising

c. Bleeding and pallor

d. Petichiae and mucosal ulcers



Answer CA child with leukemia has low platelet coutwhich contributes to spontaneous bleeding.



80. A client is admitted with thediagnosis of meningitis. Which finding

would the nurse expect in assessing thisclient?

A)Hyperextension of the neck with passiveshoulder flexion

B) Flexion of the hip and knees with passiveflexion of the neck

C) Flexion of the legs with rebound tenderness

D) Hyperflexion of the neck with rebound flexionof the legs



Answer is B:

Flexion of the hip and knees with passive flexionof the neck. A positive Brudzinski’s sign—flexionof hip and knees with passive flexion of the neck;a positive Kernig’s sign—inability to extend theknee to more than 135 degrees, without painbehind the knee, while the hip is flexed usuallyestablishes the diagnosis of meningitis

82 During an examination of a 2 year old



82. During an examination of a 2 year-oldchild with a tentative diagnosis of Wilm's

tumor, the nurse would be most concernedabout which statement by the mother?

A) My child has lost 3 pounds in the last

month.B) Urinary output seemed to be less over thepast 2 days.C) All the pants have become tight around

the waist.D) The child prefers some salty foods morethan others.



Answer C:Clothing has become tight around the waistParents often recognize the increasingabdominal girth first. This is an early sign of

Wilm''s tumor, a malignant tumor of the kidney.

87. Which of the actions suggested to the



. f ggRN by the PN during a planning conferencefor a 10 month-old infant admitted 2 hoursago with bacterial meningitis would beacceptable to add to the plan of care?

A)Measure head circumferenceB) Place in airborne isolation

C) Provide passive range of motion

D) Provide an over-the-crib protective top



Answer A

Measure head circumferenceIn meningitis, assessment of neurological signsshould be done frequently. Head circumference ismeasured because subdural effusions and

obstructive hydrocephalus can develop as acomplication of meningitis. The client will havealready been on airborne precautions and crib topapplied to bed on admission to the unit.

88 An eighteen month old has been brought



88. An eighteen month-old has been broughtto the emergency room with irritability,

lethargy over 2 days, dry skin and increasedpulse. Based upon the evaluation of theseinitial findings, the nurse would assess thechild for additional findings of:

A)Septicemia

B) Dehydration

C) Hypokalemia

D) Hypercalcemia



Answer BDehydrationClinical findings dehydration includelethargy, irritability, dry skin, and

increased pulse.



Answer A

"Touching the abdomen could cause cancer cellsto spread."Manipulation of the abdomen can lead todissemination of cancer cells to nearby and

distant areas. Bathing and turning the childshould be done carefully. The other options aresimilar but not the most specific.



Answer D

half-strength hydrogen peroxide is recommendedfor cleansing the suture line after cleft lip repair.The bubbling action of the hydrogen peroxide iseffective for removing debris. Normal saline also may

be used. Mouthwashes frequently contain alcoholwhich can be irritating. Povidone-iodine solution is notused because iodine contained in the solution can beabsorbed through the skin, leading to toxicity. A mildantiseptic solution has some antibacterial propertiesbut is ineffective in removing suture-line debris.

21108577 Nclex 100 Questions and Answers With Rationale Pediatric Nursing2

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