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A nurse on a pediatric unit is caring for a 5-week-old infant.

Exhibits

Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

Nurses' Notes

2000:

Infant awake and alert in parent's arms in bedside chair. Trunk, arms, and hands warm to palpation. Edema noted to hands, feet, and periorbital area. Weak bilateral femoral pulses. Lower extremities cool to palpation. Lungs clear bilaterally on auscultation. Mucous membranes pink and moist.

2200:

Infant asleep in crib. Heart rate regular, no murmur on auscultation.

Vital Signs

2000:

Blood pressure 98/60 mm Hg right arm: 60/40 mm Hg right leg Heart rate 168/min

Respiratory rate 34/min

Temperature 37° C (98.6° F)

Oxygen saturation 97% on room air, right wrist

Trunk, arms, and hands warm to palpation

Edema noted to hands, feet, and periorbital area

Weak bilateral femoral pulses

Lower extremities cool to palpation

Mucous membranes pink and moist

Blood pressure 98/60 mm Hg right arm: 60/40 mm Hg right leg Heart rate 168/min

Respiratory rate 34/min

Answer and Explanation

The Correct Answer is ["B","C","D","F"]

Findings that require follow-up:

Edema noted to hands, feet, and periorbital area: Edema in these areas, especially periorbital edema, could indicate fluid retention, possibly from heart failure, kidney issues, or circulatory problems. This should be further evaluated to determine the underlying cause.
Weak bilateral femoral pulses: Weak femoral pulses could suggest a circulatory problem or arterial insufficiency. This is concerning as it could indicate a vascular or cardiac issue that requires immediate investigation.
Lower extremities cool to palpation: Cool lower extremities may indicate poor circulation, which can be caused by a cardiovascular issue, such as shock or impaired circulation, which needs immediate attention.
Blood pressure discrepancy (right arm: 98/60 mm Hg, right leg: 60/40 mm Hg): A significant difference in blood pressure readings between the arms and legs (known as a differential blood pressure) can indicate conditions like coarctation of the aorta (a congenital heart defect), which requires immediate follow-up.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. "My child will be awake for this procedure.": Incorrect because the child will be under sedation or anesthesia for safety and to prevent distress.
B. "I can take my child home as soon as the procedure is over.": Incorrect because the child must be monitored post-procedure for complications like airway swelling or sedation effects.
C. "The provider will remove the object during this procedure." A bronchoscopy allows visualization and removal of foreign objects from the airway, which is the purpose of the procedure.
D. "After this procedure, I have to wait 48 hours before I can give my child solid foods.": Incorrect because eating is typically resumed after the child recovers from sedation and demonstrates a safe swallow reflex.

A. "I will ensure that my child takes a 1 hour nap each day." B. "I will give my child prednisone as needed for pain." C. "I will apply cool compresses to my child's painful joints during exacerbations." D. "I will have my child wear splints during the night."

Correct Answer is D

Explanation

A. "I will ensure that my child takes a 1-hour nap each day." Prolonged inactivity, like frequent naps, may increase joint stiffness. Physical activity should be encouraged to maintain joint mobility.
B. "I will give my child prednisone as needed for pain." Prednisone is not typically used as needed for pain. NSAIDs are the first-line treatment for inflammation and pain in JIA.
C. "I will apply cool compresses to my child's painful joints during exacerbations." Warm compresses, not cool, are typically more effective in relieving joint stiffness in JIA.
D. "I will have my child wear splints during the night." Wearing splints at night helps maintain joint position and prevent contractures.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is providing pre-procedure teaching to the parents of a child who is to undergo a bronchoscopy due to aspiration of a foreign body. Which of the following parent statements indicate understanding of the teaching?

Correct Answer is C

Explanation

A nurse is providing discharge teaching to the parent of a school-age child who has juvenile idiopathic arthritis (JIA). The nurse should identify that which of the following responses by the parent indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is caring for an infant who has returned to the pediatric unit following surgical repair of a cleft lip. Which of the following actions should the nurse take?

A nurse is providing discharge teaching to the parent of a 5-year-old child who has leukemia and is receiving chemotherapy. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is assessing a 2-year-old child following a surgical procedure. Which of the following pain tools should the nurse use?

A nurse is planning care for a child who has cerebral palsy and is experiencing muscle spasms. Which of the following medications should the nurse expect to administer?

A nurse in a pediatric clinic is providing teaching to the parent of an infant who has gastroesophageal reflux (GER). The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching?

A nurse is providing home care instructions to the parents of a child who is in the edema phase of nephrotic syndrome. Which of the following instructions should the nurse include in the teaching?

A nurse is planning care for a newly admitted child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan?