The nurse is assisting with a physical exam on a child who has been admitted with a diagnosis of possible child abuse (child maltreatment). Which finding might alert the nurse to this possibility that the child may have been abused?

The child has a fractured bone.

The child is hyperactive and angry.

The child has bruises on the knees and elbows.

The child has a burn that has not been treated.

Answer and Explanation

The Correct Answer is D

Choice A reason: A fractured bone can occur from accidents or abuse, but alone, it is not specific to maltreatment without inconsistent history or pattern. An untreated burn is more suggestive of neglect or abuse, as it indicates failure to seek care, making this less definitive and incorrect compared to a clear neglect indicator.

Choice B reason: Hyperactivity and anger are behavioral responses that may occur in abused children but are nonspecific and common in other conditions. An untreated burn is a clearer physical sign of potential neglect or abuse, making this behavioral finding less indicative and incorrect for alerting to possible child maltreatment.

Choice C reason: Bruises on knees and elbows are typical in active children from play, not necessarily indicative of abuse. An untreated burn raises stronger suspicion of neglect or intentional injury, making this common finding less concerning and incorrect for identifying potential child maltreatment in a clinical setting.

Choice D reason: An untreated burn is highly suggestive of child abuse or neglect, as it indicates failure to seek medical care for a serious injury. This finding, especially if unexplained or inconsistent with history, aligns with child maltreatment indicators, making it the most alerting sign for the nurse to investigate further.

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Correct Answer is C

Explanation

Choice A reason: Removing equipment reduces clutter but is less urgent than preventing falls, especially post-procedure when a child may be disoriented. Ensuring side rails and a low bed prioritizes safety, making this secondary and incorrect for the most immediate action in pediatric post-procedure care.

Choice B reason: Handling contaminated linens follows infection control but is not the immediate safety concern post-procedure. Preventing falls with side rails and a low bed is critical, making this less urgent and incorrect compared to the priority of ensuring the child’s physical safety after the procedure.

Choice C reason: Assessing side rails up and bed lowered prevents falls, the most immediate safety risk post-procedure when a child may be sedated or unsteady. This aligns with pediatric safety protocols, making it the correct statement for the most urgent action in post-procedure interventions.

Choice D reason: Documentation is essential but not immediate compared to fall prevention, which protects the child post-procedure. Side rails and bed positioning take precedence, making this subsequent and incorrect for the most urgent safety action required after a pediatric procedure in the hospital.

A. Place the probe of the oximeter on the child’s chest and secure it with tape. B. Explain that pulse oximetry is done to detect respiratory retractions. C. Explain that pulse oximetry measures the oxygen saturation of arterial hemoglobin. D. Ensure the oximeter probe site is checked every 8 hours for possible reactions.

Correct Answer is C

Explanation

Choice A reason: Placing the probe on the chest is not a standard pulse oximetry site and gives inaccurate readings. Explaining the device’s purpose addresses the caregiver’s concern, making this ineffective and incorrect compared to educating about the sensor’s role in monitoring the infant’s oxygen levels.

Choice B reason: Pulse oximetry measures oxygen saturation, not respiratory retractions, which are observed visually. Clarifying its purpose reassures the caregiver, making this inaccurate and incorrect compared to explaining the device’s function to address concerns about the sensor’s use on the infant.

Choice C reason: Explaining that pulse oximetry measures oxygen saturation clarifies its importance, reassuring the caregiver about its necessity and addressing tightness concerns. This aligns with pediatric nursing education principles, making it the prioritized response to ensure compliance with monitoring the infant’s respiratory status.

Choice D reason: Checking the probe site every 8 hours prevents skin issues but doesn’t address the caregiver’s concern about tightness. Explaining the device’s purpose promotes understanding, making this secondary and incorrect compared to educating to maintain the sensor’s use on the infant.

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The nurse is assisting with a physical exam on a child who has been admitted with a diagnosis of possible child abuse (child maltreatment). Which finding might alert the nurse to this possibility that the child may have been abused?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing post-procedure interventions with new pediatric nurses. Which statement addresses the most immediate safety action required?

Correct Answer is C

Explanation

The caregiver of an infant keeps removing the pulse oximetry sensor claiming it is too tight and hurting the baby. Which response should the nurse prioritize in addressing this situation?

Correct Answer is C

Explanation

The nursing instructor is conducting a class on the development of an infant. The instructor determines the class is successful when the students correctly illustrate which as the proximodistal development in an infant?

The nurse is assessing a teenage client and notes his lower front teeth are slightly crossed over. The nurse points out to his caregiver that he should see an orthodontist about this to prevent which potential situation?

The nurse is developing a care plan for several clients who were seen in the clinic that day. Which situation will the nurse conclude is most likely to experience challenges in the growth and development of the children?

What information is most correct regarding the nervous system of the child?

The nurse is teaching an in-service program to a group of nurses on the topic of children diagnosed with Kwashiorkor. The nurses in the group make the following statements. Which statement is most accurate related to the diagnosis of Kwashiorkor?

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