1

Pediatric Nursing Practice

Test Part 1
1.

a.

While performing physical assessment of a 12

6.

When assessing an 18-month-old, the

month-old, the nurse notes that the infants

nurse notes a characteristic protruding abdomen.

anterior fontanel is still slightly open. Which of the

Which of the following would explain the rationale

following is the nurses most appropriate action?

for this finding?

Notify the physician immediately because there is

a.

Increased food intake owing to age

a problem.

b.

Underdeveloped abdominal muscles

b.

Perform an intensive neurologic examination.

c.

Bowlegged posture

c.

Perform an intensive developmental examination.

d.

Linear growth curve

d.

Do nothing because this is a normal finding for the

7.

If parents keep a toddler dependent in areas

age.
2.

where he is capable of using skills, the toddle will

When teaching a mother about introducing

develop a sense of which of the following?

solid foods to her child, which of the following

a.

Mistrust

indicates the earliest age at which this should be

b.

Shame

done?

c.

Guilt

a.

1 month

d.

Inferiority

b.

2 months

8.

Which of the following is an appropriate toy for

c.

3 months

d.

4 months

a.

Multiple-piece puzzle

3.

The infant of a substance-abusing mother is at

b.

Miniature cars

risk for developing a sense of which of the

c.

Finger paints

following?

d.

Comic book

9.

When teaching parents about the childs

an 18-month-old?

a.

Mistrust

b.

Shame

readiness for toilet training, which of the following

c.

Guilt

signs should the nurse instruct them to watch for

d.

Inferiority

in the toddler?

4.

Which of the following toys should the

nurse recommend for a 5-month-old?

a.

Demonstrates dryness for 4 hours

b.

Demonstrates ability to sit and walk

a.

A big red balloon

c.

Has a new sibling for stimulation

b.

A teddy bear with button eyes

d.

Verbalizes desire to go to the bathroom

c.

A push-pull wooden truck

10.

When teaching parents about typical toddler

d.

A colorful busy box

eating patterns, which of the following should be

5.

The mother of a 2-month-old is concerned that

included?

a.

she may be spoiling her baby by picking her up

a.

Food jags

when she cries. Which of the following would be

b.

Preference to eat alone

the nurses best response?

c.

Consistent table manners

d.

Increase in appetite

11.

Which of the following suggestions should the

Let her cry for a while before picking her up,

so you dont spoil her

b.

Babies need to be held and cuddled; you

nurse offer the parents of a 4-year-old boy who

wont spoil her this way

c.

Crying at this age means the baby is hungry;

resists going to bed at night?

a.

give her a bottle

d.

If you leave her alone she will learn how to

cry herself to sleep

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

he gets out of bed one more time.

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c.

Encourage active play at bedtime to tire him

out so he will fall asleep faster.

d.

c.

Reading

d.

Sorting

17.

A child age 7 was unable to receive the

Read him a story and allow him to play

quietly in his bed until he falls asleep.

12.

When providing therapeutic play, which of the

following toys would best promote imaginative
play in a 4-year-old?

a.

Large blocks

measles, mumps, and rubella (MMR) vaccine at

b.

Dress-up clothes

the recommended scheduled time. When

c.

Wooden puzzle

would the nurse expect to administer MMR

d.

Big wheels

vaccine?

13.

Which of the following activities, when voiced

a.

In a month from now

by the parents following a teaching session about

b.

In a year from now

the characteristics of school-age cognitive

c.

At age 10

development would indicate the need for

d.

At age 13

additional teaching?

18.

The adolescents inability to develop a sense

a.

Collecting baseball cards and marbles

of who he is and what he can become results in a

b.

Ordering dolls according to size

sense of which of the following?

c.

Considering simple problem-solving options

a.

Shame

d.

Developing plans for the future

b.

Guilt

14.

A hospitalized schoolager states: Im not

c.

Inferiority

afraid of this place, Im not afraid of anything.

d.

Role diffusion

This statement is most likely an example of which

19.

Which of the following would be most

of the following?

appropriate for a nurse to use when describing

a.

Regression

menarche to a 13-year-old?

b.

Repression

c.

Reaction formation

d.

Rationalization

b.

The first year of menstruation or period

15.

After teaching a group of parents about

c.

The entire menstrual cycle or from one

a.

periods

accident prevention for schoolagers, which of the

following statements by the group would indicate

period to another
d.

the need for more teaching?

a.

Schoolagers are more active and

20.

Schoolagers are more susceptible to home

mirror all the time. Which of the following remarks

d.

by the nurse would be least helpful in talking to

Schoolagers are unable to understand

potential dangers around them.

the boy and his parents?

a.

Schoolargers are less subject to parental

Which of the following skills is the most

This is probably the only concern he has

about his body. So dont worry about it or the time

control than are younger children.

16.

A 14-year-old boy has acne and according to

his parents, dominates the bathroom by using the

hazards than are younger children.

c.

The onset of uterine maturation or peak

growth

adventurous than are younger children.

b.

A females first menstruation or menstrual

he spends on it.
b.

Teenagers are anxious about how their peers

significant one learned during the schoolage

perceive them. So they spend a lot of time

period?

grooming.

a.

Collecting

b.

Ordering

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c.

A teen may develop a poor self-image when

d.

experiencing acne. Do you feel this way

sometimes?
d.

ear.
25.

You appear to be keeping your face well

21.

a.

While performing a neurodevelopmental

assessment on a 3-month-old infant, which of the

washed. Would you feel comfortable discussing

your cleansing method?

Associated congenital defects of the middle

following characteristics would be expected?

a.

A strong Moro reflex

b.

A strong parachute reflex

nurse suspect when noting that a 3-year-old is

c.

Rolling from front to back

engaging in explicit sexual behavior during doll

d.

Lifting of head and chest when prone

play?

26.

By the end of which of the following would the

Which of the following should the

The child is exhibiting normal pre-school

nurse most commonly expect a childs birth

curiosity

weight to triple?

b.

The child is acting out personal experiences

a.

4 months

c.

The child does not know how to play with dolls

b.

7 months

d.

The child is probably developmentally

c.

9 months

d.

12 months

27.

Which of the following best describes parallel

delayed.
22.

Which of the following statements by the

parents of a child with school phobia would
indicate the need for further teaching?

a.

Well keep him at home until phobia

subsides.

b.

a.

Sharing crayons to color separate pictures

b.

Playing a board game with a nurse

c.

Sitting near each other while playing with

Well work with his teachers and counselors

at school.

c.

play between two toddlers?

Well try to encourage him to talk about his

separate dolls
d.

Sharing their dolls with two different nurses

28.

Which of the following would the nurse identify

problem.
d.

Well discuss possible solutions with him and

his counselor.

23.

a.

as the initial priority for a child with acute

lymphocytic leukemia?
a.

Instituting infection control precautions

b.

Encouraging adequate intake of iron-rich foods

of high school students about teenage

c.

Assisting with coping with chronic illness

pregnancy, the nurse would keep in mind which of

d.

Administering medications via IM injections

the following?

29.

Which of the following information, when

When developing a teaching plan for a group

The incidence of teenage pregnancies is

voiced by the mother, would indicate to the nurse

increasing.

that she understands home care instructions

b.

Most teenage pregnancies are planned.

following the administration of a diphtheria,

c.

Denial of the pregnancy is common early on.

tetanus, and pertussis injection?

d.

The risk for complications during pregnancy is

a.

Measures to reduce fever

b.

Need for dietary restrictions

c.

Reasons for subsequent rash

nurse is aware that the child is at risk for more

d.

Measures to control subsequent diarrhea

frequent episodes of otitis media due to which of

30.

Which of the following actions by a community

rare.
24.

When assessing a child with a cleft palate, the

the following?

health nurse is most appropriate when noting

a.

Lowered resistance from malnutrition

multiple bruises and burns on the posterior trunk

b.

Ineffective functioning of the Eustachian tubes

of an 18-month-old child during a home visit?

c.

Plugging of the Eustachian tubes with food

particles

a.

Report the childs condition to Protective

Services immediately.

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b.

Schedule a follow-up visit to check for more

35.

bruises.

Which of the following should the nurse do

first for a 15-year-old boy with a full leg cast who

c.

Notify the childs physician immediately.

is screaming in unrelenting pain and exhibiting

d.

Do nothing because this is a normal finding in

right foot pallor signifying compartment

a toddler.
31.

Which of the following is being used when the

syndrome?
a.

Medicate him with acetaminophen.

mother of a hospitalized child calls the student

b.

Notify the physician immediately

nurse and states, You idiot, you have no idea how

c.

Release the traction

to care for my sick child?

d.

Monitor him every 5 minutes

36.

At which of the following ages would the nurse

a.

Displacement

b.

Projection

expect to administer the varicella zoster vaccine

c.

Repression

to child?

d.

Psychosis

a.

At birth

32.

Which of the following should the nurse expect

b.

2 months

to note as a frequent complication for a child with

c.

6 months

congenital heart disease?

d.

12 months

37.

When discussing normal infant growth and

a.

Susceptibility to respiratory infection

b.

Bleeding tendencies

development with parents, which of the following

c.

Frequent vomiting and diarrhea

toys would the nurse suggest as most appropriate

d.

Seizure disorder

for an 8-month-old?

33.

Which of the following would the nurse do first

a.

Push-pull toys

b.

Rattle

c.

Large blocks

d.

Mobile

38.

Which of the following aspects of psychosocial

for a 3-year-old boy who arrives in the emergency

development is necessary for the nurse to keep in

room with a temperature of 105 degrees F,

mind when providing care for the preschool child?

inspiratory stridor, and restlessness, who is

a.

learning forward and drooling?

a.

Auscultate his lungs and place him in a mist

out situations.
b.

tent.
b.

Have him lie down and rest after encouraging

fluids.

c.

d.

34.

c.

The child engages in competitive types of play

d.

Immediate gratification is necessary to

develop initiative.

39.

Notify the physician immediately and prepare

for intubation.

Fear of body mutilation is a common preschool

fear

Examine his throat and perform a throat

culture

The child can use complex reasoning to think

Which of the following is characteristic of a

preschooler with mid mental retardation?

a.

Slow to feed self

b.

Lack of speech

to keep in mind as a predisposing factor when

c.

Marked motor delays

formulating a teaching plan for child with a urinary

d.

Gait disability

tract infection?

40.

Which of the following assessment findings

Which of the following would the nurse need

a.

A shorter urethra in females

would lead the nurse to suspect Down syndrome

b.

Frequent emptying of the bladder

in an infant?

c.

Increased fluid intake

a.

Small tongue

d.

Ingestion of acidic juices

b.

Transverse palmar crease

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c.

Large nose

c.

Wheat

d.

Restricted joint movement

d.

Chicken

41.

While assessing a newborn with cleft lip, the

47.

Which of the following would the nurse expect

nurse would be alert that which of the following

to assess in a child with celiac disease having a

will most likely be compromised?

celiac crisis secondary to an upper respiratory

a.

Sucking ability

b.

Respiratory status

a.

Respiratory distress

c.

Locomotion

b.

Lethargy

d.

GI function

c.

Watery diarrhea

42.

When providing postoperative care for the

d.

Weight gain

48.

Which of the following should the nurse do

child with a cleft palate, the nurse should position

infection?

the child in which of the following positions?

first after noting that a child with Hirschsprung

a.

Supine

disease has a fever and watery explosive

b.

Prone

diarrhea?

c.

In an infant seat

a.

Notify the physician immediately

d.

On the side

b.

Administer antidiarrheal medications

43.

While assessing a child with pyloric stenosis,

c.

Monitor child ever 30 minutes

the nurse is likely to note which of the following?

d.

Nothing, this is characteristic of Hirschsprung

a.

Regurgitation

disease

b.

Steatorrhea

c.

Projectile vomiting

the first 24 hours after birth may indicate which of

d.

Currant jelly stools

the following?

44.

Which of the following nursing diagnoses

49.

A newborns failure to pass meconium within

a.

Hirschsprung disease

would be inappropriate for the infant with

b.

Celiac disease

gastroesophageal reflux (GER)?

c.

Intussusception

a.

Fluid volume deficit

d.

Abdominal wall defect

b.

Risk for aspiration

50.

When assessing a child for possible

c.

Altered nutrition: less than body requirements

intussusception, which of the following would be

d.

Altered oral mucous membranes

least likely to provide valuable information?

45.

Which of the following parameters would the

a.

Stool inspection

b.

Pain pattern

c.

Family history

d.

Abdominal palpation

nurse monitor to evaluate the effectiveness of

thickened feedings for an infant with
gastroesophageal reflux (GER)?
a.

Vomiting

b.

Stools

c.

Uterine

d.

Weight

between 12 to 18 months of age. Thus, assessing

46.

Discharge teaching for a child with celiac

the anterior fontanel as still being slightly open is

Answers and Rationale

1. D. The anterior fontanel typically closes anywhere

disease would include instructions about avoiding

a normal finding requiring no further action.

which of the following?

Because it is normal finding for this age, notifying

a.

Rice

b.

Milk

he physician or performing additional

examinations are inappropriate.

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2. D. Solid foods are not recommended before age 4

decreases, not increases. Toddlers are

to 6 months because of the sucking reflex and

characteristically bowlegged because the leg

the immaturity of the gastrointestinal tract and

muscles must bear the weight of the relatively

immune system. Therefore, the earliest age at

large trunk. Toddler growth patterns occur in a

which to introduce foods is 4 months. Any time

steplike, not linear pattern.

earlier would be inappropriate.

3. A. According to Erikson, infants need to have their

7. B. According to Erikson, toddlers experience a

sense of shame when they are not allowed to

needs met consistently and effectively to

develop appropriate independence and autonomy.

develop a sense of trust. An infant whose needs

Infants develop mistrust when their needs are not

are consistently unmet or who experiences

consistently gratified. Preschoolers develop guilt

significant delays in having them met, such as in

when their initiative needs are not met while

the case of the infant of a substance-abusing

schoolagers develop a sense of inferiority when

mother, will develop a sense of uncertainty,

their industry needs are not met.

leading to mistrust of caregivers and the

8. C. Young toddlers are still sensorimotor learners

environment. Toddlers develop a sense of shame

and they enjoy the experience of feeling different

when their autonomy needs are not met

textures. Thus, finger paints would be an

consistently. Preschoolers develop a sense of guilt

appropriate toy choice. Multiple-piece toys, such

when their sense of initiative is thwarted.

as puzzle, are too difficult to manipulate and may

Schoolagers develop a sense of inferiority when

be hazardous if the pieces are small enough to be

they do not develop a sense of industry.

aspirated. Miniature cars also have a high

4. D. A busy box facilitates the fine motor

potential for aspiration. Comic books are on too

development that occurs between 4 and 6

high a level for toddlers. Although they may enjoy

months. Balloons are contraindicated

looking at some of the pictures, toddlers are more

because small children may aspirate balloons.

likely to rip a comic book apart.

Because the button eyes of a teddy bear may

9. D. The child must be able to sate the need to go to

detach and be aspirated, this toy is unsafe for

the bathroom to initiate toilet training. Usually, a

children younger than 3 years. A 5-month-old is

child needs to be dry for only 2 hours, not 4 hours.

too young to use a push-pull toy.

The child also must be able to sit, walk, and squat.

5. B. Infants need to have their security needs met by

being held and cuddled. At 2 months of age, they
are unable to make the connection between crying

A new sibling would most likely hinder toilet

training.
10. A. Toddlers become picky eaters, experiencing

and attention. This association does not occur

food jags and eating large amounts one day and

until late infancy or early toddlerhood. Letting

very little the next. A toddlers food gags express

the infant cry for a time before picking up

a preference for the ritualism of eating one type of

the infant or leaving the infant alone to cry herself

food for several days at a time. Toddlers typically

to sleep interferes with meeting the infants need

enjoy socialization and limiting others at meal

for security at this very young age. Infants cry for

time. Toddlers prefer to feed themselves and thus

many reasons. Assuming that the child s hungry

are too young to have table manners. A toddlers

may cause overfeeding problems such as obesity.

appetite and need for calories, protein, and fluid

6. B. Underdeveloped abdominal musculature gives

the toddler a characteristically protruding
abdomen. During toddlerhood, food intake

decrease due to the dramatic slowing of growth

rate.

7
11. D. Preschoolers commonly have fears of the dark,

adherence to rules. Thus, schoolagers should be

being left alone especially at bedtime, and ghosts,

able to understand the potential dangers around

which may affect the childs going to bed at night.

them. With growth comes greater freedom and

Quiet play and time with parents is a positive

children become more adventurous and daring.

bedtime routine that provides security and also

The school-aged child is also still prone to

readies the child for sleep. The child should sleep

accidents and home hazards, especially because

in his own bed. Telling the child about locking him

of increased motor abilities and independence.

in his room will viewed by the child as a threat.

Plus the home hazards differ from other age

Additionally, a locked door is frightening and

groups. These hazards, which are potentially lethal

potentially hazardous. Vigorous activity at bedtime

but tempting, may include firearms, alcohol, and

stirs up the child and makes more difficult to fall

medications. School-age children begin to

asleep.

internalize their own controls and need less

12. B. Dress-up clothes enhance imaginative play and

outside direction. Plus the child is away from home

imagination, allowing preschoolers to engage in

more often. Some parental or caregiver assistance

rich fantasy play. Building blocks and wooden

is still needed to answer questions and provide

puzzles are appropriate for encouraging finemotor

guidance for decisions and responsibilities.

development. Big wheels and tricycles encourage

16. C. The most significant skill learned during the

gross motor development.

13. D. The school-aged child is in the stage of

school-age period is reading. During this time the

child develops formal adult articulation patterns

concrete operations, marked by inductive

and learns that words can be arranged in

reasoning, logical operations, and reversible

structure. Collective, ordering, and sorting,

concrete thought. The ability to consider the

although important, are not most significant skills

future requires formal thought operations, which

learned.

are not developed until adolescence. Collecting

17. C. Based on the recommendations of

baseball cards and marbles, ordering dolls by size,

the American Academy of Family Physicians and

and simple problem-solving options are examples

the American Academy of Pediatrics, the MMR

of the concrete operational thinking of the

vaccine should be given at the age of 10 if the

schoolager.

child did not receive it between the ages of 4 to 6

14. C. Reaction formation is the schoolagers typical

defensive response when hospitalized. In reaction
formation, expression of unacceptable thoughts or

years as recommended. Immunization for

diphtheria and tetanus is required at age 13.
18. D. According to Erikson, role diffusion develops

behaviors is prevented (or overridden) by the

when the adolescent does not develop a sense of

exaggerated expression of opposite thoughts or

identity and a sense or where he fits in. Toddlers

types of behaviors. Regression is seen in toddlers

develop a sense of shame when they do not

and preshcoolers when they retreat or return to an

achieve autonomy. Preschoolers develop a sense

earlier level of development. Repression refers to

of guilt when they do not develop a sense of

the involuntary blocking of unpleasant feelings

initiative. School-age children develop a sense of

and experiences from ones awareness.

inferiority when they do not develop a sense of

Rationalization is the attempt to make excuses to

industry.

justify unacceptable feelings or behaviors.

15. C. The schoolagers cognitive level is sufficiently
developed to enable good understanding of and

19. A. Menarche refers to the onset of the first

menstruation or menstrual period and refers only

8
to the first cycle. Uterine growth and broadening

recognition by a parent or health care provider

of the pelvic girdle occurs before menarche.

may be crucial to timely initiation of prenatal care.

20. A. Stating that this is probably the only concern

The incidence of adolescent pregnancy has

the adolescent has and telling the parents not to

declined since 1991, yet morbidity remains high.

worry about it or the time her spends on it shuts

Most teenage pregnancies are unplanned and

off further investigation and is likely to make the

occur out of wedlock. The pregnant adolescent is

adolescent and his parents feel defensive. The

at high risk for physical complications including

statement about peer acceptance and time spent

premature labor and low-birth-weight infants, high

in front of the mirror for the development of self

neonatal mortality, iron deficiency anemia,

image provides information about the adolescents

prolonged labor, and fetopelvic disproportion as

needs to the parents and may help to gain trust

well as numerous psychological crises.

with the adolescent. Asking the adolescent how he

24. B. Because of the structural defect, children with

feels about the acne will encourage the

cleft palate may have ineffective functioning of

adolescent to share his feelings. Discussing the

their Eustachian tubes creating frequent bouts of

cleansing method shows interest and concern for

otitis media. Most children with cleft palate remain

the adolescent and also can help to identify any

well-nourished and maintain adequate nutrition

patient-teaching needs for the adolescent

through the use of proper feeding techniques.

regarding cleansing.

Food particles do not pass through the cleft and

21. B. Preschoolers should be developmentally

into the Eustachian tubes. There is no association

incapable of demonstrating explicit sexual

between cleft palate and congenial ear

behavior. If a child does so, the child has been

deformities.

exposed to such behavior, and sexual abuse

25. D. A 3-month-old infant should be able to lift the

should be suspected. Explicit sexual behavior

head and chest when prone. The Moro reflex

during doll play is not a characteristic of preschool

typically diminishes or subsides by 3 months. The

development nor symptomatic of developmental

parachute reflex appears at 9 months. Rolling

delay. Whether or nor the child knows how to play

from front to back usually is accomplished at

with dolls is irrelevant.

about 5 months.

22. A. The parents need more teaching if they state

26. D. A childs birth weight usually triples by 12

that they will keep the child home until the phobia

months and doubles by 4 months. No specific birth

subsides. Doing so reinforces the childs feelings

weight parameters are established for 7 or 9

of worthlessness and dependency. The child

months.

should attend school even during resolution of the

27. C. Toddlers engaging in parallel play will play near

problem. Allowing the child to verbalize helps the

each other, but not with each other. Thus, when

child to ventilate feelings and may help to uncover

two toddlers sit near each other but play with

causes and solutions. Collaboration with the

separate dolls, they are exhibiting parallel play.

teachers and counselors at school may lead to

Sharing crayons, playing a board game with a

uncovering the cause of the phobia and to the

nurse, or sharing dolls with two different nurses

development of solutions. The child should

are all examples of cooperative play.

participate and play an active role in developing

possible solutions.
23. C. The adolescent who becomes pregnant
typically denies the pregnancy early on. Early

28. A. Acute lymphocytic leukemia (ALL) causes

leukopenia, resulting in immunosuppression and
increasing the risk of infection, a leading cause of
death in children with ALL. Therefore, the initial

9
priority nursing intervention would be to institute

unconscious. Psychosis is a state of being out of

infection control precautions to decrease the risk

touch with reality.

of infection. Iron-rich foods help with anemia, but

32. A. Children with congenital heart disease are more

dietary iron is not an initial intervention. The

prone to respiratory infections. Bleeding

prognosis of ALL usually is good. However, later

tendencies, frequent vomiting, and diarrhea and

on, the nurse may need to assist the child and

seizure disorders are not associated with

family with coping since death and dying may still

congenital heart disease.

be an issue in need of discussion. Injections

33. D. The child is exhibiting classic signs of

should be discouraged, owing to increased risk

epiglottitis, always a pediatric emergency. The

from bleeding due to thrombocytopenia.

physician must be notified immediately and the

29. A. The pertusis component may result in fever and

nurse must be prepared for an emergency

the tetanus component may result in injection

intubation or tracheostomy. Further assessment

soreness. Therefore, the mothers verbalization of

with auscultating lungs and placing the child in a

information about measures to reduce fever

mist tent wastes valuable time. The situation is a

indicates understanding. No dietary restrictions

possible life-threatening emergency. Having the

are necessary after this injection is given. A

child lie down would cause additional distress and

subsequent rash is more likely to be seen 5 to 10

may result in respiratory arrest. Throat

days after receiving the MMR vaccine, not the

examination may result in laryngospasm that

diphtheria, pertussis, and tetanus vaccine.

could be fatal.

Diarrhea is not associated with this vaccine.

30. A. Multiple bruises and burns on a toddler are

34. A. In females, the urethra is shorter than in males.

This decreases the distance for organisms to

signs child abuse. Therefore, the nurse is

travel, thereby increasing the chance of the child

responsible for reporting the case to Protective

developing a urinary tract infection. Frequent

Services immediately to protect the child from

emptying of the bladder would help to decrease

further harm. Scheduling a follow-up visit is

urinary tract infections by avoiding sphincter

inappropriate because additional harm may come

stress. Increased fluid intake enables the bladder

to the child if the nurse waits for further

to be cleared more frequently, thus helping to

assessment data. Although the nurse should notify

prevent urinary tract infections. The intake of

the physician, the goal is to initiate measures to

acidic juices helps to keep the urine pH acidic and

protect the childs safety. Notifying the physician

thus decrease the chance of flora development.

immediately does not initiate the removal of the

35. B. Compartment syndrome is an emergent

child from harm nor does it absolve the nurse from

situation and the physician needs to be notified

responsibility. Multiple bruises and burns are not

immediately so that interventions can be initiated

normal toddler injuries.

to relieve the increasing pressure and restore

31. B. The mother is using projection, the defense

circulation. Acetaminophen (Tylenol) will be

mechanism used when a person attributes his or

ineffective since the pain is related to the

her own undesirable traits to another.

increasing pressure and tissue ischemia. The cast,

Displacement is the transfer of emotion onto an

not traction, is being used in this situation for

unrelated object, such as when the mother would

immobilization, so releasing the traction would be

kick a chair or bang the door shut. Repression is

inappropriate. In this situation, specific action not

the submerging of painful ideas into the

continued monitoring is indicated.

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36. D. The varicella zoster vaccine (VZV) is a live

second and big toes, hyperextensible and lax

vaccine given after age 12 months. The first dose

joints, large protruding tongue, and muscle

of hepatitis B vaccine is given at birth to 2

weakness.

months, then at 1 to 4 months, and then again at

41. A. Because of the defect, the child will be unable

6 to 18 months. DtaP is routinely given at 2, 4, 6,

to from the mouth adequately around nipple,

and 15 to 18 months and a booster at 4 to 6

thereby requiring special devices to allow for

years.

feeding and sucking gratification. Respiratory

37. C. Because the 8-month-old is refining his gross

status may be compromised if the child is fed

motor skills, being able to sit unsupported and

improperly or during postoperative period,

also improving his fine motor skills, probably

Locomotion would be a problem for the older

capable of making hand-to-hand transfers, large

infant because of the use of restraints. GI

blocks would be the most appropriate toy

functioning is not compromised in the child with a

selection. Push-pull toys would be more

cleft lip.

appropriate for the 10 to 12-month-old as he or

42. B. Postoperatively children with cleft palate should

she begins to cruise the environment. Rattles and

be placed on their abdomens to facilitate

mobiles are more appropriate for infants in the 1

drainage. If the child is placed in the supine

to 3 month age range. Mobiles pose a danger to

position, he or she may aspirate. Using an infant

older infants because of possible strangulation.

seat does not facilitate drainage. Side-lying does

38. B. During the preschool period, the child has

mastered a sense of autonomy and goes on to

not facilitate drainage only prone can.

43. C. Projectile vomiting is a key symptom of pyloric

master a sense of initiative. During this period, the

stenosis. Regurgitation is seen more commonly

child commonly experiences more fears than at

with GER. Steatorrhea occurs in malabsorption

any other time. One common fear is fear of the

disorders such as celiac disease. Currant jelly

body mutilation, especially associated with painful

stools are characteristic of intussusception.

experiences. The preschool child uses simple, not

44. D. GER is the backflow of gastric contents into the

complex, reasoning, engages in associative, not

esophagus resulting from relaxation or

competitive, play (interactive and cooperative

incompetence of the lower esophageal (cardiac)

play with sharing), and is able to tolerate longer

sphincter. No alteration in the oral mucous

periods of delayed gratification.

membranes occurs with this disorder. Fluid volume

39. A. Mild mental retardation refers to development

disability involving an IQ 50 to 70. Typically, the
child is not noted as being retarded, but exhibits

deficit, risk for aspiration, and altered nutrition are

appropriate nursing diagnoses.
45. A. Thickened feedings are used with GER to stop

slowness in performing tasks, such as self-feeding,

the vomiting. Therefore, the nurse would monitor

walking, and taking. Little or no speech, marked

the childs vomiting to evaluate the effectiveness

motor delays, and gait disabilities would be seen

of using the thickened feedings. No relationship

in more severe forms mental retardation.

exists between feedings and characteristics of

40. B. Down syndrome is characterized by the

stools and uterine. If feedings are ineffective, this

following a transverse palmar crease (simian

should be noted before there is any change in the

crease), separated sagittal suture, oblique

childs weight.

palpebral fissures, small nose, depressed nasal

46. C. Children with celiac disease cannot tolerate or

bridge, high-arched palate, excess and lax skin,

digest gluten. Therefore, because of its gluten

wide spacing and plantar crease between the

content, wheat and wheat-containing products

11
must be avoided. Rice, milk, and chicken do not
contain gluten and need not be avoided.
47. C. Episodes of celiac crises are precipitated by
infections, ingestion of gluten, prolonged fasting,
or exposure to anticholinergic drugs. Celiac crisis
is typically characterized by severe watery
diarrhea. Respiratory distress is unlikely in a
routine upper respiratory infection. Irritability,
rather than lethargy, is more likely. Because of the
fluid loss associated with the severe watery
diarrhea, the childs weight is more likely to be
decreased.
48. A. For the child with Hirschsprung disease, fever
and explosive diarrhea indicate enterocolitis, a
life-threatening situation. Therefore, the physician
should be notified immediately. Generally,
because of the intestinal obstruction and
inadequate propulsive intestinal movement,
antidiarrheals are not used to treat Hirschsprung
disease. The child is acutely ill and requires
intervention, with monitoring more frequently than
every 30 minutes. Hirschsprung disease typically
presents with chronic constipation.
49. A. Failure to pass meconium within the first 24
hours after birth may be an indication of
Hirschsprung disease, a congenital anomaly
resulting in mechanical obstruction due to
inadequate motility in an intestinal segment.
Failure to pass meconium is not associated with
celiac disease, intussusception, or abdominal wall
defect.
50. C. Because intussusception is not believed to have
a familial tendency, obtaining a family history
would provide the least amount of information.
Stool inspection, pain pattern, and abdominal
palpation would reveal possible indicators of
intussusception. Current, jelly-like stools
containing blood and mucus are an indication of
intussusception. Acute, episodic abdominal pain is
characteristics of intussusception. A sausageshaped mass may be palpated in the right upper
quadrant.