Cleft Lip and Palate Exam #3

Cleft lip/palate repair – 3 A nurse is caring for an infant who is 24 hours post-op following a cleft palate repair. Which action is appropriate by the nurse? Administer opioids for pain A nurse is caring for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take? A. Encourage the parents to rock the infant. B. Offer the infant a pacifier. C. Administer ibuprofen as needed for pain. D. Position the infant on her abdomen. A rocking motion will calm and soothe the infant. Additionally, involving the parents in the infant's care can reduce feelings of helplessness. A nurse is planning care for a 10-month-old infant who is 8 hr postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care? A. Feed the infant with a spoon for 48 hr. B. Apply and release elbow restraints every hour. C. Keep the infant supine. D. Suction the mouth with an oral suction tube. It is essential to apply elbow restraints after surgery to keep the infant from placing her hands in and around her mouth. The nurse should remove them periodically to inspect the skin and allow the infant to exercise her arms. A nurse is providing care for an infant following a surgical repair of a cleft lip. Which action should the nurse take to minimize infant crying? Rock the infant with favorite blanket A 2 month old infant just underwent cleft lip and palate repair. The surgeon prescribes restraints. The nurse should apply which of the following restraints? Elbow A 2 month old infant just underwent cleft lip and palate surgery. The nurse should include which of the following in the plan of care? Apply and release elbow restraints every 2 hours A nurse is caring for an infant who just underwent surgery for a cleft lip. In which position should the nurse place the infant? Low Fowler A nurse is caring for an infant with a cleft lip and palate. What information should the nurse include when teaching the parents about this diagnosis? Expectation that these children will have no other defect and otherwise will be healthy An infant is born with a cleft lip. What nursing intervention is unique to infants with cleft lip? Using modified techniques for feeding At 18 months of age a child born with a cleft lip and palate is readmitted for palate surgery. Why does the nurse teach the parents not to brush their child's teeth immediately after the surgery? The suture line might be injured. What is the priority nursing intervention for an infant during the immediate postoperative period after surgical repair of a cleft lip? Minimize crying. A newborn with a cleft lip and palate is born to a mother who has a history of epilepsy. Which drug might be responsible for this malformation? Topiramate Used to treat epilepsy, topiramate may have teratogenic effects that cause a newborn to develop a cleft lip with cleft palate. Carbamazepine and valproic acid may cause fetal neural tube defects. Phenytoin may cause fetal central nervous system defects. An adolescent gives birth to an infant with a severe cleft lip and palate who is immediately placed on the radiant warmer. After ensuring that there is an adequate airway, the nurse gives the newborn to the mother. Which response to the infant would the nurse anticipate? Oh no! This is the wrong baby!" Denial or disbelief and shock are considered initial grieving responses. There is a feeling of guilt and inadequacy when an infant is born with a defect. It is unusual for a client to initially verbalize feelings of punishment or guilt so directly. A sense of shame and guilt is voiced later, after denial, disbelief, and shock have occurred. It is unusual for a client to use rationalization and voice it so obviously. The mother of an infant who just underwent cleft lip repair tells the nurse, "He seems restless. May I hold him?" What information influences the nurse's response? Holding may meet needs and reduce tension on the suture line. Touching and cuddling provide a sense of well-being and relieve strain on the suture line that results from restlessness and crying. It is inappropriate to sedate an infant for its calming effect or to decrease activity. Careful handling will not damage the suture line. Arm movement can be controlled by applying elbow restraints to prevent the infant's hands from touching the suture line. A mother asks why her 2-year-old toddler's cleft palate was not repaired at the same time that the cleft lip was repaired. What is the best response by the nurse? "The palate usually is repaired before a child starts to speak. Some surgeons prefer to wait up to 2 years." At the age of 3 weeks an infant undergoes surgery to repair a cleft lip. What should postoperative nursing care include? Cleansing the suture line to prevent infection An infant with a cleft lip is fed with a special nipple. What should the nurse teach the parents about feeding their infant to minimize regurgitation? Burp frequently during a feeding. A 4-day-old infant is admitted to the pediatric unit with a cleft lip and palate. Surgery to repair the lip is scheduled for later in the week. Which assessment finding requires notification of the surgeon and will probably result in cancellation of the surgery? Oral candidiasis What is the priority of preoperative nursing care for an infant with a cleft lip? Modifying feeding After a cleft lip repair a nurse places elbow restraints on the infant. The parents ask the nurse, "Why does our child have to have restraints?" How should the nurse respond? "Because we're keeping the arms straight, your baby won't be able to touch the mouth." The parents of an infant born with a unilateral cleft lip and palate are upset about the defect and ask the nurse, "What caused our baby to be born deformed?" What is the most therapeutic response? "It sounds like you're concerned that you may have caused this situation." What intrauterine medication exposure may lead to the child being born with a cleft lip? The mother was on nitrofurantoin therapy. Which item should a nurse use to feed an infant born with a unilateral cleft lip and palate? Rubber-tipped syringe Because the infant with a cleft lip and palate is unable to form the vacuum needed for sucking, a rubber-tipped syringe or dropper is used. This allows formula to flow along the sides to the back of the mouth, minimizing the danger of aspiration. A spoon is ineffective because the infant's extrusion reflex will prevent fluid from entering the mouth. A cross-cut nipple may be used with some infants, but rapid flow is dangerous because it can cause aspiration. Feeding can be accomplished with the use of special equipment; intravenous fluids are not necessary. A nurse is feeding an infant who recently underwent surgical repair of a cleft lip. What does the nurse plan to do for the infant just after each feeding? Rinse the suture line. Meticulous care of the suture line is necessary, because inflammation and sloughing of tissue disrupt healing. Burping should be done throughout the feeding. Placing the infant on the abdomen is contraindicated, not only because the infant may rub the face on the sheet and irritate the suture line but also because this position has been linked to sudden infant death syndrome. The infant may be held at any time. A nurse is teaching the parents of an infant with a cleft lip and palate how to prevent infection. What information should the nurse include about why the infant is predisposed to infection? Mouth breathing dries the oropharyngeal mucous membranes. A newborn with a severe bilateral cleft lip and palate is shown to the father. The father says, "How could this happen to us? What's my wife going to do? It would've been better if she'd never gotten pregnant." How should the nurse respond? "This must be very hard on you. I can go with you when your wife sees the baby." A nurse is contributing to the plan of care for a 12-month-old infant following cleft palate repair. Which of the following actions should the nurse include? A. Allow the infant to have soft foods. B. Maintain elbow restraints on the infant. C. Instruct the parents to feed the infant with a spoon. D. Tell the parents to avoid brushing the infant's teeth for two weeks. A nurse is collecting data from a 3-month-old infant who is 6 hr postoperative following a cleft palate repair. Which of the following pain rating tools should the nurse use? A. FACES Scale B. FLACC Scale C. Color tool D. Numeric scale A nurse is planning care for a 10-month-old infant who is 8 hours postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care? A. Apply and release elbow restraints every hour B. Keep the infant supine C. Feed the infant with a spoon for 48 hours D. Suction the mouth with an oral suction tube A nurse is caring for a toddler who is 24 hr postoperative following a cleft palate repair. Which of the following actions should the nurse take? A. Administer opioids for pain. B. Apply bilateral wrist restraints. C. Implement a soft diet. D. Offer fluids through a straw. Hirschsprung's disease/repair – 2 A nurse is caring for an infant who has inadequate motility of part of the intestine resulting from mechanical obstruction. Which of the following does the infant have? Hirschsprung's Disease A nurse is providing teaching to a parent of a child who has Hirschsprung disease and is scheduled for initial surgery. Which of the following statements by the parent indicates an understanding of the teaching? A. "I'm glad that my child's ostomy is only temporary." B. "I want to learn how to empty my child's urinary catheter bag." C. "I want to learn how to use my child's feeding tube as soon as possible." D. "I'm glad my child will have normal bowel movements now." Which assessment finding should the nurse expect in an infant with Hirschsprung disease? A Constipation with passage of foul-smelling, ribbon-like stools B Diarrhea X C Foul-smelling, fatty stools X D "Currant jelly" stools X Pyloric Stenosis – 2 A one-month old male infant is brought to the clinic by his mother who states that her son has been vomiting forcefully after each meal for the last three days. The infant is afebrile, dehydrated, and pyloric stenosis is suspected. Which other findings should the nurse identify that are consistent with pyloric stenosis? A. Rooting, hunger, and irritability. B. An olive-shaped mass in the abdominal area. C. Bile-stained emesis. D. Perianal diaper rash from persistent diarrhea A nurse is caring for a 6 week old client who was admitted for suspected pyloric stenosis. Which nursing assessment is consistent with the diagnosis? Projectile vomiting A nurse is caring for a 6-week-old infant who has pyloric stenosis. Which of the following clinical manifestations should the nurse expect? A. Distended neck veins B. Rigid abdomen C. Projectile vomiting D. Red currant jelly stools The nurse is caring for an infant with suspected pyloric stenosis. Which clinical manifestation would indicate pyloric stenosis? A. Abdominal rigidity and pain on palpation B. Rounded abdomen and hypoactive bowel sounds C. Visible peristalsis and weight loss D. Distention of lower abdomen and constipation A nurse on the pediatric unit is assessing an infant who is 2 months old. The infant was born by spontaneous vaginal delivery at 39 2/7 weeks, Apgar 8 and 9, received regular newborn care and screening, and was discharged home with the mother. The infant weighed 2.04 kg (4 lbs 8 oz) and was 18 inches (45.7 cm) in length at birth. The guardians report that in the last 3 days, the infant has been fussy and hard to console within the first hour after feeding. The infant takes formula and vomits after each feeding, about 60-90 mL (2 to 3 ounces) of partially digested formula. Which of the following conditions is the infant most likely to have? A. Pyloric stenosis B. Gastroesophageal reflux C. Celiac disease D. Lactose intolerance A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make? A. "Burp your baby more frequently during feedings." B. "Bring your baby into the clinic today." C. "Try switching to a different formula." D. "Give your infant an oral rehydration solution." A parent tells a nurse the 2 month old infant was will until 2 weeks ago when they infant began spitting up after eating. Now the vomit practically shoots across the room. After baby vomits, she cries and acts hungry. The appropriate response by the nurse is? You should bring your infant to the clinic to be seen Volume depletion/dehydration – 6 Which statement best describes why infants are at greater risk for dehydration than older children? a. A. Infants have an increased ability to concentrate urine. X B. Infants have an increased extracellular flued volume A. C. Infants have a greater volume of intracellular fluid. X B. D. Infants have a smaller body surface area. X A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss? A. Skin integrity B. Body weight C. Blood pressure D. Respiratory rate A nurse in an emergency department is assessing an infant who is dehydrated. Which of the following findings should the nurse expect? A. Irritability B. Slow, bounding pulse C. Decreased temperature D. Tetany Which of the following is an appropriate consideration for pediatric fluid replacement? A. Using the same fluid replacement guidelines as adults. B. Providing excessive fluid replacement to prevent dehydration. C. Adjusting fluid replacement based on weight and age. D. Ignoring fluid replacement and relying solely on oral intake. A nurse is caring for a child who has had watery diarrhea for the past 3 days. Which of the following is an action for the nurse to take? A. Administer a broad-spectrum antibiotic B. Administer an over-the-counter antidiarrheal medication C. Encourage the child to eat a high-fiber diet D. Monitor the child's hydration status closely A nurse is caring for a 3-year-old child who has had 160 mL of urine output over the past 8 hr period. The child weighs 33 lb. Which of the following actions should the nurse take? A. Continue to monitor the client. B. Notify the provider. C. Provide oral rehydration fluids. D. Perform a bladder scan at the bedside. With such low urine output, especially considering the child's weight, notifying the healthcare provider is essential for further evaluation and management. At 33 lbs, the child's expected urine output is closer to 1 ml/kg/hr (around 33 ml/hr). Appendicitis – 10 A nurse is caring for a child who has suspected appendicitis. Which order should the nurse QUESTION? Administer sodium biphosphate/sodium phosphate (fleet enema) A nurse is caring for a 6 year old client who is admitted with possible acute appendicitis. Which of the following manifestations indicate that the client's condition could be becoming worse? Sudden decrease in abdominal pain A nurse is caring for a child with acute appendicitis. Which lab value should the nurse anticipate? WBCs - 17,000 A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse clarify? Medicate the client for pain every 4 hours as needed. Maintain NPO status. Monitor oral temperature every 4 hours. Administer an enema. A nurse is admitting a client with suspected appendicitis. Identify where the nurse will palpate to assess for pain at McBurney's point. McBurney's point is located by drawing a line from the navel to the right iliac crest. Divide the line into three equal lengths. McBurney's point is midway between the navel to the iliac crest. Pressure over this point will elicit pain in clients with appendicitis. A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child's appendix is perforated? Absent Rovsing's sign Low-grade fever Sudden decrease in abdominal pain Flaccid abdomen A flaccid abdomen (soft and lacking muscular tension) can be a sign of peritonitis, which may occur due to perforation of the appendix. It suggests irritation of the peritoneum and is a more significant concern than a localized infection. 16. A nurse on a pediatric unit is caring for a child who is 1 day postoperative following a laparoscopic appendectomy. Which of the following actions should the nurse prioritize as urgent, nonurgent and contradicted? Turn the child on their left side Restart the child’s IV Leave the child alone to get further assistance Place pillow under the Child’s head Check the child’s pupils Loosen the child’s tight clothing Hold the child’s extremities firmly Correct Answer: Urgent: Turn the child on their left side, Place pillow under the Child’s head, Loosen the child’s tight clothing. Nonurgent: Restart the child’s IV, Check the child’s pupils Contraindicated: Leave the child alone to get further assistance, Hold the child’s extremities firmly. Leukemia – 1 A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same room with this child? A. A child who has nephrotic syndrome B. A child recovering from a ruptured appendix C. A child who has rheumatic fever D. A child who has cystic fibrosis A nurse is caring for a 17-year-old client who is experiencing a relapse of leukemia and is refusing treatment. The client's mother insists that the client receive treatment. Which of the following actions should the nurse take? A. offer the client antiemetic B. Notify the provider of the situation C. Administer a sedative to calm the client. D. initiate the IV per the parent's request. VP shunt – 1 A nurse is caring for a child who is postoperative following ventriculoperitoneal (VP) shunt placement. In which of the following positions should the nurse place the client? On the unoperated side The nurse is monitoring a child with hydrocephalus who received a repeat ventriculoperitoneal (VP) shunt yesterday. Which assessment finding indicates to the nurse that the shunt is functioning normally? A. The child has grown in height since the previous shunt placement. B. The child is afebrile with normal vital signs postoperatively. C. An intracranial pressure (ICP) monitoring probe is in place. D. The child reports no evidence of continuous headaches. Bacterial meningitis – 4 A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority? A. Reduce environmental stimuli. B. Document intake and output. C. Administer antibiotics when available. D. Maintain seizure precautions. A nurse is planning care for a 6-year-old child who has bacterial meningitis. Which of the following nursing interventions is unnecessary in the client's plan of care? A. Measure head circumference every shift B. Admit the client to a private room C. Place the client in a semi-Fowler's position D. Implement seizure precautions A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following actions is the nurse's priority? A. Obtain blood cultures. B. Prepare the child for a lumbar puncture. C. Administer an intravenous antibiotic. D. Place the child in isolation. A nurse is preparing to admit a client who has bacterial meningitis. Which of the following items should the nurse place in the client's room? A. Oral irrigating device B. Seizure pads C. Sterile gloves D. Tongue blade An oral irrigating device is not necessary for a client with bacterial meningitis. Bacterial meningitis primarily affects the central nervous system and does not require oral care interventions. The focus of care for these clients is on managing the infection, monitoring vital signs, and providing supportive care. A nurse is assisting with the admission of an adolescent client who is suspected to have bacterial meningitis. Which of the following findings should the nurse expect? A. 2+ pedal edema B. Jaundice C. Nuchal rigidity D. Hematuria A nurse is preparing to administer ceftriaxone (Rocephin) to a client who has bacterial meningitis. The nurse should recognize that this medication is effective against which type of bacteria? A. Gram-positive B. Gram-negative C. Anaerobic D. Aerobic. Lumbar puncture – 1 A nurse is planning care for a 5-month-old infant who is scheduled for a lumbar puncture to rule out meningitis. Which of the following actions should the nurse include in the plan of care? A. Apply a eutectic mixture of lidocaine and prilocaine cream topically 15 min prior to the procedure. B. Keep the infant NPO for 6 hr prior to the procedure. C. Hold the infant's chin to his chest and knees to his abdomen during the procedure. D. Place the infant in an infant seat for 2 hr following the procedure. A nurse is caring for a child who has had a lumbar puncture. The nurse should monitor the child for which of the following complications? A. Nuchal rigidity when standing B. Double vision C. Headache D. Pain in the posterior iliac crest Intake/Output calculations – 2 The child's urine output should be greater than 1 mL/kg/hr. 12. A nurse is caring for a 3-year-old child who was admitted with acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective? A) Urine specific gravity of 1.034 B) Urine specific gravity of 1.015 C) Urine output of less than 1 mL/kg/hr D) Increase in weight over the first 24 hours Correct Answer: B 14.⁠ ⁠A nurse is tracking the urinary output of a 6-month-old infant who has dehydration. Which of the following urinary output amounts should indicate that the treatment has corrected the fluid imbalance? A) 1 mL/kg/hr B) 2 mL/kg/hr C) 4 mL/kg/hr D) 5 mL/kg/hr Seizures – 3 A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority? A. Loosen restrictive clothing. B. Place a pillow under the child's head. C. Clear the area of hazards. D. Position the child side-lying. A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take? A. Restrain the child's arms. B. Use a padded tongue blade. C. Attempt to stop the seizure. D. Position the child laterally. A nurse is providing teaching to the parents of a school-age child newly diagnosed with a seizure disorder. The nurse should teach the parents to take which of the following actions during a seizure? A. Minimize movement of the limbs. B. Clear the area of hard objects. C. Place the child in a prone position. D. Insert a tongue blade between the teeth. Hemophilia – 1 A nurse is caring for a client about to receive chemo for leukemia. The nurse reviews the lab results and notes the platelets are low. What should the nurse add to the child's care plan? Bleeding precautions A nurse is teaching a parent of a child with hemophilia how to control a minor bleeding episode. Which statement needs further teaching? I will apply heat Gastroenteritis - 1 A nurse is admitting an infant who has severe dehydration from acute gastroenteritis. Which of the following findings should the nurse expect? A. 13% weight loss B. Bulging anterior fontanel C. Capillary refill 3 seconds D. Bradypnea A nurse is caring for a child who has acute gastroenteritis but is able to tolerate oral fluids. The nurse should anticipate providing which of the following types of fluid? A. Broth B. Water C. Diluted apple juice D. Oral rehydration solution Oral rehydration solution is the fluid of choice for infants and children who have dehydration due to diarrhea. A nurse is preparing to develop a plan of care for a school-aged child who has been hospitalized with gastroenteritis. Which of the following conditions and client findings should the nurse identify that the child has developed? A. Dehydration and hypovolemic shock B. Peritonitis and septic shock C. Pancreatitis and cardiogenic shock D. Peptic ulcer and anaphylactic shock A nurse is caring for a 6-month-old infant who has gastroenteritis. Which of the following findings should the nurse identify as a manifestation of severe dehydration? A. Capillary refill time 3 seconds B. Sunken anterior fontanel C. Weight loss of 5% D. Produces tears when crying When caring for a child with viral gastroenteritis. What is the nurse's priority? A. Monitor fluid input and output closely. B. Encourage the child to eat a regular diet to maintain nutrition. C. Administer antibiotics to treat the viral infection. D. Administer antiemetic medication to control vomiting. GER/GERD – 3 A nurse is caring for an infant with GERD. What's the best action to take after feedings? Place in an infant seat after feeding. A nurse is caring for an infant with GERD. Which findings are associated with this condition? -vomiting -weight loss -wheezing A nurse is providing teaching to the parent of an infant who has GERD. Which statement shoes the parent understands the teaching? I will keep my baby upright after feedings A nurse is caring for an infant who has gastroesophageal reflux. The nurse should place the infant in which of the following positions following feedings? A. Place the infant on his left side B. Place the infant on his right side C. Place the infant in a prone position D. Place the infant in an infant seat Sickle cell disease/crisis – 2 A nurse is d/c a patient with sickle cell anemia after an acute crisis episode. Which of the following should the nurse teach the child's parents to do? encourage the child to drink lots of fluids A nurse is planning care for a child with sickle cell crisis. Which action should be included in the care? promote hydration with IVF, and oral fluids A Peds client in sickle cell crisis comes to the hospital with his mother. When assessing, the nurse should expect what manifestation? Pain A nurse is preparing to develop a plan of care for a school-aged child who has been diagnosed with sickle cell anemia. Which of the following findings should the nurse include in the plan of care? A. The child has a normal potassium level. B. The child has a low hemoglobin level. C. The child has a high platelet level. D. The child has a low blood glucose level. Von Willebrand – 1 A nurse receives a call from a parent of a child who has von Willebrand disease and has had a nosebleed. Which of the following instructions should the nurse give to the parent? A. "Have your child sit with her head tilted forward and hold pressure on her nose for 10 minutes." B. "Apply ice at the base of the nose for 5 min and then check for bleeding. C. "Place your child in a supine position with a pillow under her back." D. "Place your child in a sitting position with her head tilted back The nurse recognizes that patients with von Willebrand disease are at risk for prolonged bleeding times for which reason? A. Adequate platelet production. B. Deficiency in intrinsic clotting system factor. C. Impairment of the thrombin fibrinogen reaction. D. Variable factor VIII deficiencies and platelet dysfunction. Intussusception – 1 A nurse is caring for a child with a palpable RUQ mass, and passage of stools mixed with blood and mucous. Which of the following are these finding associated with? Intussusception A 6 month old infant just had surgery to correct intussusception. The surgeon prescribed clear liquids by mouth. The nurse administers which of the following? Oral electrolyte solution A nurse is caring for a 6-month-old infant who has a prescription for clear liquids by mouth after a repair of an intussusception. Which of the following fluids should the nurse select for the infant? A. Half-strength infant formula B. Half-strength orange juice C. Sterile water D. Oral electrolyte solution Wilm's tumor – 1 A child is admitted with possible diagnosis of Wilms tumor. The nurse should obtain a sign with which of the following warning to be placed over the child's bed? Do not palpate abdomen The parents of a child with Wilms tumor ask the nurse why surgery is necessary before a biopsy is performed. Which information should the nurse provide? A. Biopsy may rupture the encapsulated tumor and cause the cancer cells to spread. B. Metal clips are surgically applied at the tumor site for exact marking for radiation. C. Surgery is necessary to stage the tumor and determine metastasis to other sites. D. The surgery provides a visualization of other pathology and dysfunction of the kidney. A nurse is planning to admit a preschooler from the PACU following the removal of a Wilms tumor. Which of the following children should the nurse identify as an appropriate roommate for the preschooler? A. A child who has impetigo B. A child who has a fractured left femur C. A child who has viral pneumonia D. A child who has cellulitis of the right radius The client has a history of Wilms tumor with left radical nephrectomy diagnosed at age five for which he completed treatment nine months ago. A septic episode, while undergoing treatment for his Wilms tumor, resulted in an acute kidney injury. This Injury, along with antibiotic therapy and chemotherapy, has resulted in chronic kidney disease. The client is followed by oncology and nephrology services. For each nursing action, click to indicate whether the action is indicated or contraindicated for this client's plan of care. Each row must have only one response option selected. A. Continuous pulse oximetry monitoring. INDICATED B. Calculation of intake and output INDICATED C. Daily weights INDICATED D. IV 0.9% normal saline continuous infusion at 100 mL/hr INDICATED E. IV potassium sparing diuretic--CONTRAININDICATED Celiac disease – 1 A nurse is providing d/c teaching for a child with celiac disease. Which of the following is an acceptable food choice for this child? Rice A nurse is providing teaching to a parent of a child who has celiac disease. The nurse should instruct the parent to avoid giving which of the following food choices to the child? A. Barley B. Wheat (this is a no too) C. Rice D. Potatoes Which change in status should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury? A. Confusion and altered mental status B. Increased diastolic pressure with narrowing pulse pressure X C. Irregular, rapid heart rate X D. Rapid, shallow breathing X What is a sign of increased intracranial pressure (ICP) in a 10-year-old child? A. Tachypnoea X B. Bulging fontanel X C. Headache D. Increase in head circumference X Which change in status should alert the nurse to increased intracranial pressure (ICP) in a child with a head injury? A. Confusion and altered mental status B. Increased diastolic pressure with narrowing pulse pressure X C. Irregular, rapid heart rate X D. Rapid, shallow breathing X Mucosal ulcerations post chemotherapy – 5 A client with hemophilia experiences mucosal bleeding episodes such as epistaxis and oral bleeding. Which drug, used as adjunctive therapy to inhibit the breakdown of fibrin clots, should the nurse consider? A. Factor replacement therapy. A. Desmopressin acetate (DDAVP) B. Aminocaproic acid. C. Gene therapy. Iron deficiency anemia – 1 A nurse at a Peds office is contacted by a parent who's child just ingested half a bottle of vitamins with ferrous sulfate. Which instructions should the nurse give? contact the poison control center A parent tells the nurse at the clinic that her toddler drinks a quart of milk a day and has poor appetite for solid foods. The nurse should explain this client is at risk for? iron deficiency anemia A nurse is the clinic is caring for a child with iron deficiency anemia with a new prescription for ferrous sulfate tablets. Which instructions should be given to the patient? give with orange juice A nurse is providing teaching about iron deficient anemia to the parents. Which should be recommended to help prevent this anemia? Avoid a diet consisting of primarily milk A nurse is reinforcing teaching for a patient with iron supplements. Which statement by the parents indicates understanding? Our childs blood count will need to be monitored routinely for several weeks A nurse is providing teaching about iron deficiency anemia to the parents of an infant. Which of the following should the nurse recommend as a method of preventing iron deficiency anemia? A. Limit intake of high-protein foods. B. Mom should continue prenatal vitamins if breastfeeding or formula with an iron supplement. C. Administer fat-soluble vitamins daily. D. Include fluoridated water in the toddler's diet. A nurse in a pediatric clinic is caring for a child who has iron deficiency anemia and a new prescription for ferrous sulfate tablets. Which of the following instructions should the nurse provide the parents regarding the administration of this medication? A. Iron (Ferrous Sulfate) may turn stools tarry green. B. Administer at bedtime. C. Give with a 240 mL (8 oz) glass of milk. D. Administer at mealtimes. A parent tells a nurse that her toddler drinks a quart of milk a day and has a poor appetite for solid foods. The nurse should explain that the toddler is at risk for which of the following disorders? A. Iron deficiency anemia B. Diabetes mellitus C. Obesity D. Rickets A nurse is administering ferrous sulfate elixir to a client who has iron deficiency anemia. Which of the following actions should the nurse take? A. Dilute the medication with milk. B. Give the medication with a caffeinated beverage. C. Administer the medication through a straw. D. Provide an antacid with the medication.