Description
58. The nurse is measuring the frontal occipital circumference (FOC) of a 3−month−old infant, notes
that the FOC has increased 5 inches since birth and the child’s head appears large in relation to
body size. Which action is most important for the nurse to take next?
a. Measure the infant’s head to heel length
b. Observe the infant forsunset eyes
c. Palpate the anterior fontanel for tension and bulging
d. Plot the measurement on the infant’s growth chart
59. A 16−year−old gravida 1, para 0 client hasjust been admitted to the hospital with a diagnosis of
eclampsia. She is not presently convulsing. Which intervention should the nurse plan to include
in this client’s nursing care plan?
a. Keep airway equipment at the bedside.
b. Allow liberal family visitation
c. Monitor blood pressure, pulse, and respirations q4h
d. Assess temperature q1h
60. During a well−child visit for their child, one of the parent who has an autosomal dominant
disorder tellsthe nurse, <We don’t plan on having any more children,since the next child islikely
to inherit this disorder=. How should the nurse respond?
a. Explain that the risk of inhering the disorder decrease by 50% with each child the couple has.
b. Acknowledge that the next that the next child will inherit the disordersince the first child did
not.
c. Encourage the couple to reconsidertheir decision since the inheritance pattern may be sex−
linked.
d. Confirm that there is a 50% chance of their future children inheriting the disorder.
61. The nurse is caring for a one−year−old child following surgical correction of hypospadias. The
nursing action has the highest priority?
a. Monitor urinary output
b. Auscultate bowelsounds
c. Observe appearance ofstool
d. Record percent of diet eaten
62. Patient with Duchenne Disease. The nurse hasto explain to the mother that:
a. This condition isinherited in an X-linked recessive chromosome pattern.
63. Primipara patient. What is the pet to share time a, home that is not recommended?
a. CAT
64. The nurse is preparing a 10−year−old with a lacerated forehead forsuturing. Both parents and 12
year old sibling at the child’s bedside. Which instruction best supports family?
a. While waiting forthe healthcare provider, only one visitor may stay with the child.
b. All of you should leave while the healthcare providersutures the child’s forehead
c. It is best if the sibling goes to the waiting room until the suturing is completed
d. Please decide who willstay when the healthcare provider beginssuturing
65. The parents of a 3 year−old boy who has Duchenne muscular dystrophy (DMD) ask <how can our
son have this disease? We are wondering if we should have any more children= What
information should the nurse provide these parents?
a. Thisis an inherited X-linked recessive disorder, which primarily affects male children in the
family.
b. The male infant had a viral infection that went unnoticed and untreated,so muscle damage was
incurred.
c. The XXXX muscle groups of males can be impacted by a lack of the protein dystrophy in the
mother.
d. Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening the
muscles.
66. A 4 month old girl is brought to the clinic by her mother because she has had a cold for 2 or 3
days and woke up this morning with a hacking cough and difficulty breathing. Which additional
assessment finding should alert the nurse that the child is in acute respiratory distress?
a. Bilateral bronchial breath sounds
b. Diaphragmatic respiration
c. A resting respiratory rate of 35 breathe per minute
d. Flaring of the nares
67. A two year old child with a heart failure (HF) is admitted for replacement of a graft for
coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin) the nurse
obtains an apical heart rate of 128 bpm. What action should the nurse implement?
a. Determine the pulse deficit
b. Administer the schedule dose
c. Calculate the safe dose range
d. Review the serum digoxin level
68. Which nursing intervention is most important to include in the plan of care for a child with acute
glomerulonephritis?
a. Encourage fluid intake
b. Promote complete bed rest
c. Weight the child daily
d. Administer vitamin supplements
69. A 7 year old child is admitted to the hospital with acute glomerulonephritis (AGN). When
obtaining the nursing history which finding should the nurse expect to obtain?
a. High blood cholesterol level on routine screening
b. Increased thirst and urination
c. A recentstrep throat infection
d. A recent DPT immunization