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ATI LPN Pediatric Nursing~2021

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Exam Details !

Title : ATI LPN Pediatric Nursing~2021

Type : Nursing

Category : LPN Nursing Exam(s)

Subcategory : LPN ATI Exams

Domain : Pediatrics

Fragment : N/A

Module : LPN-NURSING

Exam Status : active

Rating : 95.00%

Attempts Allowed : 100

Exam Year : 2021

Duration : 90 minutes

Total Questions : 53

Passing Score : 90%

Difficulty : Medium

Instructions : Read each question carefully and choose the best answer based on current nursing standards. You will have a limited time to complete the exam, so manage your time wisely

Description : Exam is designed to assess the knowledge and clinical decision-making skills of practical nursing students in the care of pediatric clients. It covers key topics such as growth and development, common childhood illnesses, pediatric medication administration, health promotion, and family-centered care. This exam ensures that students are prepared to deliver safe, effective nursing interventions for infants, children, and adolescents across various healthcare settings.

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1 :
A nurse is monitoring a 6-month-old infant 20 minutes after administering a hepatitis B immunization. Which of the following findings is the nurse's priority?

Redness at the injection site.

Temperature 37.7°C (99.9°F).

Hives on the child's neck.

Prolonged crying.

Hint : Hives = potential anaphylaxis 🐝

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

2 :
A nurse is preparing to administer medications to a 5-month-old infant.
Tympanic temperature 39.2°C (102.6°F).
Heart rate 84/min.
Respiratory rate 30/min.
Blood pressure 80/30 mmHg.
Oxygen saturation 96% on 0.5 L oxygen via nasal cannula.
Weight 7.2 kg (15.9 lb). The nurse should clarify the prescription for which medication?

Ibuprofen.

Acetaminophen.

Heart rate.

Temperature.

Hint : Ibuprofen not under 6 months 🚫💊

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

3 :
A nurse is assisting with the care of a school-age child who is terminally ill. Which of the following interventions should the nurse perform?

Collect vital signs every 2 hours as the child's condition deteriorates.

Reinforce with the family that they should avoid discussing death with the child.

Encourage the family to involve siblings when caring for the child.

Perform passive range of motion to the child's extremities every 4 hours.

Hint : Include siblings for support 🧸

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

4 :
A nurse is caring for a child and suspects the child has experienced physical maltreatment. Which of the following statements should the nurse make?

"This should not have happened to you.”.

"I promise I won't tell anyone about this.”.

"It is not your fault that this happened.”.

"You should have told someone about this sooner.”.

Hint : Reassure without blame 🛡️

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

5 :
A nurse is collecting data from an infant. Which of the following areas should the nurse palpate to check for an inguinal hernia?

Groin area.

Abdomen.

Lower back.

Upper thigh.

Hint : Hernia = groin bulge 👶🩺

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

6 :
A nurse is preparing to administer cephalexin 50 mg/kg/day in divided doses every 8 hours to a child who weighs 33 lb. The amount available is cephalexin oral suspension 250 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) .

Hint : ✅ Final Answer: 5 mL

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

7 :
A nurse is assisting with the care of a preschooler who is immediately postoperative following a tonsillectomy. Which of the following actions should the nurse take?

Provide cherry fruit juice.

Remind the child to cough and deep breathe.

Encourage the child to use a straw.

Apply an ice collar.

Hint : Cold collar = safe comfort 🧊

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

8 :
A nurse is reinforcing teaching about bicycle safety with a school-age child. Which of the following instructions should the nurse include?

Ensure the balls of your feet touch the ground when you are seated on the bicycle.

Choose a helmet that is light in color and covers your ears.

Ride instead of walk your bicycle through crosswalks and intersections.

Ride against traffic to allow visibility to oncoming vehicles.

Hint : Helmet = bright and snug 🪖

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

9 :
A nurse is reinforcing dietary teaching with the guardians of a toddler. Which of the following snack foods should the nurse recommend?

Grapes.

Hard-boiled egg.

Raw carrots.

Popcorn.

Hint : Choose soft, safe snacks 🍽️

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

10 :
A nurse is reinforcing teaching with a parent of a child who has gastroesophageal reflux disease and a new prescription for lansoprazole capsules.
Which of the following statements by the parent indicates an understanding of the teaching?

I will have my child chew the capsule completely.

I should place the capsule under my child's tongue.

I will administer this medication four times per day.

I should administer this medication 30 minutes before breakfast.

Hint : Give before meals 🍽️

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

11 :
A nurse in an urgent care clinic is collecting data from a preschooler who reports painful urination. Which of the following findings should the nurse identify as a possible manifestation of a urinary tract infection?

Facial edema.

Increased temperature.

Muscle twitching.

Moist mucus membranes.

Hint : Fever + dysuria = UTI sign 🔥

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

12 :
A nurse is preparing a child who has suspected bacterial meningitis for a lumbar puncture. Which of the following cerebrospinal fluid findings supports the diagnosis?

Decreased pressure.

Decreased WBCs.

Elevated glucose.

Elevated total protein.

Hint : Think protein = pus & pathogens 🧬

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

13 :
A nurse is assisting with the care of several clients. The nurse should identify that which of the following client conditions requires contact precautions?

Clostridium difficile.

Streptococcal pharyngitis.

Haemophilus influenzae.

Mycoplasma pneumoniae.

Hint : Contact = contaminated stool spores 🚽🧤

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

14 :
A nurse is assisting with the care of a school-age child who has shigella. Which of the following actions should the nurse take?

Administer antiviral medication.

Give antidiarrheal agents every 4 hours.

Provide a diet high in sodium.

Maintain oral rehydration therapy.

Hint : Rehydrate to combat diarrhea 💦

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

15 :
A nurse is caring for a 2-year-old child who has pneumonia and a temperature of 39.4° C (103° F). Which of the following actions should the nurse take?

Lower the temperature of the room.

Place the child in an ice bath.

Give 500 mg acetaminophen every 2 hours.

Administer a 100 mg aspirin suppository.

Hint : Cool room, not risky meds ❄️

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

16 :
A nurse is reinforcing teaching with the guardian of a 1-year-old infant about administering a liquid oral medication. Which of the following statements should the nurse make?

You should add the medication to your child's formula prior to feeding.

You should put small bits of ice on your child's tongue before administering the medication.

You should position your child on their back during the administration of the medication.

You should place the medication along the inside of your child's cheek during administration.

Hint : Cheek side = safe and effective 👶💊

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

17 :
A nurse is contributing to the plan of care for an infant who has heart failure. Which of the following interventions should the nurse recommend?

Implement bolus gavage feedings.

Provide feedings every 3 hours.

Place the infant in a lateral position during feeding.

Dilute formula to half strength.

Hint : Frequent, small feedings = energy support 🕒

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

18 :
A nurse is preparing to administer immunizations to a 4-year-old child who is currently up to date with the recommended immunization schedule.
Which of the following immunizations should the nurse plan to administer? (Select all that apply)

Diphtheria, tetanus, acellular pertussis (DTaP)

Measles, mumps, rubella (MMR)

Varicella (VAR)

Rotavirus (RV)

Hint : School-age = booster protection 🎓💉

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

19 :
A nurse is preparing to administer a vaccine to a toddler. Which of the following actions should the nurse plan to take?

Massage the injection site for 15 seconds after administration.

Aspirate for the presence of blood return prior to administering the vaccine.

Ensure the guardian signed a consent form for the immunization.

Hint : Consent is always required ✍️

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

20 :
A nurse is reinforcing teaching with the guardian of a school-age child who has a severe peanut allergy. Which of the following information should the nurse include?

The child will likely outgrow the allergy in adolescence.

The child should refrain from eating any type of nut.

The child should carry an epinephrine auto-injector.

The child's allergy will become more severe with prolonged exposure.

Hint : Epinephrine = lifesaving action 🧯

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

21 :
A nurse is preparing to collect data from a toddler during a well-child visit. Which of the following actions should the nurse plan to take?

Allow the toddler to inspect the stethoscope.

Remove the toddler's outer clothing.

Perform traumatic procedures first.

Discourage the toddler from sitting in the parent's lap.

Hint : Build trust with curiosity 🩺

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

22 :
A nurse is preparing to collect data from a toddler during a well-child visit. Which of the following actions should the nurse plan to take?

Allow the toddler to inspect the stethoscope.

Remove the toddler's outer clothing.

Perform traumatic procedures first.

Discourage the toddler from sitting in the parent's lap.

Hint : Let toddlers explore to reduce fear 👶🩺

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

23 :
A nurse is caring for a child who has had diarrhea for 3 days. Which of the following actions should the nurse take?

Collect a stool culture.

Offer the child 120 mL (4 oz) of apple juice every 2 hr.

Keep the child NPO for the next 12 hr.

Weigh the child weekly.

Hint : Identify the cause early 🔬

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

24 :
A nurse is reinforcing teaching with an adolescent client who has a new diagnosis of lactose intolerance. Which of the following instructions should the nurse include in the teaching?

You should eat flavored yogurt instead of plain yogurt.

You should limit your intake of calcium-fortified orange juice.

You should gradually increase lactose products in your diet.

You should drink rice milk instead of cow's milk.

Hint : Choose lactose-free calcium sources 🥥🥛

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

25 :
A nurse is preparing to administer a vaccine to a toddler. Which of the following actions should the nurse plan to take?

Massage the injection site for 15 seconds after administration.

Aspirate for the presence of blood return prior to administering the vaccine.

Ensure the guardian signed an informed consent form for the immunization.

Administer the vaccine into the dorsogluteal muscle.

Hint : Consent ensures legal and safe care ✍️

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

26 :
A nurse is reinforcing teaching with an adolescent female client who has recurrent urinary tract infections. Which of the following statements by the adolescent indicates an understanding of the teaching?

I will need to urinate frequently throughout the day.

I should wear cotton underwear.

I will test my urine for ketones daily.

I should avoid bubble baths.

Hint : Cotton + no irritants 🩲🛁

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

27 :
A nurse is reinforcing teaching with an adolescent who has a prescription for tretinoin topical for the treatment of acne. Which of the following instructions should the nurse include in the teaching?

Apply the medication 5 minutes after washing the face.

Use a dime-sized amount of the medication.

Use a sunscreen with an SPF of 15 or higher while using the medication.

Apply the medication in the morning.

Hint : Tretinoin = sun-sensitive skin ☀️

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

28 :
A nurse is preparing to collect data from a school-age child. Which of the following areas should the nurse palpate to find the radial pulse?

Palpate the wrist.

Palpate the inner side of the elbow.

Palpate the neck.

Palpate the upper arm.

Hint : Radial = wrist (thumb side) ⌚

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

29 :
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to see first?

A school-age child who has endocarditis and a new onset of lethargy.

A toddler who has Kawasaki disease and erythema of the lips.

A school-age child who has rheumatic fever and an increased erythrocyte sedimentation rate.

A toddler who has coarctation of the aorta and weak pedal pulses.

Hint : Sudden lethargy = urgent red flag 🛑

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

30 :
A nurse is caring for an 18-month-old infant who is 12 hours postoperative following a myringotomy. Which of the following pain rating scales should the nurse use?

Numeric scale.

Poker Chip Tool.

FLACC Scale.

Color tool.

Hint : FLACC = behavior-based pain tool 🍼

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

31 :
A nurse in a clinic is speaking with a parent of a 1-year-old toddler who received her scheduled immunizations 1 hour ago. Which of the following findings reported by the parent is the nurse's priority?

"My child has a temperature of 100.7 degrees Fahrenheit.”.

"My child only ate 2 ounces during her last feeding.”.

"My child cries when I touch the area where she received the shot.”.

"My child has some swelling around her eyelids and mouth.”.

Hint : Swelling + vaccine = possible anaphylaxis ⚠️

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

32 :
A nurse is collecting data from a school-age child who has Cushing's syndrome. Which of the following findings should the nurse expect?

Hypotension.

Rapid weight loss.

Rounded facial features.

Hypersomnia.

Hint : Cortisol = round face & weight gain 🌙

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

33 :
A nurse is contributing to the care plan of an infant who has pneumonia. Which of the following toys should the nurse select for the child's play activity?

Wooden building blocks.

Alphabet flash cards.

Colored paper and safety scissors.

Stringing beads.

Hint : Choose simple, safe, low-effort play 🧱

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

34 :
A nurse is preparing to administer medications to a child via a nasogastric tube. Which of the following actions should the nurse take?

Flush the tube with 2 ml sterile water after all medications are administered.

Allow medications to flow into the tube by gravity.

Crush sustained-release tablets prior to administration.

Mix all the medications together prior to administration.

Hint : Gravity = gentle and safe ⬇️💊

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

35 :
A nurse is preparing to perform a heel stick using a spring-loaded automatic puncture device on a 1-week-old infant. In which of the following locations should the nurse puncture the infant's foot?

Heel.

Toe.

Ankle.

Sole.

Hint : Medial or lateral heel = safest site 🦶💉

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

36 :
A nurse is reinforcing teaching with a parent of a toddler who has conjunctivitis. Which of the following instructions should the nurse include in the teaching?

Clean the eye with a moist cloth.

Remove secretions by wiping from the outer corner of the eye to the inner canthus.

Apply eye ointment in the morning.

Keep the eye covered with a compress.

Hint : Gently clean with moist cloth 🧼👶

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

37 :
A nurse observes circumoral cyanosis in an infant who is choking. Which of the following actions should the nurse take?

Deliver back blows with the infant face down over the rescuer's arm.

Move the infant into an upright position and suction the airway with a bulb syringe.

Perform a head tilt and a chin lift and then give two rescue breaths.

Place the infant in a side-lying position and perform abdominal thrusts.

Hint : Choking infant = back blows + chest thrusts 🫁💥

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

38 :
A nurse is reinforcing teaching about the purpose of the HbA1c test with an adolescent who has type 1 diabetes mellitus.Which of the following statements by the adolescent indicates an understanding of the teaching?

This test checks my blood sugar over the last few months.

This test checks for ketones in my urine.

This test measures the amount of hemoglobin in my blood.

This test tells me how much oxygen my body is carrying.

Hint : HbA1c = 3-month glucose average 📊

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

39 :
A nurse is caring for a child who received an initial dose of antibiotics 20 minutes ago.Which of the following findings is the priority to report to the provider?

Increased pulse.

Wheezing.

Maculopapular rash.

Headache.

Hint : Wheeze = airway emergency 🌬️🛑

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

40 :
A nurse is preparing to administer recommended immunizations to an 11-year-old child who is up-to-date with current immunizations.Which of the following immunizations should the nurse plan to administer?

Human papillomavirus.

Rotavirus.

Hepatitis A.

Meningococcal vaccine.

Hint : Age 11 = cancer & meningitis protection 🧬🛡️

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

41 :
A nurse is discussing allergies with the guardians of a school-age child prior to administration of the influenza vaccine.The nurse should identify that a prior anaphylactic reaction to which of the following is a contraindication to this immunization?

Eggs.

Gelatin.

Gluten.

Neomycin.

Hint : Egg allergy = flu shot caution 🥚💉

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

42 :
A nurse is reinforcing teaching with the guardian of a school-age child who has asthma.Which of the following instructions should the nurse include in the teaching?

Avoid allowing your child to participate in school sports.

Have your child inhale deeply and quickly when using the peak flow meter.

Obtain a pneumococcal immunization for your child.

Use salmeterol to manage your child's acute exacerbations.

Hint : Protect with pneumococcal vaccine 💉🫁

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

43 :
A nurse is reinforcing teaching with the parent of a preschooler who has a hip fracture and is in a spica cast.Which of the following findings should the nurse identify as an indication of infection?

Hot spot on the cast.

Pruritus under the cast.

General edema of the toes.

Pain at the fracture site.

Hint : Warm spot = possible infection under cast ♨️🦴

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

44 :
A nurse is assisting with the collection of a bone marrow specimen from a preschooler. Which of the following actions should the nurse take?

Place the child supine with legs flexed outward into a frog-like position.

Position the child sitting with their buttocks at the edge of the table.

Position the child side-lying to expose the vertebrae.

Place the child in prone position to expose the posterior iliac crest.

Hint : Bone marrow = prone for iliac crest 📍

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

45 :
A nurse is caring for a preschooler who is terminally ill. Which of the following reactions to death should the nurse expect?

Worries about physical body changes.

Has feelings of isolation.

Perceives death as a punishment.

Understands that death is permanent.

Hint : Preschoolers link death to punishment 💔

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

46 :
A nurse is reinforcing teaching about food choices with a parent of a child who has celiac disease. Which of the following responses by the parent indicates an understanding of the teaching?

I will give my child a chocolate malt for a snack.

I will feed my child a barley-based breakfast cereal.

I should make my child's sandwiches using rye bread.

I should provide my child with rice pudding for dessert.

Hint : Choose gluten-free grains 🍚

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

47 :
A nurse is contributing to the plan of care for a school-age child who has autism and is scheduled for surgery. Which of the following interventions should the nurse include in the plan?

Leave the television on for the child during the night.

Minimize physical contact with the child.

Place the child in a semi-private room.

Maintain eye contact if the child is agitated.

Hint : Reduce sensory stimulation 🧠

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

48 :
A nurse is caring for a toddler who has been vomiting for the past 8 hours. Which of the following findings indicates to the nurse that the child is dehydrated?

Increased pulse.

Increased blood pressure.

Distended jugular veins.

Fat anterior fontanel.

Hint : Tachycardia signals fluid loss

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

49 :
A nurse is collecting data from a school-age child who has erythema infectiosum (fifth disease). The nurse should expect the rash to appear on which area of the child's body first?

Face.

Arms.

Legs.

Back.

Hint : Slapped cheek rash

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

50 :
A nurse is collecting data from an infant who has respiratory syncytial virus (RSV). Which of the following findings should the nurse expect?

Vesicles on the trunk.

Rhinorrhea.

Barrel chest.

Clubbing of the fingers.

Hint : Early nasal discharge

Correct Answers:

No Correct Answers Available !

Rationale :

Rationale to be Available Soon

51 :
A nurse in the emergency department (ED) is assisting with the care of a 10-year-old child.

Nurses' Notes
Vital Signs
Medical History
Provider's Prescriptions

• 1100: Child presents to the ED via stretcher, transported by emergency medical services (EMS). EMS reports the school nurse notified them that the child began having difficulty breathing during lunch and started coughing and wheezing. Child appears anxious, sitting upright, and using accessory muscles to breathe. Lung auscultation reveals bilateral wheezing. Parent reports child has a history of asthma and has been using an albuterol inhaler more frequently over the past week.

• Heart rate: 120/min

• Respiratory rate: 32/min

• Temperature: 37.2°C (99°F)

• Oxygen saturation: 92% on room air

• Asthma diagnosed at age 3, managed with albuterol inhaler as needed.

• Tonsillectomy at age 5.

• Streptococcal pharyngitis diagnosed 2 weeks ago, treated with amoxicillin.

• Administer albuterol nebulizer treatment stat.

• Monitor oxygen saturation continuously.

• Obtain peak expiratory flow rate (PEFR) before and after nebulizer treatment.

identify the potential condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client’s progress

Hint : Asthma = albuterol + airflow tracking

Rationale :

Rationale to be Available Soon

52 :
A nurse is assisting in the care of an 8-month-old infant in the pediatric unit.

Vital Signs
Nurses' Notes

• Heart rate: 148/min

• Temperature: 37.6°C (99.6°F) axillary

• Respiratory rate: 28/min

• Oxygen saturation: 98% on room air

0900: Infant presents with a history of nasal congestion and cough for the past 3 days. Parent reports infant has been fussy and feeding less than usual. Infant is alert but irritable. Nasal flaring and mild intercostal retractions noted. Lung auscultation reveals clear breath sounds bilaterally.

Provider's Prescriptions

• Administer saline nasal drops.

• Encourage oral hydration.

• Monitor respiratory status hourly

identify the potential condition the infant is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the infant's progress.

Hint : RSV = Saline + Sip + Saturation

Rationale :

Rationale to be Available Soon

53 :
A nurse is caring for a newborn in the neonatal unit. Review the following exhibits to answer the questions.

History and Physical
Vital Signs
Physical Examination Results
Diagnostic Results
Provider's Prescriptions
Nurse's Notes

A male newborn weighing 4337 grams (9 lb 9 oz) was delivered via cesarean section approximately 1 hour ago at 39 weeks gestation due to cephalopelvic disproportion. Apgar scores were 8 at 1 minute and 9 at 5 minutes. Vitamin K was administered in the left vastus lateralis shortly after birth. No known maternal infections or complications were noted during the pregnancy. The mother tested negative for Group B Streptococcus, syphilis, and HIV. The newborn's gestational age assessment is consistent with full-term development.

• Heart rate: 178 beats per minute

• Respiratory rate: 64 breaths per minute

• Axillary temperature: 36.2°C (97.2°F)

• Oxygen saturation: 94% on room air

• Blood glucose: 35 mg/Dl

The newborn exhibits tachypnea with nasal flaring and intercostal retractions. The extremities are cool to touch, and capillary refill is delayed at 4 seconds. The abdomen is soft, non-distended, and bowel sounds are present. Neurological assessment reveals increased irritability and tremors during stimulation. Reflexes are brisk but symmetric

• Complete Blood Count (CBC): o White blood cells: 18,000/mm³ o Hemoglobin: 18 g/dL o Platelets: 140,000/mm³

• Serum electrolytes: o Sodium: 135 mEq/L o Potassium: 4.6 mEq/L o Calcium: 7.0 mg/dL

• Blood glucose: 35 mg/dL (repeat confirmatory value)

• Start intravenous dextrose 10% solution at 80 mL/kg/day.

• Monitor blood glucose every 30 minutes until stable, then every 2 hours.

• Obtain serum calcium levels and administer calcium gluconate IV if calcium remains below 8.0 mg/dL.

• Initiate phototherapy if bilirubin exceeds 15 mg/dL.

• Continue routine newborn care, including thermoregulation and monitoring vital signs every 2 hours

0700: The newborn is noted to be jittery and has decreased muscle tone. Poor feeding and poor suck were observed during an attempt to initiate breastfeeding. Loose stool was found in the diaper during a diaper change. Skin appears mottled, and the newborn is crying intermittently but inconsolably.
0720: A follow-up feeding attempt was made. The newborn continued to demonstrate poor suck and latch. Excessive yawning and sneezing were also observed during the assessment.
0745: The newborn has a weak, high-pitched cry. Skin examination reveals petechiae on the chest and extremities

Which of the following actions should the nurse take to address the newborn’s condition? Select all that apply.

Answer Options

Administer intravenous dextrose as prescribed.

Warm the newborn using skin-to-skin contact to maintain thermoregulation.

Administer phototherapy immediately.

Monitor blood glucose levels every 30 minutes.

Administer antibiotics to treat suspected neonatal sepsis.

Hint : Low sugar = cold, shaky baby

Correct Answers:

No Correct Answers Available !

Rationale :

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1 : A nurse is monitoring a 6-month-old infant 20 minutes after administering a hepatitis B immunization. Which of the following findings is the nurse's priority?

3 : A nurse is assisting with the care of a school-age child who is terminally ill. Which of the following interventions should the nurse perform?

4 : A nurse is caring for a child and suspects the child has experienced physical maltreatment. Which of the following statements should the nurse make?

5 : A nurse is collecting data from an infant. Which of the following areas should the nurse palpate to check for an inguinal hernia?

7 : A nurse is assisting with the care of a preschooler who is immediately postoperative following a tonsillectomy. Which of the following actions should the nurse take?

8 : A nurse is reinforcing teaching about bicycle safety with a school-age child. Which of the following instructions should the nurse include?

9 : A nurse is reinforcing dietary teaching with the guardians of a toddler. Which of the following snack foods should the nurse recommend?

10 : A nurse is reinforcing teaching with a parent of a child who has gastroesophageal reflux disease and a new prescription for lansoprazole capsules. Which of the following statements by the parent indicates an understanding of the teaching?

11 : A nurse in an urgent care clinic is collecting data from a preschooler who reports painful urination. Which of the following findings should the nurse identify as a possible manifestation of a urinary tract infection?

12 : A nurse is preparing a child who has suspected bacterial meningitis for a lumbar puncture. Which of the following cerebrospinal fluid findings supports the diagnosis?

13 : A nurse is assisting with the care of several clients. The nurse should identify that which of the following client conditions requires contact precautions?

14 : A nurse is assisting with the care of a school-age child who has shigella. Which of the following actions should the nurse take?

15 : A nurse is caring for a 2-year-old child who has pneumonia and a temperature of 39.4° C (103° F). Which of the following actions should the nurse take?

16 : A nurse is reinforcing teaching with the guardian of a 1-year-old infant about administering a liquid oral medication. Which of the following statements should the nurse make?

17 : A nurse is contributing to the plan of care for an infant who has heart failure. Which of the following interventions should the nurse recommend?

18 : A nurse is preparing to administer immunizations to a 4-year-old child who is currently up to date with the recommended immunization schedule. Which of the following immunizations should the nurse plan to administer? (Select all that apply)

19 : A nurse is preparing to administer a vaccine to a toddler. Which of the following actions should the nurse plan to take?

20 : A nurse is reinforcing teaching with the guardian of a school-age child who has a severe peanut allergy. Which of the following information should the nurse include?

21 : A nurse is preparing to collect data from a toddler during a well-child visit. Which of the following actions should the nurse plan to take?

22 : A nurse is preparing to collect data from a toddler during a well-child visit. Which of the following actions should the nurse plan to take?

23 : A nurse is caring for a child who has had diarrhea for 3 days. Which of the following actions should the nurse take?

24 : A nurse is reinforcing teaching with an adolescent client who has a new diagnosis of lactose intolerance. Which of the following instructions should the nurse include in the teaching?

25 : A nurse is preparing to administer a vaccine to a toddler. Which of the following actions should the nurse plan to take?

26 : A nurse is reinforcing teaching with an adolescent female client who has recurrent urinary tract infections. Which of the following statements by the adolescent indicates an understanding of the teaching?

27 : A nurse is reinforcing teaching with an adolescent who has a prescription for tretinoin topical for the treatment of acne. Which of the following instructions should the nurse include in the teaching?

28 : A nurse is preparing to collect data from a school-age child. Which of the following areas should the nurse palpate to find the radial pulse?

29 : A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to see first?

30 : A nurse is caring for an 18-month-old infant who is 12 hours postoperative following a myringotomy. Which of the following pain rating scales should the nurse use?

31 : A nurse in a clinic is speaking with a parent of a 1-year-old toddler who received her scheduled immunizations 1 hour ago. Which of the following findings reported by the parent is the nurse's priority?

32 : A nurse is collecting data from a school-age child who has Cushing's syndrome. Which of the following findings should the nurse expect?

33 : A nurse is contributing to the care plan of an infant who has pneumonia. Which of the following toys should the nurse select for the child's play activity?

34 : A nurse is preparing to administer medications to a child via a nasogastric tube. Which of the following actions should the nurse take?

35 : A nurse is preparing to perform a heel stick using a spring-loaded automatic puncture device on a 1-week-old infant. In which of the following locations should the nurse puncture the infant's foot?

36 : A nurse is reinforcing teaching with a parent of a toddler who has conjunctivitis. Which of the following instructions should the nurse include in the teaching?

37 : A nurse observes circumoral cyanosis in an infant who is choking. Which of the following actions should the nurse take?

38 : A nurse is reinforcing teaching about the purpose of the HbA1c test with an adolescent who has type 1 diabetes mellitus.Which of the following statements by the adolescent indicates an understanding of the teaching?

39 : A nurse is caring for a child who received an initial dose of antibiotics 20 minutes ago.Which of the following findings is the priority to report to the provider?

40 : A nurse is preparing to administer recommended immunizations to an 11-year-old child who is up-to-date with current immunizations.Which of the following immunizations should the nurse plan to administer?

41 : A nurse is discussing allergies with the guardians of a school-age child prior to administration of the influenza vaccine.The nurse should identify that a prior anaphylactic reaction to which of the following is a contraindication to this immunization?

42 : A nurse is reinforcing teaching with the guardian of a school-age child who has asthma.Which of the following instructions should the nurse include in the teaching?

43 : A nurse is reinforcing teaching with the parent of a preschooler who has a hip fracture and is in a spica cast.Which of the following findings should the nurse identify as an indication of infection?

44 : A nurse is assisting with the collection of a bone marrow specimen from a preschooler. Which of the following actions should the nurse take?

45 : A nurse is caring for a preschooler who is terminally ill. Which of the following reactions to death should the nurse expect?

46 : A nurse is reinforcing teaching about food choices with a parent of a child who has celiac disease. Which of the following responses by the parent indicates an understanding of the teaching?

47 : A nurse is contributing to the plan of care for a school-age child who has autism and is scheduled for surgery. Which of the following interventions should the nurse include in the plan?

48 : A nurse is caring for a toddler who has been vomiting for the past 8 hours. Which of the following findings indicates to the nurse that the child is dehydrated?

49 : A nurse is collecting data from a school-age child who has erythema infectiosum (fifth disease). The nurse should expect the rash to appear on which area of the child's body first?

50 : A nurse is collecting data from an infant who has respiratory syncytial virus (RSV). Which of the following findings should the nurse expect?

51 : A nurse in the emergency department (ED) is assisting with the care of a 10-year-old child.

52 : A nurse is assisting in the care of an 8-month-old infant in the pediatric unit.

53 : A nurse is caring for a newborn in the neonatal unit. Review the following exhibits to answer the questions.

Answer Options

1 :
A nurse is monitoring a 6-month-old infant 20 minutes after administering a hepatitis B immunization. Which of the following findings is the nurse's priority?

3 :
A nurse is assisting with the care of a school-age child who is terminally ill. Which of the following interventions should the nurse perform?

4 :
A nurse is caring for a child and suspects the child has experienced physical maltreatment. Which of the following statements should the nurse make?

5 :
A nurse is collecting data from an infant. Which of the following areas should the nurse palpate to check for an inguinal hernia?

7 :
A nurse is assisting with the care of a preschooler who is immediately postoperative following a tonsillectomy. Which of the following actions should the nurse take?

8 :
A nurse is reinforcing teaching about bicycle safety with a school-age child. Which of the following instructions should the nurse include?

9 :
A nurse is reinforcing dietary teaching with the guardians of a toddler. Which of the following snack foods should the nurse recommend?

10 :
A nurse is reinforcing teaching with a parent of a child who has gastroesophageal reflux disease and a new prescription for lansoprazole capsules.
Which of the following statements by the parent indicates an understanding of the teaching?

11 :
A nurse in an urgent care clinic is collecting data from a preschooler who reports painful urination. Which of the following findings should the nurse identify as a possible manifestation of a urinary tract infection?

12 :
A nurse is preparing a child who has suspected bacterial meningitis for a lumbar puncture. Which of the following cerebrospinal fluid findings supports the diagnosis?

13 :
A nurse is assisting with the care of several clients. The nurse should identify that which of the following client conditions requires contact precautions?

14 :
A nurse is assisting with the care of a school-age child who has shigella. Which of the following actions should the nurse take?

15 :
A nurse is caring for a 2-year-old child who has pneumonia and a temperature of 39.4° C (103° F). Which of the following actions should the nurse take?

16 :
A nurse is reinforcing teaching with the guardian of a 1-year-old infant about administering a liquid oral medication. Which of the following statements should the nurse make?

17 :
A nurse is contributing to the plan of care for an infant who has heart failure. Which of the following interventions should the nurse recommend?

18 :
A nurse is preparing to administer immunizations to a 4-year-old child who is currently up to date with the recommended immunization schedule.
Which of the following immunizations should the nurse plan to administer? (Select all that apply)

19 :
A nurse is preparing to administer a vaccine to a toddler. Which of the following actions should the nurse plan to take?

20 :
A nurse is reinforcing teaching with the guardian of a school-age child who has a severe peanut allergy. Which of the following information should the nurse include?

21 :
A nurse is preparing to collect data from a toddler during a well-child visit. Which of the following actions should the nurse plan to take?

22 :
A nurse is preparing to collect data from a toddler during a well-child visit. Which of the following actions should the nurse plan to take?

23 :
A nurse is caring for a child who has had diarrhea for 3 days. Which of the following actions should the nurse take?

24 :
A nurse is reinforcing teaching with an adolescent client who has a new diagnosis of lactose intolerance. Which of the following instructions should the nurse include in the teaching?

25 :
A nurse is preparing to administer a vaccine to a toddler. Which of the following actions should the nurse plan to take?

26 :
A nurse is reinforcing teaching with an adolescent female client who has recurrent urinary tract infections. Which of the following statements by the adolescent indicates an understanding of the teaching?

27 :
A nurse is reinforcing teaching with an adolescent who has a prescription for tretinoin topical for the treatment of acne. Which of the following instructions should the nurse include in the teaching?

28 :
A nurse is preparing to collect data from a school-age child. Which of the following areas should the nurse palpate to find the radial pulse?

29 :
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to see first?

30 :
A nurse is caring for an 18-month-old infant who is 12 hours postoperative following a myringotomy. Which of the following pain rating scales should the nurse use?

31 :
A nurse in a clinic is speaking with a parent of a 1-year-old toddler who received her scheduled immunizations 1 hour ago. Which of the following findings reported by the parent is the nurse's priority?

32 :
A nurse is collecting data from a school-age child who has Cushing's syndrome. Which of the following findings should the nurse expect?

33 :
A nurse is contributing to the care plan of an infant who has pneumonia. Which of the following toys should the nurse select for the child's play activity?

34 :
A nurse is preparing to administer medications to a child via a nasogastric tube. Which of the following actions should the nurse take?

35 :
A nurse is preparing to perform a heel stick using a spring-loaded automatic puncture device on a 1-week-old infant. In which of the following locations should the nurse puncture the infant's foot?

36 :
A nurse is reinforcing teaching with a parent of a toddler who has conjunctivitis. Which of the following instructions should the nurse include in the teaching?

37 :
A nurse observes circumoral cyanosis in an infant who is choking. Which of the following actions should the nurse take?

38 :
A nurse is reinforcing teaching about the purpose of the HbA1c test with an adolescent who has type 1 diabetes mellitus.Which of the following statements by the adolescent indicates an understanding of the teaching?

39 :
A nurse is caring for a child who received an initial dose of antibiotics 20 minutes ago.Which of the following findings is the priority to report to the provider?

40 :
A nurse is preparing to administer recommended immunizations to an 11-year-old child who is up-to-date with current immunizations.Which of the following immunizations should the nurse plan to administer?

41 :
A nurse is discussing allergies with the guardians of a school-age child prior to administration of the influenza vaccine.The nurse should identify that a prior anaphylactic reaction to which of the following is a contraindication to this immunization?

42 :
A nurse is reinforcing teaching with the guardian of a school-age child who has asthma.Which of the following instructions should the nurse include in the teaching?

43 :
A nurse is reinforcing teaching with the parent of a preschooler who has a hip fracture and is in a spica cast.Which of the following findings should the nurse identify as an indication of infection?

44 :
A nurse is assisting with the collection of a bone marrow specimen from a preschooler. Which of the following actions should the nurse take?

45 :
A nurse is caring for a preschooler who is terminally ill. Which of the following reactions to death should the nurse expect?

46 :
A nurse is reinforcing teaching about food choices with a parent of a child who has celiac disease. Which of the following responses by the parent indicates an understanding of the teaching?

47 :
A nurse is contributing to the plan of care for a school-age child who has autism and is scheduled for surgery. Which of the following interventions should the nurse include in the plan?

48 :
A nurse is caring for a toddler who has been vomiting for the past 8 hours. Which of the following findings indicates to the nurse that the child is dehydrated?

49 :
A nurse is collecting data from a school-age child who has erythema infectiosum (fifth disease). The nurse should expect the rash to appear on which area of the child's body first?

50 :
A nurse is collecting data from an infant who has respiratory syncytial virus (RSV). Which of the following findings should the nurse expect?

51 :
A nurse in the emergency department (ED) is assisting with the care of a 10-year-old child.

52 :
A nurse is assisting in the care of an 8-month-old infant in the pediatric unit.

53 :
A nurse is caring for a newborn in the neonatal unit. Review the following exhibits to answer the questions.