Question

A nurse is teaching a group of parents of children with tonic-clonic seizures about the phases of the seizure. Which statement, made by a parent, indicates understanding of the post-ictal phase?

Answer 1

Correct Answers:

The parent should mention that the post-ictal phase is the period of altered consciousness after the seizure.

Rationale :

✍️ The post-ictal phase occurs immediately after seizure activity has stopped and represents the brain's recovery period following abnormal electrical activity.

✍️ During this phase, the child may experience confusion, drowsiness, fatigue, headache, muscle soreness, or temporary altered consciousness.

✍️ Some children may sleep deeply for a period of time because tonic-clonic seizures consume significant amounts of energy.

✍️ The nurse should maintain the child's airway, place the child in a side-lying position when appropriate, and monitor neurologic status during recovery.

✍️ Recognizing the post-ictal period is important because persistent unconsciousness, respiratory difficulty, or failure to return toward baseline can indicate a serious complication requiring further evaluation.

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Answer 2

Correct Answers:

Tell the parents that the child will be monitored closely during and after the procedure.
Inform the parents that the child will need to fast before the procedure.
Explain to the parents that the child will receive sedation before the procedure.

Rationale :

The child will be monitored closely during and after the procedure.

♦️ Cardiac catheterization involves advancing a catheter into the heart and blood vessels, so continuous cardiovascular monitoring is essential.

♦️ During the procedure, the healthcare team monitors the child's heart rhythm, blood pressure, oxygen saturation, and overall hemodynamic status.

♦️ Afterward, the insertion site must be observed closely for bleeding, hematoma formation, and impaired distal circulation.

♦️ Peripheral pulses, skin temperature, color, and capillary refill are checked to identify possible vascular complications.

♦️ Close monitoring is therefore necessary to detect complications such as arrhythmias, hemorrhage, or decreased circulation as early as possible.

The child will need to fast before the procedure.

♦️ Children are usually required to remain NPO for a prescribed period before cardiac catheterization because sedation or anesthesia may be used.

♦️ Fasting reduces the risk of vomiting and aspiration while the child's protective airway reflexes are depressed.

♦️ The exact fasting period depends on the child's age, type of intake, and institutional anesthesia guidelines.

♦️ Parents should receive clear instructions regarding when to stop solid foods, formula, breast milk, and clear fluids.

♦️ Following the prescribed NPO instructions is an important safety measure before sedation and invasive cardiac procedures.

The child will receive sedation before the procedure.

♦️ Sedation is commonly administered before pediatric cardiac catheterization to help the child remain calm, comfortable, and still.

♦️ Excessive movement during catheter placement could interfere with the procedure and increase the risk of complications.

♦️ Sedation also reduces fear, pain, and procedural anxiety, particularly in younger children.

♦️ The child must be monitored closely because sedative medications can affect respiratory status, blood pressure, and level of consciousness.

♦️ Parents should understand that sedation is a planned part of care intended to promote safe and effective completion of the catheterization.

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Answer 3

Correct Answers:

Check the child's daily weight.

Rationale :

🖍️ Acute glomerulonephritis decreases renal filtration and can cause sodium and water retention, leading to edema and hypertension.

🖍️ Daily weight is one of the most sensitive indicators of changes in fluid volume because rapid weight gain usually reflects retained fluid rather than increased body tissue.

🖍️ The child should be weighed at the same time each day, using the same scale and similar clothing, whenever possible.

🖍️ Weight trends help the nurse evaluate the severity of fluid retention and the effectiveness of therapies such as fluid restriction, sodium restriction, or diuretics when prescribed.

🖍️ Close monitoring is essential because excessive fluid accumulation can contribute to severe hypertension, pulmonary edema, and heart failure.

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Answer 4

Correct Answers:

Place the infant in a knee-chest position.
Administer morphine via IV bolus.
Provide 100% oxygen by face mask.

Rationale :

Place the infant in a knee-chest position.

📗 The knee-chest position is a key intervention during a hypercyanotic spell, particularly in children with tetralogy of Fallot.

📗 Flexing the child's knees toward the chest increases systemic vascular resistance, which decreases right-to-left intracardiac shunting.

📗 This encourages more blood to flow toward the lungs, where it can become oxygenated.

📗 The position can therefore improve oxygen saturation and reduce the severity of acute cyanosis.

📗 Prompt positioning is especially important because prolonged hypoxemia can result in syncope, seizures, or cardiovascular collapse.

Administer morphine via IV bolus as prescribed.

📗 Morphine may be administered during a severe hypercyanotic spell to decrease agitation, catecholamine release, and excessive respiratory effort.

📗 Calming the infant can reduce worsening of the right-to-left shunt caused by crying or extreme distress.

📗 Morphine can also decrease infundibular spasm and improve pulmonary blood flow in children with tetralogy of Fallot.

📗 Because opioids can cause respiratory depression, the nurse must monitor respiratory rate, oxygen saturation, blood pressure, and level of consciousness.

📗 When prescribed, morphine is therefore an important adjunct to positioning and oxygen therapy during a severe cyanotic episode.

Provide 100% oxygen by face mask.

📗 Supplemental high-concentration oxygen should be provided during a hypercyanotic episode to maximize the amount of available oxygen reaching the lungs and tissues.

📗 Oxygen can help improve arterial oxygenation while other measures are used to reduce the degree of right-to-left shunting.

📗 It also supports organs that are vulnerable to hypoxic injury, particularly the brain and heart.

📗 The nurse should continuously monitor oxygen saturation and the infant's clinical response during treatment.

📗 Oxygen is therefore an appropriate immediate supportive intervention for a child experiencing acute cyanosis from congenital heart disease.

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Answer 5

Correct Answers:

Trimethoprim-sulfamethoxazole

Rationale :

⚽ Trimethoprim-sulfamethoxazole is an antibacterial medication that may be prescribed to treat susceptible organisms responsible for urinary tract infections.

⚽ It works by interfering with sequential steps in bacterial folate synthesis, which inhibits bacterial growth and survival.

⚽ Treatment of a pediatric UTI is important because untreated infection can ascend from the bladder to the kidneys and cause pyelonephritis or renal damage.

⚽ The nurse should verify the child's medication allergies, prescribed dose, renal status, and culture results when available.

⚽ Because it directly targets susceptible bacteria, trimethoprim-sulfamethoxazole is the medication among these choices that treats the underlying bacterial infection.

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Answer 6

Correct Answers:

Pedialyte

Rationale :

🌹 Pedialyte is a clear oral rehydration solution that contains water, electrolytes, and glucose in concentrations designed to support hydration.

🌹 It is easier to absorb and is more appropriate for fluid replacement than milk or other opaque feeding products when a clear liquid is ordered.

🌹 Infants with pyloric stenosis often develop dehydration and electrolyte disturbances because repeated projectile vomiting prevents adequate fluid retention.

🌹 A clear electrolyte solution can help provide hydration when oral clear fluids are specifically permitted by the healthcare provider.

🌹 The nurse should still closely monitor the infant's intake, vomiting, urine output, weight, and electrolyte status, especially because definitive treatment of pyloric stenosis is surgical.

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Answer 7

Correct Answers:

"I will keep my baby in an upright position after feedings."

Rationale :

♠️ Keeping an infant upright after feeding uses gravity to help reduce the movement of stomach contents back into the esophagus.

♠️ The infant can generally be held upright for approximately 20 to 30 minutes after feeding, according to individualized instructions.

♠️ Smaller, more frequent feedings may also reduce gastric distention and help decrease episodes of reflux.

♠️ While awake and supervised, positioning strategies can improve comfort, but for sleep the infant should always be placed supine on a firm, flat surface to reduce the risk of sudden infant death.

♠️ Appropriate post-feeding positioning therefore helps manage reflux while preserving safe infant sleep practices.

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Answer 8

Correct Answers:

Potassium

Rationale :

🍊 Furosemide is a loop diuretic that blocks sodium and chloride reabsorption in the ascending loop of Henle, producing significant diuresis.

🍊 Increased urine production also causes increased potassium excretion, placing the client at risk for hypokalemia.

🍊 Low potassium can cause muscle weakness, fatigue, cardiac dysrhythmias, and increased sensitivity to medications such as digoxin.

🍊 The nurse should therefore review the serum potassium level before administration and continue monitoring electrolytes during treatment.

🍊 Potassium assessment is particularly important in heart failure because both electrolyte imbalance and dysrhythmias can worsen cardiovascular instability.

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Answer 9

Correct Answers:

Maintaining catheter patency and monitoring urine output closely.

Rationale :

👉 After epispadias repair, maintaining unobstructed urinary drainage is essential because urine must flow freely without placing pressure on the healing surgical site.

👉 Catheter obstruction can lead to bladder distention, urine leakage, increased surgical-site pressure, and disruption of the repair.

👉 The nurse should ensure the catheter tubing is not kinked or compressed and should monitor urine amount, color, and characteristics closely.

👉 Reduced or absent urine output may indicate catheter obstruction, dehydration, bleeding, or another postoperative complication requiring prompt evaluation.

👉 Protecting catheter patency therefore supports optimal wound healing while reducing the risk of urinary retention, infection, and surgical breakdown.

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Answer 10

Correct Answers:

Changes in the oral mucous membranes, such as erythema, "strawberry" tongue

Rationale :

🎯 Kawasaki disease is an acute systemic vasculitis in children that classically presents with fever lasting at least 5 days along with characteristic mucocutaneous findings.

🎯 Oral manifestations include bright red or cracked lips, erythematous oral mucosa, and a strawberry tongue with prominent papillae.

🎯 Other major findings can include bilateral nonpurulent conjunctival injection, polymorphous rash, cervical lymphadenopathy, and changes of the hands or feet.

🎯 Early recognition is critical because untreated Kawasaki disease can cause coronary artery dilation or aneurysm formation, creating a risk for thrombosis and myocardial ischemia.

🎯 A persistent fever accompanied by strawberry tongue and oral mucosal erythema is therefore highly characteristic and should strongly raise suspicion for Kawasaki disease.

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ASN Pediatrics NSG2530 Exam 2B Spring 26

No.

1 :
A nurse is teaching a group of parents of children with tonic-clonic seizures about the phases of the seizure. Which statement, made by a parent, indicates understanding of the post-ictal phase?

2 :
Which of these instructions should a nurse include when teaching the parents of a child who is scheduled to have a cardiac catheterization about the procedure? Select All That Apply.

3 :
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority?

4 :
A nurse is caring for an infant who has congenital heart disease. Which of the following actions should the nurse plan to take? Select All That Apply.

5 :
A child with a urinary tract infection is prescribed medication. Which medication should the nurse prepare to administer to specifically target the bacterial infection?

6 :
A nurse is caring for an infant with pyloric stenosis. The healthcare provider orders a clear liquids diet. Which of the following fluids should the nurse select for the infant?

7 :
A nurse is providing teaching to the parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching?

8 :
A nurse is caring for a client who has heart failure and a new prescription for furosemide. Which of the following laboratory values should the nurse review before administering furosemide?

9 :
A nurse is caring for a 5-month-old infant postoperative from epispadias repair. Which nursing intervention should be prioritized to prevent complications and promote optimal healing?

10 :
A nurse is assessing a child who has had a persistent fever for 6 days and exhibits several signs. Which clinical manifestation should the nurse identify as most indicative of Kawasaki disease?

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ASN Pediatrics NSG2530 Exam 2B Spring 26

No.

1 : A nurse is teaching a group of parents of children with tonic-clonic seizures about the phases of the seizure. Which statement, made by a parent, indicates understanding of the post-ictal phase?

2 : Which of these instructions should a nurse include when teaching the parents of a child who is scheduled to have a cardiac catheterization about the procedure? Select All That Apply.

3 : A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority?

4 : A nurse is caring for an infant who has congenital heart disease. Which of the following actions should the nurse plan to take? Select All That Apply.

5 : A child with a urinary tract infection is prescribed medication. Which medication should the nurse prepare to administer to specifically target the bacterial infection?

6 : A nurse is caring for an infant with pyloric stenosis. The healthcare provider orders a clear liquids diet. Which of the following fluids should the nurse select for the infant?

7 : A nurse is providing teaching to the parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching?

8 : A nurse is caring for a client who has heart failure and a new prescription for furosemide. Which of the following laboratory values should the nurse review before administering furosemide?

9 : A nurse is caring for a 5-month-old infant postoperative from epispadias repair. Which nursing intervention should be prioritized to prevent complications and promote optimal healing?

10 : A nurse is assessing a child who has had a persistent fever for 6 days and exhibits several signs. Which clinical manifestation should the nurse identify as most indicative of Kawasaki disease?

1 :
A nurse is teaching a group of parents of children with tonic-clonic seizures about the phases of the seizure. Which statement, made by a parent, indicates understanding of the post-ictal phase?

2 :
Which of these instructions should a nurse include when teaching the parents of a child who is scheduled to have a cardiac catheterization about the procedure? Select All That Apply.

3 :
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority?

4 :
A nurse is caring for an infant who has congenital heart disease. Which of the following actions should the nurse plan to take? Select All That Apply.

5 :
A child with a urinary tract infection is prescribed medication. Which medication should the nurse prepare to administer to specifically target the bacterial infection?

6 :
A nurse is caring for an infant with pyloric stenosis. The healthcare provider orders a clear liquids diet. Which of the following fluids should the nurse select for the infant?

7 :
A nurse is providing teaching to the parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching?

8 :
A nurse is caring for a client who has heart failure and a new prescription for furosemide. Which of the following laboratory values should the nurse review before administering furosemide?

9 :
A nurse is caring for a 5-month-old infant postoperative from epispadias repair. Which nursing intervention should be prioritized to prevent complications and promote optimal healing?

10 :
A nurse is assessing a child who has had a persistent fever for 6 days and exhibits several signs. Which clinical manifestation should the nurse identify as most indicative of Kawasaki disease?