Chapter 21: Caring for the Child in the Hospital, the Community, and Across Care Settings Nursing School Test Banks

Chapter 21: Caring for the Child in the Hospital, the Community, and Across Care Settings

MULTIPLE CHOICE

1. The pediatric nurse clarifies the history of a child who is brought to the emergency room with abdominal pain. The nurse uses the mnemonic OLD CAT to ask the appropriate questions, including which of the following?
A. Activity
B. Diet
C. Output
D. Timing
ANS: D
The mnemonic OLD CAT stands for: onset (When did the child become ill?), location (Where is the pain?), duration (How long does the pain last?), character (Can you tell me on a scale of 1 to 10 how bad it is?), aggravating/alleviating (What has made the pain better or worse?), and timing (When does the pain start/stop?).

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

2. The pediatric nurse takes a comprehensive health history of a 10-year-old patient and asks the parents about their use of herbal products or home remedies. What information does the nurse know regarding herbal products?
A. Aloe vera can affect clotting time by decreasing platelets.
B. Bilberry can cause hypersensitivity in patients with allergies to plants.
C. Echinacea is contraindicated for patients with autoimmune disorders.
D. Fennel is contraindicated in patients with diabetes, hypertension, or liver disease.
ANS: C
There are no known side effects for topical application of aloe vera. Bilberry can affect clotting time by decreasing platelet aggregation. Echinacea should not be used for patients with autoimmune disorders, diabetes, AIDS, or HIV. Fennel may have a laxative effect; licorice is contraindicated in patients with diabetes, hypertension, or liver and kidney disease.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

3. The pediatric nurse performs a health assessment on a 9-year-old girl who weighs 23 kg and is 132 cm tall. How does the nurse document the patients BMI?
A. 13.20
B. 13.82
C. 14.25
D. 14.68
ANS: A
The BMI-for-age is calculated by dividing the weight (in kilograms) by the height squared (in meters). However, because most health-care providers obtain height in centimeters, an alternative calculation is to divide the weight (in kilograms) by the height squared (in centimeters), then multiply by 10,000.

Cognitive Level: Analysis
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

4. On physical assessment of the skin of a patient, the nurse documents cyanosis. What other related assessment should the nurse perform?
A. Ask the parent about yellow and orange vegetable intake.
B. Draw blood for hemoglobin, hematocrit, and liver function studies.
C. Palpate all the childs lymph nodes, assessing for enlargement.
D. Take the childs vital signs, including blood pressure and pulse.
ANS: D
Cyanosis may indicate a compromised cardiorespiratory state, and the nurse should assess measures of cardiac output and respiratory function. Taking vital signs will give the nurse information about these two systems. Vegetable intake, laboratory studies (including liver function tests), and palpating lymph nodes are not related to cyanosis.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

5. A nursing manager is concerned about frequent errors on the pediatric unit and wants to decrease them. What action by the manager is best?
A. Have two nurses verify all new orders when they are written.
B. Institute a standardized handoff format at shift change.
C. Provide remedial education to nurses who make errors.
D. Require charge nurses to verify care plans with staff nurses.
ANS: B
The Joint Commission has identified handoff communication as contributing to up to 80% of all serious, preventable errors. To remedy this situation, a standardized handoff communication format is suggested. The other actions might work to some degree, but not to the extent that improving handoff communication would.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

6. The pediatric nurse assessing a patient for breath sounds documents a loud, high-pitched sound heard only over the trachea. The nurse should document this finding as which of the following?
A. Adventitious breath sound
B. Bronchial breath sound
C. Bronchovesicular breath sound
D. Vesicular breath sound
ANS: B
Bronchial breath sounds are loud, high-pitched, and heard only over the trachea. Bronchovesicular breath sounds are of intermediate intensity and pitch, with equal inspiratory and expiratory phases. These sounds are best heard between the scapulae and over the mainstem bronchi. Vesicular breath sounds are heard throughout the lung fields. These soft and low-pitched sounds have a longer inspiratory than expiratory phase. Adventitious sounds of these three classifications are described as crackles, wheezes, and rhonchi, respectively.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Communication and Documentation
Difficulty: Easy

PTS: 1

7. The pediatric nurse is assessing a 5-year-old for developmental milestones. Which assessment tool should the nurse use?
A. CHEOPS scale
B. Denver II screening tool
C. FLACC scale
D. OLD CAT questions
ANS: B
The Denver II assesses personal-social, fine motor-adaptive, gross motor, and language skills to gauge performance on developmental milestones. The CHEOPS and FLACC scales are used to assess pain. The mnemonic OLD CAT is used to obtain a patients pain history and includes questions on onset, location, duration, character, aggravating and alleviating factors, and timing.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

8. A nurse is explaining to a nursing student that a patient experienced a sentinel event during a previous hospitalization. What does the student understand about this event?
A. Experienced an unusual event that is rare in the literature
B. Had an unexpected response to treatment or nursing care
C. Meeting a major milestone in treatment for an illness
D. Unexpected event resulting in serious injury (or death)
ANS: D
A sentinel event is an unexpected event that results in the death or serious injury of a patient. The other descriptions are inaccurate.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

9. The pediatric nurse working in a hospital setting uses both standard precautions and transmission-based precautions for patients. Which patient requires only standard precautions?
A. Infectious diarrhea
B. Staphylococcal infection
C. Tonsillitis
D. Tuberculosis
ANS: C
Transmission-based precautions are intended to prevent the transmission of pathogens from those with infectious diseases. Transmission-based precautions include airborne, droplet (TB), and contact precautions (infectious diarrhea and staph infection). Standard precautions are used on all patients, including those with tonsillitis.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Nursing Process: Implementation
Difficulty: Easy

PTS: 1

10. A pediatric nurse needs to administer acetaminophen (Childrens Tylenol) to patients in the intensive care unit (ICU). Which dose, based on age, is correct?
A. 0 to 3 months, 40 mg
B. 4 to 11 months, 220 mg
C. 2 to 3 years, 120 mg
D. 4 to 5 years, 100 mg
ANS: A
The proper dosage based on age is 0 to 3 months, 40 mg; 4 to 11 months, 80 mg; 12 to 23 months, 120 mg; 2 to 3 years, 160 mg; and 4 to 5 years, 240 mg.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

11. A parent of a teething child asks for guidance on nonpharmacological treatments for gum pain. What herbal preparation can the nurse suggest?
A. Aloe vera
B. Chamomile
C. Echinacea
D. Tea tree oil
ANS: B
Chamomile is used for the pain of teething, colic, and stomach aches. Aloe vera is used orally for constipation and topically for minor skin irritation. Echinacea is used for colds, fever, and inflammation of the mouth and pharynx. Tea tree oil is a topical treatment for skin infections.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Teaching/Learning
Difficulty: Easy

PTS: 1

12. A nurse is attempting to assess a toddler, who is being uncooperative. What action by the nurse would be best to accomplish this task?
A. Get on the floor while assessing the child.
B. Give the child toys to play with.
C. Have the parent restrain the toddler.
D. Visit with the parent for a short while.
ANS: D
Young children need to feel comfortable with the nurse before they will be cooperative. At this age, the best way to improve the childs comfort level is for the nurse to establish a rapport with the parent(s). Once the child becomes comfortable with the nurse present, he or she is more likely to cooperate. Giving toys and getting on the same level of the child are helpful, age-appropriate actions, but not the best answer. Having the parent restrain the child would be the last resort unless the assessment technique could injure a struggling child (e.g., otoscopic examination of the ear).

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

13. A middle-aged woman has brought a fussy baby to the pediatric clinic. After placing the woman and child in an exam room, which of the following questions should the nurse ask first?
A. Have you taken the babys temperature?
B. How are you related to the baby?
C. How long has the baby been so fussy?
D. What brings you to the office today?
ANS: B
It is crucial to establish the relationship between a child and the adult who brings the child in for treatment. The nurse should ascertain the womans identity; it is possible she is not legally able to provide consent for treatment. The other questions are important assessment questions, but establishing the identity of the adult comes first.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

14. A teenager is in the family practice clinic for a school physical. When the parent leaves the room, the teen admits to cutting myself after a relative touched me in my private area. What action by the nurse is most appropriate?
A. Document the statements and alert the provider.
B. Explain that this information must be shared.
C. Have the secretary call the police department.
D. Reassure the teen of confidentiality rules.
ANS: B
Older children (teens and preteens) often prefer to be interviewed in private where concerns of a personal nature can be shared in a safe area. Information about sexuality is often discussed at this time. The nurse is responsible for maintaining privacy except in situations of abuse or where a life-threatening situation exists. The nurse should first explain to the teen that this information needs to be shared with the parent before doing anything else. The information does need to be documented and the provider alerted, but not as the priority. Each facility will have policies in place to report possible abuse, which may or may not involve calling the police, Child Protective Services, or a social worker. However, reporting will wait until the nurse explains to the teen that the information needs to be shared.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Management of Care
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

15. A nurse is assessing a school-age child who complains of stomach aches after eating. Which question is appropriate for the D component of the OLD CAT mnemonic?
A. Can you describe how your tummy pain feels?
B. Have you tried any over-the-counter drugs?
C. How long does the pain last after you eat?
D. What day did you first notice the pain?
ANS: C
OLD CAT stands for onset, location, duration, character, aggravating/alleviating factors, and timing. Asking the child how long the pain lasts reflects duration.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

16. A nurse is assessing a school-age child in the clinic with an earache and fever. Using the SODA mnemonic, what question by the nurse best relates to S?
A. Does it keep you from sleeping?
B. Has this affected your schoolwork?
C. How long have you been sick?
D. How sore is your ear today?
ANS: A
The SODA mnemonic stands for sleep, output, diet, and activity. Asking if the childs earache is affecting sleep is the appropriate question for the S component of this mnemonic.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

17. A 1-week-old infant is in the pediatric clinic. The birth weight was 8 lb, 1 oz (3.65 kg). Today the infant weighs 7 lb (3.17 kg). The mother breastfeeds exclusively. What action by the nurse is best?
A. Assess the mothers breastfeeding technique.
B. Document the finding and alert the provider.
C. Reassure the woman that weight loss is normal.
D. Refer the mother to a lactation consultant.
ANS: B
Newborns often lose 510% of their birth weight during the first week of life. However, a weight loss greater than 10% needs further evaluation. This baby has lost just over 10% of birth weight. The nurse should document the finding and alert the health-care provider. Assessing breastfeeding technique and referral to a lactation consultant may be appropriate depending on the etiology of the problem. The nurse should not reassure the mother that the weight loss is normal because it is excessive for the first week of life.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

18. A nurse is providing nutritional information to a parent group. Which information is most appropriate?
A. At least 35% of calories should come from protein.
B. Limit carbohydrates to 1015% of daily calories.
C. Saturated fats are the healthiest fat choice.
D. Use whole milk until your child is 2 years old.
ANS: D
Children should be switched from whole milk to skim or low-fat varieties after age 2 years. Ten to 35% of calories should be from protein sources. Unsaturated fats are healthier than saturated fats. Carbohydrates form the bulk of a childs diet and should be 4565% of the daily calorie intake.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Basic Care and Comfort
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

19. A nurse is weighing a 2-month-old infant in the clinic. To ensure safety, which action is most appropriate?
A. Have the parent hold the child while standing on an adult scale.
B. Place the baby in the scale and place one hand on top of the baby.
C. Place the baby in the scale and hold one hand just over the baby.
D. Prop the infant sitting up in the scale, then weigh the prop separately.
ANS: C
To protect a child from an accidental fall from the infant scale, the nurse places the baby in the scale and holds one hand just over the baby. Weighing the adult and baby, then subtracting the adults weight is not as accurate as using the infant scale, which reads in smaller increments. Placing a hand on top of the baby will add weight. Propping up a 2-month old-infant is not as safe as laying the infant down.

Cognitive Level: Applying/Application
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

20. A nurse is assessing a 10-month-old babys anterior fontanel and finds it slightly depressed; the fontanel measures 2 inches (5.08 cm). What conclusion and action are most appropriate?
A. Delayed closing; alert health-care provider.
B. Fontanel is closing; document findings.
C. Large for age; assess for Downs syndrome.
D. Sign of dehydration; assess fluid status.
ANS: D
The anterior fontanel remains open until 1218 months of age. The normal size is 0.42.8 inches (17 cm). A depressed fontanel is a sign of possible dehydration, and the nurse should assess for other signs of fluid status. The closing is not delayed, it is not overly large, nor should it be closing as part of normal growth and development.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

21. A child has had eye testing. The nurse reads in the childs chart that the Hirschberg test demonstrated displacement of light reflection in one eye. What does this indicate to the nurse?
A. Color blindness
B. Normal ocular alignment
C. Presence of cataracts
D. Presence of strabismus
ANS: D
Ocular alignment is demonstrated through the Hirschberg test. When a light is shone directly into the childs eyes, the reflection should fall in the same location on the cornea of both eyes. Displacement of the corneal light reflection is indicative of strabismus. Color blindness is assessed with the Ishihara pseudochromatic charts. Cataracts are assessed via the red reflex.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

22. A child needs hearing assessments. To assess air and bone conduction of sound, which assessment technique is most appropriate?
A. Have the child place a block into a box each time he or she hears a sound.
B. Place a probe into the ear canal and measure the amount of sound reflected.
C. Strike a tuning fork and place the handle against the back of the childs head.
D. Strike a tuning fork, place it on the mastoid process, then move it to within1 inch of the ear canal.
ANS: D
Air and bone conduction of sound are assessed with both the Weber test and the Rinne test. The Rinne test uses as vibrating tuning fork placed against the childs mastoid process. When the child can no longer hear the fork, the nurse moves it to within 12 inches of the auditory meatus. The child should hear this sound twice as long as the bone-conducted sound. The Weber test uses the vibrating tuning fork placed against the midline on top of the childs head. Engaging in a play activity related to hearing sounds is called conditioned-play audiometry and assesses hearing. Using a probe in the ear canal is called tympanometry and assesses the status of the middle ear.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

23. A nurse reads in a childs chart that the child has pectus carinatum. What does the nurse understand this term to mean?
A. Barrel chest from chronic illness
B. Depression of the lower chest
C. Protrusion of the chest
D. Underdeveloped breast bone
ANS: C
Pectus carinatum is an abnormal protrusion of the chest. Depression of the lower portion of the sternum is known as pectus excavatum.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

24. A 5-year-old child is having an acute asthma attack. How does the nurse position the child while waiting for a respiratory treatment?
A. Prone across the parents lap
B. Semi-Fowlers position in bed
C. Upright in a hard-backed chair
D. Upright in the tripod position
ANS: D
Tripod positioning is often seen in children with respiratory distress. In this position the child sits upright leaning forward on outstretched arms with the jaw thrust forward. This position maximizes airway opening and use of accessory muscles. The nurse can assist the child into this position. The other positions will not be as helpful. However, it is important to note that because children having respiratory distress are often anxious, it is important to allow the child to assume the position in which he or she is most comfortable.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Basic Care and Comfort
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

25. A school-age child with asthma came to the emergency department with a respiratory rate of 44 breaths/minute and wheezes heard throughout. After two breathing treatments, the nurse assesses a respiratory rate of 8 breaths/minute and hears no wheezing. The child is lying quietly on the bed. What action by the nurse is best?
A. Allow the child to rest undisturbed.
B. Call for another respiratory treatment.
C. Obtain oxygen saturation; notify provider.
D. Reassess the child in 30 minutes.
ANS: C
This respiratory rate is too low for a child of any age and is indicative of exhaustion and the inability to breathe effectively. The absence of wheezes may indicate lack of ventilation. The nurse should obtain an oxygen saturation and notify the provider immediately. Without action, the child could progress to respiratory arrest. There is no indication that the child needs another breathing treatment.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

26. A toddler is brought to the clinic with a low-grade fever and the mother describes a grunting sound made by the child on expiration. The respiratory rate is 24 breaths/minute. What action by the nurse is most appropriate?
A. Assess nose and throat for foreign bodies.
B. Facilitate a stat chest x-ray.
C. Obtain an oxygen saturation; notify provider.
D. Weigh and measure child then calculate BMI.
ANS: C
Grunting noises are heard at the end of expiration and are caused by glottal closing. They can be indicative of respiratory distress or pneumonia. This childs respiratory rate is normal for age. The nurse should perform further assessments and notify the provider. Grunting is not associated with foreign bodies. The child is stable and does not need a stat chest x-ray, although he or she probably will have one after being seen. The BMI might be important for a child who snores or breathes noisily because snoring is often associated with obesity (along with foreign body, nasal polyps, choanal obstruction, or hypertrophied adenoid tissue).

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

27. A nurse is listening to a school-age childs heart sounds and hears an abnormal noise after S2 that is heard best when the child is lying in the left lateral position. What action by the nurse is most appropriate?
A. Arrange a cardiology consult.
B. Document the findings in the chart.
C. Notify the provider immediately.
D. Perform assessments for fluid balance.
ANS: B
This sound is an S3 and is often heard in children and young adults. It is usually a benign finding but should be documented in the chart. A cardiology consult is not needed, nor does the nurse need to notify the provider immediately. Because this sound is not usually associated with heart disease, the nurse does not need to perform an assessment of fluid balance.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

28. A visiting nurse is making a home visit on a male 2-month-old child who was born prematurely. The nurse notes that the child has not been circumcised. What action by the nurse is most important?
A. Assess the number of the babys wet diapers per day.
B. Give parents a referral to have the child circumcised.
C. Instruct parents not to retract the foreskin until after age 1.
D. Teach parents to retract the foreskin for cleaning.
ANS: C
The foreskin of an uncircumcised male baby should not be forcibly retracted until after he is 1 year of age. Assessing the number of wet diapers per day is important for any infant and is not directly related to the uncircumcised baby. The nurse should not just give a referral for circumcision, as the parents have chosen the option of not circumcising their baby, which may be for personal, religious, or cultural reasons. After 1 year of age, the foreskin will need to be retracted for cleaning. It should be returned to its original position afterward.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

29. A nurse has been asked to perform a Romberg test on a school-age child. What action does the nurse take to perform this assessment?
A. Ask the child to smile, frown, and make other faces.
B. Have the child touch a finger to the nose several times.
C. Instruct the child to walk across the room and back.
D. Tell the child to stand, close his or her eyes, and hold the arms out in front.
ANS: D
The Romberg test assesses cerebellar functioning and is performed by asking the child to stand, shut the eyes, and then hold the arms outstretched in front. A normal result is performing these actions without swaying. Looking at facial expressions tests cranial nerve VII. The finger-to-nose test also assesses cerebellar function. Observing posture and gain gives information about the childs musculoskeletal system.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

30. A nurse is caring for a 5-year-old who broke his arm and is complaining of pain. What statement by the nurse to the child would be most helpful?
A. I bet your arm will stop hurting really soon.
B. You dont have to stand pain; I can give you medicine.
C. You didnt do anything wrong that caused the hurt.
D. Wait until you see the cool cast you are going to get.
ANS: C
Children age 2 to 7 years often view pain as a punishment. The most comforting thing the nurse can say is to reassure the child that this is not the case. Empty reassurances such as telling the child the pain will go away soon or that the cast will be really cool are not comforting. An adolescent often wants control over health-care situations but may think he or she needs to be strong and bear the pain, especially if he or she believes adults think it is important to act that way.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Caring
Difficulty: Moderate

PTS: 1

31. A 66-lb child complains of mild pain after a procedure. What action by the nurse is best?
A. Administer 0.3 mg of naloxone (Narcan) every 4 hours orally if needed.
B. Administer 300 mg of acetaminophen (Tylenol) orally and provide a movie to watch.
C. Administer 450 mg of acetaminophen (Tylenol) orally every 3 hours as requested.
D. Administer morphine sulfate (Astromorph) 9 mg orally every 4 hours if needed.
ANS: B
For mild pain, acetaminophen and other mild analgesics work well along with a distraction or other comfort measures. The most appropriate choice is 300 mg of acetaminophen (within the dose range of 1015 mg/kg every 46 hours) and a movie to distract the child. Naloxone (Narcan) is a reversal agent for opioid analgesics and is not warranted in this situation. A dose of 450 mg of acetaminophen is appropriate, but the frequency is wrong. Morphine (Astromorph) would not be used for mild discomfort.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Difficult

PTS: 1

32. A new nurse caring for a toddler in pain after a procedure is reluctant to medicate the child for fear of causing a respiratory arrest. What action by the nurses preceptor is best?
A. Agree about withholding medication and teach some distraction techniques.
B. Explain that pain has detrimental health effects and needs treatment.
C. Have the new nurse get naloxone (Narcan) and place it at the childs bedside.
D. Tell the new nurse to give the child analgesics and not worry about respiratory arrest.
ANS: B
Pain has both detrimental physical and psychosocial effects and must be treated. It is a myth that analgesics (especially narcotics) are dangerous to give children. The other options will not treat the childs pain.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

33. A student nurse on the pediatric floor finds a patient in pain and gives the child some toys to play with. The registered nurse asks why the student did not medicate the child. The student states that because the child was easily distracted, it did not appear that the child needed pain medication. What action by the registered nurse is most appropriate?
A. Give the child some pain medication.
B. Have the student reassess the childs pain.
C. Instruct the student to take the childs vital signs.
D. Thank the student for distracting the child.
ANS: B
It is a myth that a child who can be distracted is not in pain; distraction serves as a coping mechanism. The nurse should have the student do a comprehensive pain assessment on the patient and then medicate the patient appropriately. Just giving the child pain medication without assessment does not follow the nursing process, nor does it teach the student anything. Vital signs do not always change with pain. Of course the nurse should compliment the student on things done to comfort the child, but this is not the best response.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Nursing Process: Assessment
Difficulty: Moderate

PTS: 1

34. A mother brings her severely disabled child to the pediatric clinic with complaints that the child has his fourth upper respiratory infection in 3 months. The mother appears disheveled and fatigued. What action by the nurse is best?
A. Ask the mother when the last time she ate or bathed was.
B. Inquire as to the whereabouts of the childs father.
C. Make a referral to the visiting nurses for a home evaluation.
D. Offer the mother information on local respite care options.
ANS: D
The mother may have caregiver fatigue, and opening up a discussion about respite care may be very helpful. Asking about hygiene, eating, and the whereabouts of the childs father all sound judgmental, although these questions could be gently included in a discussion of caregiver fatigue. Having the visiting nurses conduct a home visit to evaluate possible environmental causes of the childs frequent respiratory infections may be needed, but it is too premature at this point.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Caring
Difficulty: Moderate

PTS: 1

35. A father is at the bedside of his hospitalized disabled child. He begins crying, saying he has lost his job and no longer has insurance, so he is unsure of how to pay for the childs medical bills. What action by the nurse would be most helpful?
A. Consult with a social worker who can discuss state and federal insurance programs.
B. Give the father written information on state health insurance options for children.
C. Listen to the fathers concerns and tell him you understand how he must feel.
D. Tell the father not to worry; the health of his child is more important than money.
ANS: A
There are both state and federal insurance programs for children. The nurse should arrange a visit from the social worker who can discuss the options, give information in writing, and assist the father in applying for benefits. Simply giving written information is not as helpful; the nurse has not assessed the fathers literacy level, the father may have questions, or the father may not understand how to follow up. Never tell someone you know how they feel, because you dont and cant know exactly how they feel. Telling the father not to worry is dismissive of his concerns.

Cognitive Level: Applying/Application
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

36. A nurse is providing anticipatory guidance to the parents of a 4-year-old disabled child. What nutritional information should the nurse provide?
A. Feed the child as any other 4-year-old child.
B. Give child more than 7090 kcal/kg/day.
C. Offer extra protein and vitamins daily.
D. Provide extra carbohydrates and fat intake.
ANS: B
Children with disabilities need more calories, vitamins, minerals, and protein than do non-disabled children. A normal 4-year-old child requires 7090 kcal/kg/day, so this amount needs to be increased to a point at which the child is gaining weight and has the stamina to complete appropriate activities within his or her capabilities. The child should not be fed as any other 4-year-old. Telling parents to give extra protein and vitamins is vague. Increasing calories includes increasing all food groups, but the disabled child specifically needs more protein.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Basic Care and Comfort
Integrated Process: Teaching/Learning
Difficulty: Difficult

PTS: 1

37. A child is in the emergency department following an overdose of acetaminophen (Tylenol). What medication does the nurse anticipate administering?
A. Activated charcoal
B. N-acetylcysteine (NAC)
C. Naloxone (Narcan)
D. Syrup of ipecac
ANS: B
N-acetylcysteine (NAC solution) is the antidote for acetaminophen poisoning. The other options are not used for acetaminophen poisoning.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

38. A child is in the clinic to follow up on a blood lead level of 7 g/dL. What action by the nurse is best?
A. Call social work or Child Protective Services to evaluate home safety.
B. Instruct parents to have the child re-tested at the beginning of the school year.
C. Reassure parents that this is below the threshold for lead poisoning.
D. Teach parents to wet-mop surfaces instead of vacuuming the house.
ANS: D
The CDC has set the upper limit for blood lead at 5 g/dL. This childs level is higher, and the child may need specific treatment. The parents will have to be taught ways to eliminate lead in the house. One suggestion is to wet-mop surfaces instead of vacuuming, because the vacuum spreads lead dust. Calling social work or Child Protective Services at this point is premature. The parents need to take some sort of action now, and not just have the child tested at a later date.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Physiological Adaptation
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

39. A child will be hospitalized in the following week. In order to decrease the childs and parents stress related to the hospitalization, which action by the clinic nurse would be most helpful?
A. Arrange for the family to visit the hospital and have a tour.
B. Give the family written information on visiting hours.
C. Introduce the family to another family whose child is hospitalized.
D. Suggest the family take a break and not stay with the child.
ANS: A
There are several ways to decrease the stress of a planned hospitalization, one of which is to arrange a visit to the hospital where all involved can have a tour and visit the unit where the child will be staying. Written information is always good, but is not the best way to diminish stress.
Some families may be open to being introduced to others, but the nurse must take care to obtain permission first or risk a HIPAA violation. Parents are the main source of comfort for their children, so often a parent will stay with a hospitalized child.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Caring
Difficulty: Moderate

PTS: 1

40. A nursing manager wants to decrease the amount of stress children have during hospitalization. What environmental change can the manager implement to best meet this goal?
A. Create a treatment room for procedures.
B. Have dim lighting installed in patient rooms.
C. Keep the play area unlocked and open at all hours.
D. Provide guest trays for parents staying in the room.
ANS: A
One way to decrease the stress of hospitalization for children is to make the childs room a safe place where painful and frightening treatments and procedures do not occur. The manager should create a treatment room on the unit. Dim lighting might be peaceful and lead to better rest, but is not the best answer, nor is providing guest trays. Play areas for younger children especially should be kept secure for patient safety.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Caring
Difficulty: Moderate

PTS: 1

41. A nurse needs to administer medication to a toddler. What action by the nurse is most likely to gain cooperation from the child?
A. Allow the child to negotiate a reward.
B. Allow the parent to give the medication.
C. Explain that medicine is not a punishment.
D. Let the toddler self-administer the medicine.
ANS: B
A toddler may consider medicine to be a punishment and may resist taking it. Because the parent is a comforting figure for him or her, allowing the parent to administer the medication is a good option for the uncooperative child. Telling a child of this age that medicine is not a punishment is a good idea, but will not be as successful as letting the parent give it. Negotiation is the hallmark of the school-age child. Preschoolers may be able to self-administer medication with close supervision.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Caring
Difficulty: Moderate

PTS: 1

42. A preschool-age child is going to have a potentially painful procedure. What action by the nurse is best to prepare the child for this event?
A. Allow the child to decide if the parents stay or not.
B. Let the child touch and explore the equipment first.
C. Talk about it briefly for several days beforehand.
D. Use play to demonstrate the procedure to the child.
ANS: D
The nurse should use play to demonstrate the procedure and allow the child to perform the procedure on a doll or stuffed toy. The parents should be given the choice of staying in the room or not. Preparation should begin immediately before the procedure to keep the child from worrying about it for hours or days. An older child should be allowed to look at and explore equipment that is going to be used.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

43. A child who weighs 35 lb needs chloral hydrate (Aquachloral) for sedation prior to a medical procedure. What dose should this child receive?
A. 150 mg
B. 450 mg
C. 1,000 mg
D. 1,500 mg
ANS: C
The dose for this medication is 5075 mg/kg. The child weighs 15.9 kg, so the safe dosage range is 7951,192.5 mg.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

44. A pediatric nurse reads in a chart that a female patient is in Tanner stage 3. Which of the following best describes this patient?
A. Breast buds and thick, curly pubic hair
B. Entire breast enlarged; pubic hair in inverted triangle
C. Has breast buds and sparse, straight pubic hair
D. Nipples protruded; pubic hair extending to medial thighs
ANS: B
In Tanner stage 3, the entire breast in enlarged but the nipple and papillae are not enlarged yet. Pubic hair appears in a typical female inverted triangular pattern. Breast budding signifies stage 2, but in this stage pubic hair is not thick and curly. Protruded nipples and thigh hair are seen in stage 5.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Difficult

PTS: 1

MULTIPLE RESPONSE

1. The pediatric nurse performs a pain assessment on a 5-year-old girl who is admitted to the hospital for fractures following an accident. Depending on the assessment, the nurse could implement which of the following interventions? (Select all that apply.)
A. Manage mild pain with a combination of mild analgesics such as NSAIDs and distraction.
B. Manage mild pain with regularly timed analgesic administration of mild opioids.
C. Manage moderate pain with distraction plus regularly timed analgesic administration.
D. Manage severe pain with strong analgesics such as morphine sulfate (Astramorph).
E. Manage severe pain with strong analgesics (Astramorph) when distraction doesnt work.
ANS: A, C, D
Mild pain is a slight discomfort. Its management may include minor analgesics along with comfort measures or distraction. Moderate pain may also be relieved by using distraction in conjunction with regularly timed analgesic administration, including milder opioids such as codeine in varying combinations of acetaminophen (Tylenol). Management of severe pain, often associated with surgical interventions, usually calls for strong analgesics such as morphine. Distraction is not as helpful with severe pain.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

2. A nurse working on a pediatric unit teaches a student nurse that children may require intravenous fluids to be administered through one of several different venous access devices. The nurse tells the student that which of the following current patients are candidates for central venous access devices? (Select all that apply.)
A. Receiving blood product replacement after surgery
B. Receiving fluid maintenance prior to diagnostic testing
C. Requires long-term intravenous access for hydration
D. Will need regularly scheduled chemotherapy
E. With medication administration scheduled preoperatively
ANS: C, D
A peripheral line is used for short-term intravenous therapy, including transfusions, the possibility of future intravenous therapy, or intermittent medication administration. Those children with a condition necessitating long-term intravenous access are candidates for central venous access devices. The children who will need long-term intravenous hydration or chemotherapy are candidates for a central venous access device.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

3. The pediatric nurse caring for children with physical disabilities teaches the student nurse that coping mechanisms give rise to resiliency in children and their families. The nurse further notes that attributes of resilient children include which of the following? (Select all that apply.)
A. Dependence on family
B. Physical abilities
C. Problem-solving skills
D. Sense of purpose and future
E. Social competence
ANS: C, D, E
Four common attributes of resilient children are social competence, problem-solving skills, autonomy, and a sense of purpose and future. Dependency and degree of impairment are not related.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

4. The nurse conducts a seminar for new nurses about child safety in the hospital setting. Which of the following should be included? (Select all that apply.)
A. Asking children to state their names to ensure safe medication administration
B. Basing safety measures on the developmental level of the children
C. Keeping play areas in the hospital open at all times for children to visit
D. Providing age-appropriate transportation methods to other areas of the hospital
E. Storing toxic and nontoxic materials on the top shelf of a locked cabinet
ANS: B, D, E
Safety measures instituted on a pediatric unit are based on the developmental level of children to protect them from harm. Safety measures include keeping toxic materials out of reach, identifying children with name bands, and knowing the whereabouts of children on the unit, including in the play areas. Providing safe, age-appropriate transportation is also important.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Safe and Effective Care Environment: Safety and Infection Control
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

5. What does the pediatric nurse understand about the use of complementary and alternative medicine (CAM)? (Select all that apply.)
A. All CAM practices are the same within a cultural group.
B. CAM practices reflect ethnocultural health beliefs.
C. Only herbal remedies are considered CAM therapies.
D. Over half of the adults in America use CAM.
E. Very few doctors collaborate with CAM providers.
ANS: B, E
CAM practices reflect ethnocultural beliefs (relating to a particular ethnic group), and a culturally competent nurse will take the time to become familiar with CAM practices in the diverse communities served. According to one study, only 4% of pediatricians communicate with CAM providers or initiate the recommendations of the CAM provider. All members of the same cultural group may not adhere to the same CAM practices (although many of them will), and the nurse should not stereotype members of the group and assume they do. CAM consists of multiple modalities such as herbal therapy, massage, biofeedback, and yoga. More than a third of adults in America use CAM therapies.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Communication and Documentation
Difficulty: Moderate

PTS: 1

6. The pediatric nurse is assessing a teenagers past medical history. Which information should the nurse inquire about? (Select all that apply.)
A. All acute illnesses
B. Any chronic illnesses
C. Apgar scores at birth
D. Birth weight
E. Neonatal feeding problems
ANS: A, B
Inquiring about all acute illness episodes and any chronic illnesses present is appropriate for a child of any age. Asking about Apgar scores, birth weight, and neonatal feeding problems would be important for younger children.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

7. A nurse has been asked to perform a HEENT assessment on a child. What areas does the nurse assess? (Select all that apply.)
A. Endocrine
B. Eyes
C. Head
D. Nose
E. Throat
ANS: B, C, D, E
HEENT stands for head, eyes, ears, nose, and throat. Endocrine is not included.

Cognitive Level: Knowledge/Remembering
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Nursing Process: Assessment
Difficulty: Easy

PTS: 1

8. A family is raising a child with a serious disability, and the caregivers appear stressed and short tempered during well-child visits. What does the nurse understand about the emotional impact of this situation on the family? (Select all that apply.)
A. Caregiver fatigue is a constant threat due to ongoing medical needs.
B. Confusion and distress occur because they dont have the child they expected.
C. Family routine is disrupted by the constant needs of the disabled child.
D. Siblings adapt well to having a disabled child and enjoy helping out.
E. The family may worry about possible painful procedures and upsetting the child.
ANS: A, B, C, E
The family members of a disabled child are beset with emotional upset and confusion about the realities they face with their disabled child. They mourn because they did not get the child they expected, and they can be distressed by the childs pain and need for ongoing medical treatments. Caregiver fatigue is a real possibility, and normal routines are disrupted. Siblings can adapt to the disabled child and may enjoy helping out, but this is not a typical finding and should not be expected.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Caring
Difficulty: Moderate

PTS: 1

9. The nurse is providing discharge instructions to the parents of a 3-year-old going home after minor surgery. What information should the nurse include? (Select all that apply.)
A. Actions and side effects of prescribed medication
B. Activity that is expected and encouraged
C. How to take the childs rectal temperature
D. Signs and symptoms of infection
E. When the child can eat and drink again
ANS: A, B, D, E
Discharge teaching after minor surgery involves many items, including actions and side effects of prescribed medications; activity that is allowed, expected, and should be encouraged; signs and symptoms of infection; and when the child can eat and drink again. Usually, temperature on children is taken via the axillary route.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

10. The child development specialist explains to the nursing students that therapeutic play has several functions, including which of the following? (Select all that apply.)
A. Allows children to demonstrate their emotions
B. Decreases stress associated with hospitalization
C. Gives parents a break from watching their child
D. Helps correct childrens misconceptions about care
E. May help child learn new coping skills
ANS: A, B, D, E
Therapeutic play has several purposes, including allowing children to demonstrate their emotions, decreasing stress, helping to correct misconceptions about treatments, and helping the child learn to cope with and master stressful situations. A purpose is not to give the parents a break.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Psychosocial Integrity
Integrated Process: Caring
Difficulty: Moderate

PTS: 1

11. A nurse is providing a child safety class to a parent group. Which instructions are appropriate for the age group? (Select all that apply.)
A. Adolescent: Ride in the back seat of the car.
B. Infant: Never attach a pacifier to the infants clothing.
C. Preschool: Teach stop, drop, and roll for fire.
D. School age: Keep toilet seats down and tubs empty.
E. Toddler: Never leave unattended in a walker.
ANS: B, C
For an infant, parents should be taught not to attach a pacifier to the infant or infants clothing. Walkers are not recommended, but were used on infants in the past. Preschoolers can learn fire safety, including stop, drop, and roll. Keeping toilet lids down and bathtubs empty is appropriate for toddlers. School-age children should ride in the back seat of a car.

Cognitive Level: Comprehension/Understanding
Content Area: Pediatrics/Maternity
Patient Needs: Health Promotion and Maintenance
Integrated Process: Teaching/Learning
Difficulty: Moderate

PTS: 1

COMPLETION

1. A 34-lb child needs acetaminophen (Tylenol). The correct dose range for this child is____________________ mg .

ANS:
154.5231.8
The dose range for acetaminophen is 1015 mg/kg. This child weighs 15.45 kg, so multiplying by the correct dose gives a range of 154.5231.8 mg.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

2. A child who weighs 16 lb received an overdose of morphine sulfate and needs naloxone (Narcan). The safe dose for this child is ____________________ mg.

ANS:
0.07
The child weighs 7.27 kg. The correct dose range for naloxone is 510 g/kg or 0.01 mg/kg.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

3. A child weighs 28 lb. The nurse prepares to administer intravenous (IV) morphine sulfate. The correct dose for this child is ____________________ mg.

ANS:
1.27
The child weighs 12.72 kg. The dose of morphine sulfate IV for a child weighing less than 50 lb (22.7 kg) is 0.1 mg/kg.

Cognitive Level: Application/Applying
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

4. A child weighs 82 lb. The correct calculation for this childs 24-hour maintenance fluid requirements is ____________________ mL.

ANS:
1,845.45
For a child weighing less than 20 kg, the daily maintenance fluid requirement is 1,500 mL + 20 mL/kg for each kg above 20. This child weighs 37.27 kg, so he or she needs 1,500 mL + (20 x 17.27) = 1845.45 mL.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

5. A child weighs 8 lb. The correct calculation for this childs 24-hour maintenance fluid requirements is ____________________ mL.

ANS:
363.63
For a child weighing 110 kg, the daily maintenance fluid requirement is 100 mL/kg of body weight. This child weighs 3.63 kg, so the result is 363.63 mL.

Cognitive Level: Analysis/Analyzing
Content Area: Pediatrics/Maternity
Patient Needs: Physiological Integrity: Pharmacological and Parenteral Therapies
Integrated Process: Nursing Process: Implementation
Difficulty: Moderate

PTS: 1

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