Name:___________________________________________________________________ Date:____________

Jaime is a newborn with a bilateral cleft lip and cleft palate.1. After the physician talks with Jaime’s mother, she seems quite composed and asks to see the baby. To assess the mother’s reaction, the nurse should:a. Bring the baby to her immediatelyb. Tell her exactly what the baby looks like before bringing him to herc. Encourage her to express and explore her feelings, bring the baby to her and stay with her during this timed. Show her some pictures and give her some literature on harelip and cleft palate and discuss the treatment with her before bringing the baby to her

2. Jaime’s parents are young but seem very concerned and willing to learn about his care. Which of the following would be inappropriate to include in the teaching plans for the parents?a. Remove the nipple frequently when feeding Jaimeb. Encourage mother to breastfeedc. Jaime’s security needs can be met other than by suckingd. Jaime’s mental functioning should be normal

3. When Jaime is 2 ½ months old, he is hospitalized for repair of his cleft lip. Pre-operatively, which of the following nursing actions is most important for Jaime?a. Burp him frequently during feedingb. Offer him small, frequent feedings so as not to tire himc. Hold him in a low or flat position to facilitate swallowing d. Offer thickened bottle feeding to increase his intake

4. When Jaime is 13 months old, he is admitted for repair of his cleft palate. What is the best reason for the palate to be repaired at this stage?a. To give Jaime a chance to develop basic speech patternb. To prevent damaging tooth buds

A 6 year old is admitted to the hospital for heart surgery to repair Tetralogy of Fallot. The nurse observes that the child is cyanotic at admission.5. The nurse judges that the parents understand this disorder when they explain that one of the underlying their child’s cyanosis:a. Constriction of the aortab. Stenosis of the mitral valvec. Stenosis of the pulmonary arteryd. The aorta receiving blood directly front the vena cava

6. When teaching the parents about the echocardiogram that their child will undergo, the nurse should explain that the primary reason for this procedure is to determine:a. Cardiac structureb. Pressure of the blood in the heartc. The amount of blood entering the heartd. Various sounds made by each heartbeat

7. When planning for this client before corrective heart surgery, the nurse should choose which of the following as the priority nursing diagnosis?a. Ineffective family coping b. Painc. Knowledge deficitd. Impaired gas exchange

8. The nurse plans to teach the parents about digoxin prescribed for their child. Which of the following would the nurse tell the parents?a. Digoxin should be given with at least a full of waterb. Digoxin is absorbed better when taken 1 hour before eatingc. Signs of digoxin toxicity include increased heart rate and loss of appetited. If the child vomits 30 minutes after taking medication, the dose should be repeated

9. The parents express concern that their child wants to be held more frequently than usual postoperatively. Which of the following best describes this behavioral response to stress?a. Repression

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b. Depressionc. Regressiond. Discomfort

10. The mother asks the nurse why her child has clubbed fingers. The nurse should explain that the clubbing is due to:a. Anemiab. Peripheral hypoxiac. Delayed physical growthd. Destruction of bone marrow

Billy, 12 months old, has an elevated temperature for 48 hours. There is evidence of nuchal rigidity, increased lethargy and nausea and vomiting. He is also dehydrated. Meningitis is suspected. 11. Which of the following observations would probably alert the nurse to Billy’s dehydrated state?a. Moist mucus membranesb. Depressed anterior fontanelc. Urine specific gravity of 1.007d. 5% weight gain

12. Billy’s physician will most likely need which of the following?a. Thoracentesis trayb. Lumbar puncture trayc. NGTd. Foley catheter

13. Billy’s doctor ordered 5% dextrose in 0.33% normal saline with 20 meq of KCl to infuse at 32 ml/hr. Which of the following should be brought to the physician’s attention?a. Billy has not voided in 4 hoursb. Billy has had 3 liquid green stools c. Billy has vomited 50 ml of mucousd. Billy is fussy and irritable when moved

14. During the acute stage of Billy’s illness, which of the following nursing actions should receive the highest priority?a. Give frequent tepid sponge bathb. Perform treatment as quickly as possiblec. Reduce environmental stimulid. Monitor vital signs every 5-10 mins

Teresa 7-lb, 10 oz (3,500g) baby, was just delivered vaginally in the labor and delivery area. She has Apgar scores of 8 at 1 minute and 9 at 5 minutes. She has an elongated head and circumoral cyanosis. After allowing Teresa to remain with her parents in the labor and delivery area for 1 hour, the nurse transfers her to the neonatal nursery.15. Before conducting a routine neonatal discharge screening on Teresa for phenylketonuria, the nurse should:a. Check Teresa’s chart to ensure that her mother has signed a consent form b. Assess the financial, social, and emotional status of Teresa’s parentsc. Determine if Teresa has been on formula for at least 48 hours d. Ensure that Teresa’s hemoglobin level is within the normal range

16. Which of the following is the most important concept associated with all high-risk newborns?a. Support the high-risk newborns’ cardiopulmonary adaptation by maintaining an adequate airwayb. Identify complications with early intervention in the high risk newborn to reduce morbidity and mortalityc. Assess the high-risk newborn for any physical complications that will assist the parents with bondingd. Support the mother and significant others in their quest toward adaptation to the high-risk newborn

17. While assessing a child with pyloric stenosis, the nurse is likely to note which of the following?a. Regurgitationb. Steatorrheac. Projectile vomitingd. “Currant jelly” stools18. Discharge teaching for a child with celiac disease would include instructions about avoiding which of the following?a. Riceb. Milk

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c. Wheatd. Chicken

19. Which of the following should the nurse do first after noting that a child with Hirschsprung disease has a fever and watery explosive diarrhea?a. Notify the physician immediately b. Administer antidiarrheal medicationsc. Monitor child every 30 minutesd. Nothing, this is characteristic of Hirshsprung disease

Melanie has given birth to her fourth baby at 39 weeks gestation. The newborn has been diagnosed with a congenital diaphragmatic hernia and requires immediate surgery.20. In assessing Melanie’s newborn, the nurse will observe which or the following?a. A sunken abdomen with prominent bowel soundsb. Improved Apgar score at 10 minutesc. Increased cardiac outputd. Circumoral pallor but pink extremities

21. Melanie is concerned about her newborn’s pain after surgery. The nurse’s best response is:a. “Babies don’t feel pain; medication doesn’t need to be given after surgery.”b. “Babies don’t remember painful experiences; medication for pain may cause respiratory problems.”c. “Nonpharmacologic pain relief measures will be taken.”d. “Babies do feel pain; your baby will receive pain medication after surgery.”

22. When teaching parents about unknown antecedent infections in acute glomerulonephritis, which of the following should the nurse cover?a. Herpes simplexb. Scabiesc. Varicellad. Impetigo

23. Which of the following should be avoided if the child has hypospadias?a. Circumcisionb. Catheterizationc. Surgeryd. Intravenous pyelography

24. The primary reason for surgical repair of a myelomeningocele is to do which of the following?a. Correct the neurologic defectb. Prevent hydrocephalusc. Prevent seizure disordersd. Decrease the risk of infection

25. Signs of mild mental retardation would include which of the following?a. Lateness in walkingb. Mental age of a toddlerc. Noticeable developmental delaysd. Few communication skills

26. Which of the following assessment findings in a term neonate would cause the nurse to notify the pediatrician?a. Absence of tearsb. Unequally sized corneasc. Papillary constriction to bright light d. Red circle on pupils with ophthalmoscopic examination

27. While assessing a male neonate whose mother desires him to be circumcised, the nurse observes that the neonate’s urinary meatus appears to be located on the ventral surface of the penis. The physician is notified because the nurse suspects which of the following?a. Phimosisb. Hydrocele

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c. Epispadiasd. Hypospadias

28. Which of the following would the nurse expect to assess in a child with Down’s syndrome?a. Large noseb. Small tonguec. Oblique palpebral fissures d. Low arched palate

29. Which of the following statements by a 14 year old girl who wears a brace for structural scoliosis indicates effective use of the brace?a. “I wonder if I can take the brace off when I go to the homecoming dance.”b. “I’ll look forward to taking this off to take my bath everyday.”c. “I’m sure am glad that I only have to wear this awful thing at night.”d. “I’m really glad that I can take this thing off whenever I get tired.”

30. When assessing a newborn for developmental dysplasia of the hip, the nurse would expect to assess which of the following?a. Symmetrical gluteal foldsb. Trendelenburg signc. Ortolani’s signd. Characteristic limp

31. Which of the following is the priority nursing action for a child immediately following the application of a spica cast?a. Perform neuromuscular checksb. Elevate the castc. Cover the perineal aread. Keep the cast clean and dry

32. Which of the following types of immunity does an infant receive when given a DPT injection?a. Natural, activeb. Natural, passivec. Artificial, actived. Artificial, passive

Susan, is a newborn with Down’s syndrome. Her parent’s have been told of the diagnosis and are in the process of trying to adjust to this.33. Which of the following is most appropriate to include when counseling the parents of Susan?a. Susan’s development potential is greatest during infancyb. Susan will be severely retardedc. Susan will be spastic, so poisoning should be discussedd. Susan will be as susceptible to colds as her brother – increased susceptibility

34. Which of the following is an incorrect statement regarding Down’s syndrome?a. It is associated with higher incidence of congenital heart diseaseb. It is associated with higher incidence of GI defects – duodenal atresia or stenosisc. It is associated with higher incidence of leukemiad. It is inherited as an autosomal recessive trait

35. Which of the following measures is of primary importance for parents with a young, mentally retarded child at home?a. Limit the amount of environmental stimulation the child is exposed to b. Have the same parent teach the child new skills at all timesc. Teach the child socially acceptable behaviors so she can join the family outingsd. Maintains consistent routine for daily activities

Magdalena is at 36 weeks gestation and has been diagnosed as positive for the human immunodeficiency virus. She has had a healthy pregnancy to date but has many questions about how her health problems will affect her newborn.36. Magdalena asks the nurse if she can breastfeed her baby. Which of the following statements is the basis for the nurse’s response?a. Because Magdalena probably won’t live to raise this child, breastfeeding will provide closeness and bonding between mother and child.

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b. Because the baby is likely to be positive for the HIV, breastfeeding will provide immunity for other infectionsc. Because Magdalena doesn’t have symptoms of AIDS, she can breastfeedd. Because HIV may be transmitted through her breastmilk, breastfeeding isn’t recommended for Magdalena

37. Magdalena has delivered a baby girl at 39 weeks gestation. At 4 hours of age, the newborn has shallow respirations at 54 bpm with periods of apnea lasting 5 to 7 seconds. The nurse’s priority action would be to:a. Continue routine monitoringb. Notify the doctor immediatelyc. Request an order to administer oxygend. Prepare equipment for a respiratory arrest

38. Magdalena’s newborn is jaundiced because of an ABO blood group incompatibility and is receiving phototherapy. Which of the following nursing interventions is most appropriate for her newborn?a. Reposition the infant every 4 hoursb. Limit the infant’s oral intake to 1 oz every 4 hoursc. Remove the eye patches every 24 hours to assess for conjunctivitisd. Turn the phototherapy unit off when drawing blood for bilirubin levels

39. Before discharging Magdalena’s newborn on the 2nd day of life, the nurse completes her discharge examination. Which of the following findings would the nurse report to the doctor?a. A. black, dry umbilical cordb. A dark greenish-black stoolc. Petechiae covering the chest and abdomend. Bluish purple discoloration in the lumbosacral area

Carlo, age 8, comes in to the physician’s clinic with a sore throat, enlarged lymph nodes, elevated temperature and malaise. He has history of frequent streptococcal throat infection.40. Carlo has bacterial pharyngitis and is put on a regimen of oral penicillin, which of the following instructions of Carlo’s parents is most important at this time?a. Have him gargle with hot saline solution as needed b. Give Carlo the medicine for 10 days or until it is consumedc. Feed him soft diet until he feels betterd. Ensure he gets a lot of Vit C foods

41. Carlo returns in 2 months for a tonsillectomy. Preparations for hospitalization include books for him to read. His mother is advised to select a book with which of the following characteristics?a. Small, paperbackb. Large-size printc. Regular size printd. Large, with stiffened pages

42. After surgery, what assessment data may indicate that Carlo is hemorrhaging?a. Tachycardia, hypertension, hemoptysisb. Bradycardia, hypotension, increase swallowingc. Tachycardia, hypotension, increase swallowingd. Tachycardia, hypotension, decreased swallowing

43. Carlo’s nurse prepares the family for his discharge. Which of the following instructions should be emphasized?a. Return to school in 1-2 weeksb. No vigorous activities for 3-4 weeksc. Saline gargles as necessary for controld. Delayed hemorrhage may occur on the third post-op day

10-year-old Tanya is admitted to the hospital with a medical diagnosis of rheumatic fever. She relates a history of sore throat about a month ago. She is placed on a bed rest with BRP’s.

44. Which of the following nursing assessment would be given the highest priority when assessing Tanya?a. Her response of being hospitalizedb. The presence of a macular rash on her trunkc. Her sleeping or resting apical pulsed. The presence of polyarthritis and pain in her joints

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45. Tanya exhibits manifestation of Sydanham’s chorea. Which of the following is NOT a manifestation of this condition?a. Intellectual impairmentb. Muscle weaknessc. Purposeless tremorsd. Emotional lability

46. Which of the following nursing plans should receive the highest priority during Tanya’s hospitalization?a. Minimize cardiac damage by keeping Tanya on bed restb. Relieve pain by administering prescribed analgesicc. Help Tanya cope with hospitalization by providing age-appropriate activitiesd. Prevent injury by padding the bed side rails

47. Which activity is most appropriate for Tanya during the acute phase of her illness?a. Playing basketball b. Visiting other children in the unitc. Keeping a written diary d. Listening to the records of her favorite groups

48. Three of the following lab results are crucial indicators of Tanya’s progress. Which one does not?a. Antistreptolysin “O” titerb. C-reactive protein c. Protein in the urined. Erythrocyte sedimentation rate

49. Tanya is discharged after 3 weeks of hospitalization. Which of the following statements best indicates that Tanya’s parents have understood the discharge teaching?a. “Tanya should lead a sedentary lifestyle for at least a year.”b. “Tanya must take daily antibiotics for an extended period of time to prevent recurrence of rheumatic fever.”c. “Tanya should not return to her fifth-grade classroom but should have a home teacher the rest of the year.”d. “Tanya may have permanent neurologic sequela as a result of the Sydenham’s chorea.”

14-year-old Borat has hemophilia. He is seen at the clinic for a periodic check-up.50. When obtaining a history from Borat, which of the following reported manifestations would be the greatest cause for concern?a. Epistaxisb. Pallorc. Easy bruisingd. Hemarthrosis

51. His father tells the nurse that Borat loves football so much. He wants to try out for his junior high football team. His parents are having a hard time telling him that it is impossible. Which of the following alternatives is the best suggestion for Borat?a. Allow him to try out for the team as long as he wears a helmet and elbow and knee pads all the timeb. Start a collection of football memorabiliac. Develop an interest in swimming or table tennis insteadd. Try to become equipment manager for his junior high team

52. Borat is admitted to the hospital with an acute bleeding episode in his right elbow, which cannot be controlled at home. Which of the following will not be use to control bleeding?a. Plasma b. Plasma concentratec. Packed cellsd. Cryoprecipitate

53. Borat is recovering and will be discharged tomorrow. His father expresses concern about his failure as a family man. The nurse ascertains that Borat’s father is anxious to know if Borat can have children who do not have hemophilia. Assuming that Borat’s future spouse is not a carrier, which explanation is most accurate?a. All his children will be carriersb. His son will have the disease and his children daughters will be carriersc. There is a 50% chance that each of his children will have hemophiliad. His sons will be normal and his daughters will be carriers

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54. Which of the following is the best indicator of a successful outcome of Borat’s long-term treatment?a. Bleeding episodes are prevented or treated early to minimize sequelaeb. Borat is able to cope with his peers academicallyc. Borat’s weight is maintained within age appropriate rangesd. Borat chooses a realistic career goal

9-month-old Torio has been admitted in the pediatric unit with vomiting, colicky abdominal pain, and abdominal distention. A tentative diagnosis of intussuception is made.55. When assessing Torio, which type of stool indicates a worsening of Torio’s condition?a. Fatty, bulky, foul-smellingb. Dark, red, jelly-likec. Ribbon-like dark greend. Clay colored

56. Torio is not likely to exhibit which of the following behaviors?a. Loud crying when his parents leave himb. Fear of strangersc. Searching for hidden objectsd. Saying at least 3 words besides “dada” and “mama”

57. Torio is scheduled for surgery. His parents are anxious and ask what will be done in surgery. Which explanations should be given?a. The sigmoid colon will be resected with pull-through anastomosisb. The obstruction will be corrected by manual reductionc. The affected portion of the intestines will be resected with permanent colostomy createdd. The ileum will be resected and a permanent ileostomy created

58. Torio’s parents ask what is wrong with his intestines. Which of the following statements best describe Torio’s condition?a. A telescoping of one part of the bowel into a more distal partb. Malrotation of the intestinesc. Atresia of the intestinal tractd. Absence of parasympathetic ganglion cells

59. Preoperatively, the priority-nursing goal for Torio is to:a. Maintain Torio’s attachment to his parentsb. Meet Torio’s need for sucking and comfort while he is NPOc. Maintain adequate hydrationd. Promote adequate rest and sleep

60. Following surgery, Torio returns to the unit. He is fussy and seems to be in discomfort. The nurse palpates his abdomen and notes some distention. Which action should be implemented first?a. Call the surgeon to report this observationb. Insert a rectal tubec. Sit Torio upright and pat his backd. Check the NGT for patency

61. What is the potential greatest threat to Torio’s continued development while he is hospitalized?a. Developing mistrust towards the nursing staffb. Separation from his parentsc. Restricted mobilityd. Disruption in his sleeping and eating routines

Angel, 4 years old, is brought to the clinic with a high fever. She has been irritable for several days and is clinging to 2 dolls and her mother says she refuses to eat. While performing an initial assessment, the nurse makes several observations that may indicate that Angel is a victim of child abuse.62. Children are most frequently abused by:a. Babysitterb. Relativec. Teacherd. Casual acquaintances

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63. The child least likely at risk for being abused is one whose family:a. Moves frequentlyb. Owns their own homec. Has experience divorced. Has problems with chronic illness

64. Which test is least likely to indicate that Angel has been sexually abused?a. A Pap smearb. Urine culture c. Throat cultured. Vaginal culture

65. When interviewing a child suspected of being sexually abused, the nurse should:a. Ask leading questionsb. Have the parents consentc. Have a security guard presentd. Use the child’s words to describe body parts

66. Children who survive physical abuse are least likely to become:a. Depressedb. Drug abusersc. Abusive parents d. Academic achievers

67. Playing with her dolls while in the examination room, Angel was seen engaging in explicit sexual behavior. The nurse should know that:a. Angel is mimicking behavior seen on TVb. Angel is acting out a personal experiencec. Such play is a healthy expression of sexual developmentd. Angel needs to be directed to a more appropriate play

68. When abuse is suspected, the least appropriate nursing action is to:a. Take a wait-and-see positionb. Call a local social service agency for helpc. Prevent the child’s return to a dangerous environmentd. Confront the parent with security present

69. The nurse is planning nursing interventions for parents who abuse their children. It is important for the recall that these parents:a. Plans ahead as to when and how to abuse their childrenb. Ask for help generally only after feeling overwhelmed with the problemc. Usually feel no guilt concerning the abused. Are always a product of child abuse environment

70. When planning a client education program for sickle cell disease, the nurse should include which of the following topics?a. Proper handwashing and infection avoidanceb. A high-iron, high-protein dietc. Fluid restriction to 1 liter per dayd. Aerobic exercises to increase oxygenation

71. Which of the following is the most common form of childhood cancer?a. Lymphomab. Brain tumorsc. Leukemiad. Osteosarcoma

72. The nurse would prepare the parents of a child with suspected leukemia for which of the following tests that would confirm this diagnosis?a. Maternal drug use

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b. Bone marrow aspirationc. Complete blood countd. Blood culture

73. The nurse is caring for a neonate with erythroblastosis fetalis. The nurse knows that this disease results from:a. Maternal drug useb. Prematurityc. Destruction of red blood cellsd. Gestational diabetes

74. Rh incompatibility results when:a. The neonate’s blood group is Rh-positive and the mother’s is Rh-positiveb. The neonate’s blood group is Rh-negative and the mother’s is Rh-negativec. The neonate’s blood group is Rh-positive and the mother’s is Rh-positived. The neonate’s blood group is Rh-negative and the mother’s is Rh-negative

75. When administering an antipyretic to a child, the nurse knows that aspirin is contraindicated for children with viral infections because of the possibility of developing which of the following:a. Reye’s syndromeb. Reflux syndromec. Raynaud’s diseased. Reiter’s syndrome

76. Which of the following tests is most helpful in diagnosing hemophilia?a. Bleeding timeb. Partial prothromboplastin timec. Platelet countd. Complete blood count

77. The nurse explains to the mother of a neonate diagnosed with erthroblastosis fetalis that the exchange transfusion is necessary to prevent damage primarily to which of the following organs in the neonate?a. Kidneysb. Brainc. Lungsd. Liver

78. A parent asks the nurse about head lice infestation during a visit to the clinic. Which of the following symptoms would the nurse tell the parent is most common in a child infected with head lice?a. Itching of the scalpb. Scaling of the scalpc. Serous weeping on the scalp surfaced. Pinpoint hemorrhagic spots on the scalp surface

79. In a child with asthma, B-adrenergic agonist agents, such as albuterol, are administered primarily to do which of the following?a. Decrease postnasal dripb. Dilate bronchiolesc. Reduce airway inflammationd. Reduce secondary infections

80. Which of the following statements by the family of a child with asthma indicates a need for additional home care teaching?a. “We need to identify what things trigger these attacks.”b. “He is to use his bronchodilator inhaler before the steroid inhaler.”c. “We’ll make sure that he avoids exercise to prevent attacks.”d. “He should increase his fluid intake regularly to thin mucous secretions.”

81. When developing a plan of care for the child diagnosed with cystic fibrosis (CF), which of the following must the nurse keep in mind?a. CF is an autosomal dominant hereditary disorder

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b. Pulmonary secretions are abnormally thickc. Obstruction of the endocrine glands occursd. Elevated levels of potassium are found in the sweat

82. In children with sickle cell disease, tissue damage results from which of the following?a. A general inflammatory response due to an auto immune reaction to hypoxiab. Air hunger and respiratory alkalosis due to deoxygenated red blood cellsc. Local tissue damage with ischemia and necrosis due to obstructed circulationd. Hypersensitivity of the central nervous system due to elevated serum bilirubin

83. Which of the following would the nurse include in the plan of care for a child with juvenile rheumatoid arthritis?a. Administration of corticosteroids to decrease joint damageb. Prevention of contractures by keeping extremities in a flexed positionc. Vigorous range of motion exercises with affected jointsd. Application of heat to minimize pain and stiffness

84. Which of the following disorders leads to cyanosis from deoxygenated blood entering the systemic arterial circulation?a. Patent ductus arteriosusb. Tetralogy of Fallotc. Coarctation of the aortad. Aortic stenosis

85. While assessing a child with coarctation of the aorta, the nurse would expect to fine which of the following?a. Absent or diminished femoral pulseb. Tet spellsc. Squatting positiond. Severe cyanosis at birth

86. Which of the following nursing interventions would be appropriate to promote optimal nutrition in an infant with congestive heart failure?a. Offering formula that is high in sodium and caloriesb. Providing large feedings evenly spaced every 4 hoursc. Replacing regular nipples with easy-to-suck onesd. Allowing the infant to feed for at least 1 hour

87. When developing a teaching plan for the parents of a child with pulmonic stenosis, the nurse would keep in mind that this disorder involves which of the following?a. Return of blood to the heart entry into the left atriumb. Obstruction of blood flow from the right ventriclec. Obstruction of blood from the left ventricled. A single vessel arising from both ventricles

88. Which of the following symptoms would the nurse expect to observe in a newborn diagnosed with respiratory distress syndrome?a. Inspiratory gruntingb. Expiratory gruntingc. Inspiratory stridord. Expiratory wheezing

89. Which of the following respiratory conditions is always considered a medical emergency?a. Laryngotracheobronchitis (LTB)b. Epiglottitisc. Asthmad. Cystic fibrosis

90. The nurse is careful to cover the eyes and genitals of a newborn undergoing phototherapy. Covering the eyes prevents retinal damage; whereas covering the genitals prevents:a. Priapismb. Testicular ulceration

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c. Scrotal damaged. Prostate gland damage

91. Which nursing action is also necessary while a newborn is undergoing phototherapy?a. Turning him frequentlyb. Reducing his fluid intake c. Checking his urine glucose leveld. Decreasing environmental stimuli

92. Which assessment finding indicates that phototherapy has been effective for a newborn?a. Erythema of the body surface exposed to the lightb. Bronze baby syndrome c. Increased conjugated bilirubin levelsd. Elimination of green urine and greenish, loose stools

93. Which condition results from deposits of bilirubin in the neonate’s brain, especially in the brain stem and basal ganglia?a. Keratosisb. Kernicterusc. Athetosisd. Hydrops fetalis

94. A nurse prepares to administer digoxin (Lanoxin) to a 3-year-old child with a diagnosis of congestive heart failure. The nurse notes that the apical rate is 110 beats per minute. Based on this finding, which nursing action is most appropriate?a. Administer the digoxinb. Recheck the apical rate in 15 minutesc. Notify the physiciand. Hold the medication

95. A nurse is performing an admission assessment on a 6-month-old infant with a diagnosis of hydrocephalus. The nurse assesses for the major sign associated with hydrocephalus when the nurse:a. Tests the urine for proteinb. Takes the apical pulsec. Palpates the anterior fontaneld. Takes the blood pressure

96. A nurse has provided discharge instructions to the parents of an infant who had a ventriculoperitoneal shunt procedure performed for the treatment of hydrocephalus. Which statement if made by the parents indicates an accurate understanding of the presence of a shunt complication?a. “If my infant has a high-pitched cry, I should call the doctor.’b. I should position my infant on the side with the shunt when sleeping.”c. “My infant will pass urine more often now that the shunt is in place.”d. “I should call my doctor if my infant refuses baby food.”

97. A nurse is performing an admission assessment on a newborn infant with a diagnosis of spina bifida (meningomyelocele). The nurse assesses for a major symptom associated with this type of spina bifida when the nurse:a. Checks the capillary refill of the nail beds of the upper extremitiesb. Tests the urine for bloodc. Palpates the abdomen for massesd. Checks for responses to painful stimuli on the lower extremities

98. A nurse is caring for a newborn infant with spina bifida (meningomyelocele) who is scheduled for surgical closure of the sac. In the preoperative period the priority nursing action would be to monitor the:a. Blood pressureb. Moisture of the normal saline dressing covering the sacc. Specific gravity of the urine d. Anterior fontanel for depression

99. Later on the day, the nurse notices that Baby boy Lopez appears jaundiced. The latest laboratory results indicate the he has a serum bilirubin level of 12 mg/dl. The physician prescribes phototherapy.Considering the mother has type B positive blood, Baby boy Lopez’s condition probably is the result of:a. Rh incompatibility

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b. ABO incompatibilityc. Impaired bilirubin conjugationd. Excessive fetal hemoglobin

100. Which of the following represents an effective nursing intervention to reduce cardiac demands and decrease cardiac workload?a. Scheduling care to provide for uninterrupted rest periodsb. Developing and implementing a consistent plan of carec. Feeding the infant over long periods of timed. Allowing the infant to have her way to avoid conflict

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