NR-328 Pediatric Nursing - Set 5 - Part 2

Correct Answer: Reasonable suspicion alone triggers the duty to report

Mandatory reporting laws in all fifty states are triggered by reasonable suspicion, not proof. The nurse need not know who caused the injury or wait for imaging, because investigating is the agency's work. Option a is incorrect because demanding proof would delay protection until harm is undeniable. The reporting threshold sits deliberately low so that a child at risk is assessed by the people trained to do it. Option b is incorrect because gathering evidence is not a nursing function here. Child protective services and law enforcement investigate; the nurse assesses, documents objectively and hands the concern over without building a case. Option d is incorrect because naming a perpetrator is never a condition of reporting. Many reports are made when the person responsible is unknown, and identifying anyone falls outside what a bedside nurse does.

Correct Answer: Assess airway, breathing, circulation and neurologic status

Life threatening injury is treated before anything else. Vomiting, lethargy and a bulging fontanelle point to raised intracranial pressure, so airway, breathing, circulation and neurologic status come ahead of documentation and reporting. Option a is incorrect because photographs matter for the legal record yet do nothing for a deteriorating infant. Imaging the findings can wait until breathing and perfusion are secure and the child is stable. Option c is incorrect because the report is mandatory and immediate, but it follows stabilisation. A telephone call placed while an infant shows signs of rising intracranial pressure delays the care that keeps him alive. Option d is incorrect because history taking belongs later in the sequence and is done calmly, without confrontation. Nothing the caregiver says changes the immediate physiologic need in front of the nurse right now.

Correct Answer: Place the baby down safely and step away

Inconsolable crying is the commonest trigger for abusive head trauma. Teaching parents to put the infant down in a safe place, walk away and return when calm is primary prevention every nurse delivers. Option b is incorrect because vigorous rocking risks the very injury this teaching prevents. An infant's heavy head and weak neck muscles make rapid movement dangerous, and crying is not a problem to be forced away. Option c is incorrect because hourly feeding does not settle a baby whose crying has no hunger behind it. Overfeeding adds discomfort and exhausts the parents further, leaving frustration exactly where it started. Option d is incorrect because routinely handing the infant to someone else is not what this teaching asks. Support and respite help, yet the skill parents need is a safe response in the moment.

Correct Answer: Ask the caregiver how to prepare and calm him

The caregiver is the expert on this child, knowing which pictures work, what calms him, what escalates him and how his pain shows. That information shapes every later step, so it is gathered before the procedure is attempted. Option a is incorrect because a spoken explanation moments beforehand gives a nonspeaking child no usable warning. Preparation for him runs on photographs, a social story and a visual schedule offered early enough to be rehearsed. Option b is incorrect because physical holding is a last resort that often escalates an autistic child and damages trust for every future encounter. Child life belongs in preparation and distraction, not in restraint. Option c is incorrect because speed without preparation is how these procedures fail. Rushing floods the child with unexpected touch and noise, and the unplanned struggle that follows costs far more time than a prepared approach would.

Correct Answer: Give one short instruction and praise immediately

Structure and immediate feedback carry these children. One short step at a time, given clearly and followed by specific praise as soon as it is done, works far better than long instructions or delayed consequences. Option a is incorrect because a string of tasks exceeds working memory in a child who is already distractible. He will start the first item, lose the rest and be labeled defiant for a problem of attention. Option b is incorrect because a consequence delivered days later has no connection to the behavior it targets. Reinforcement in this disorder must be frequent and immediate, which is why daily report cards and token systems are used. Option d is incorrect because predictability, not novelty, is what steadies the morning. A routine that stays the same each day reduces the number of decisions the child has to make and cuts the arguments that follow.

Correct Answer: Draw blood cultures and start intravenous antibiotics

Fever may be the only sign a neutropenic child can produce, and sepsis can kill within hours. Cultures followed by broad-spectrum antibiotics belong within the first hour, before results or symptoms appear. Option a is incorrect because lowering the temperature erases the only warning this child has. An antipyretic given before cultures hides the emergency and buys the organism another hour to multiply. Option c is incorrect because a private room prevents new exposures but does nothing about an infection already circulating. Isolation belongs in the standing precautions, not in the response to a fever spike. Option d is incorrect because waiting for rounds spends the window that decides survival. A neutropenic child cannot form pus or an infiltrate, so looking comfortable offers no reassurance at all.

Correct Answer: Bring the child in now for evaluation

Repeated splenic infarction leaves these children unable to clear encapsulated bacteria, so overwhelming sepsis can follow a fever within hours. Any fever means immediate cultures and parenteral antibiotics, not watchful waiting at home. Option a is incorrect because an antipyretic lowers the number while bacteria multiply unchecked. Masking the only warning sign this child can produce costs the hours that decide whether treatment arrives in time. Option b is incorrect because prophylactic penicillin prevents infection and does not treat one already present. Changing a prescribed dose over the telephone is outside nursing practice and would delay the cultures this child needs. Option c is incorrect because hydration matters in this disease yet does nothing against invading organisms. Home observation treats fever here as a minor illness when it is the emergency the family was taught to fear.

Correct Answer: Schedule analgesia around the clock with breakthrough doses

Pain at the end of life is controlled with scheduled around the clock dosing and extra breakthrough doses, because as needed dosing lets pain return and rebuild before each dose arrives. Option a is incorrect because opioids are first line for moderate to severe pain in a dying child, and morphine has no ceiling dose. Stepping down the drug class leaves the child undertreated. Option c is incorrect because widening the interval guarantees longer stretches of uncontrolled pain. Fear of tolerance or addiction must not limit dosing, since the correct dose is simply the one that relieves suffering. Option d is incorrect because injections into muscle hurt and are avoided in palliative care. The least invasive effective route is chosen, so oral, buccal, transdermal or intravenous routes are preferred.

Correct Answer: Upslanting palpebral fissures, epicanthal folds, and low muscle tone

Upslanting palpebral fissures, epicanthal folds and generalized hypotonia are the classic trisomy twenty one findings, along with a single transverse palmar crease, protruding tongue, flat nasal bridge and a wide sandal gap between the first two toes. Option a is incorrect because a bulging fontanel with a high pitched cry points to rising intracranial pressure, an acute neurologic emergency. Those signs demand immediate evaluation and have no place in the picture of trisomy twenty one. Option b is incorrect because clenched hands with overlapping fingers and rocker bottom feet describe trisomy eighteen, Edwards syndrome, whose infants usually have severe cardiac defects and a very short life expectancy requiring palliative care from diagnosis. Option d is incorrect because webbed neck, lymphedema of the hands and widely spaced nipples belong to Turner syndrome, a forty five X karyotype seen only in girls. Intelligence there is usually normal, unlike the picture described.

Correct Answer: Bring her in for several hours of observation

Epinephrine wears off within about twenty minutes, and a second wave of symptoms can appear hours after the first settles. Observation in the emergency department covers that biphasic risk even when the child looks recovered. Option b is incorrect because an hour at home falls far short of the window when symptoms return, which commonly opens between one and ten hours. Home also lacks oxygen, fluids, and a second dose. Option c is incorrect because an antihistamine settles itching and does nothing for a returning airway or a falling pressure. Treating a resolved reaction at home with the wrong drug delays the care she still needs. Option d is incorrect because a returning reaction can start with wheeze, vomiting, or collapse and no rash at all. Waiting for hives as the trigger to travel misses the children who never show skin signs.

Correct Answer: Quote the child's words and describe each finding

Verbatim quotes in quotation marks, attributed to the speaker, plus the exact location, size, shape and colour of each finding make the record objective. Behaviour and caregiver interaction are described the same way, never labelled. Option a is incorrect because paraphrasing loses the child's exact language, which is the part that carries weight. A summary in nursing words invites argument later about what the child actually said. Option b is incorrect because inflicted is a conclusion, and conclusions do not belong in a chart. Describing the wound and the account given lets the investigating agency reach its own determination. Option c is incorrect because estimating how old a mark is cannot be done reliably from its appearance. Colour is recorded as seen, with measurements and a body map, and no age is asserted.

Correct Answer: "We will push extra fluids when he has a fever."

Fever raises fluid losses and dehydration concentrates the blood, so sickling accelerates. Increasing intake during fever, heat or activity is the single most useful thing the family does between clinic visits. Option b is incorrect because thinner air at altitude lowers available oxygen, and hypoxia is one of the strongest triggers for sickling. High elevations and unpressurized aircraft are avoided by these families. Option c is incorrect because chilling the skin narrows peripheral vessels and slows blood through the small circulation. Cold water and cold weather both provoke crises, so the child is kept warm and dressed in layers. Option d is incorrect because exertion carried to exhaustion raises oxygen demand and acid load together. Activity is encouraged for these children, but with rest breaks and fluids before tiredness turns into a crisis.

Correct Answer: Untreated dental disease and heavy school absence

Physical, medical and educational neglect show up as untreated dental and medical problems and excessive school absence alongside growth failure. These are objective observations the nurse records without labelling the family. Option a is incorrect because attentiveness and current immunisations describe a child whose care is being kept up. Findings like these argue against neglect and would be documented as reassuring rather than concerning. Option b is incorrect because clean skin and completed dental work show that basic needs are being met. Neglect is an omission of care, and this description records care that clearly took place. Option d is incorrect because normal language development and steady weight gain point away from deprivation. Delayed speech and growth failure are the findings that raise concern, so this option describes the opposite picture.

Correct Answer: A bulging red drum with reduced mobility

Pus behind the eardrum pushes it outward, so the membrane looks full and red and barely moves on pneumatic testing. Ear tugging, night waking, and feed refusal are the infant version of ear pain. Option a is incorrect because a retracted drum with bubbles behind it belongs to effusion without infection. That child has muffled hearing but no fever, no pain, and no acute illness. Option c is incorrect because tenderness on pressing the tragus points to the outer canal, the classic swimmer's ear finding. Middle ear infection leaves the pinna and tragus painless to touch. Option d is incorrect because a pearly gray membrane with a crisp cone of light is the healthy appearance. Nothing about that view explains the tugging, the poor feeding, or the broken sleep.

Correct Answer: "I will put the strong ointment on his cheeks when they flare."

Facial skin absorbs steroid readily, so only low potency is safe there. Putting the stronger preparation on the cheeks risks thinning, telangiectasia, and adrenal suppression, which means this caregiver needs correction before discharge. Option b is incorrect because short filed nails blunt the damage scratching does and help break the itch and scratch cycle. That statement shows the caregiver grasped a core part of eczema care. Option c is incorrect because hydrocortisone is exactly what belongs on the face, eyelids, neck, and folds, where absorption runs highest. Matching potency to the site is the rule this caregiver already follows correctly. Option d is incorrect because wool and rough synthetics rank among the common triggers, so choosing soft cotton removes one irritant. Trigger avoidance sits beside moisturizing in every eczema plan, and no correction is needed.

Correct Answer: Ask the staff to continue the conversation elsewhere

Hearing is believed to be the last sense lost, so nothing is said at the bedside that should not be heard. Moving the conversation away protects the infant and the parents at the same time. Option a is incorrect because separating parents from their dying infant removes the presence that matters most. The room stays available to them, and it is the staff conversation that has to move. Option b is incorrect because that statement is untrue and would stop the family talking and touching. Vision dims early while hearing persists, which is why the nurse encourages parents to keep speaking. Option d is incorrect because a saturation number no longer alters the plan once care is purely comfort focused. Monitoring is usually discontinued so that attention rests on the infant rather than a screen.

Correct Answer: Milk allergy usually resolves by adolescence

Milk, egg, soy, and wheat allergies are usually outgrown, with roughly four in five children losing the milk allergy by their teens. Peanut, tree nut, fish, and shellfish allergies tend to persist. Option a is incorrect because lifelong avoidance describes peanut, tree nut, fish, and shellfish far better than milk. Telling these parents to expect permanence sets up years of unnecessary restriction for their child. Option b is incorrect because starting solids has no bearing on when tolerance develops, which happens gradually over years. Reintroduction is guided by testing and a supervised food challenge, not by a feeding milestone. Option c is incorrect because one food allergy does not generate another, although a child with eczema may acquire several over time. Shellfish allergy typically shows up later on its own, unconnected to milk.

Correct Answer: Refer for diagnostic evaluation and early intervention now

A high scoring screen skips the follow up interview and goes straight to referral. Early intervention is contacted at the same time as the diagnostic evaluation, because waiting for confirmation costs the child months of therapy. Option a is incorrect because rescreening applies to a low scoring result, not a high one. Repeating the questionnaire here simply delays the evaluation, and the developmental window that therapy works within is narrowing the whole time. Option c is incorrect because services do not require a confirmed label. Eligibility for early intervention rests on delay, so the referral is filed immediately and the diagnostic workup proceeds alongside it rather than ahead of it. Option d is incorrect because no drug treats autism itself. Risperidone and aripiprazole are approved only for irritability and aggression, and the interventions that change developmental outcome are behavioral, speech and occupational therapy.

Correct Answer: Becoming distressed when the daily schedule changes

Insistence on sameness sits in the restricted and repetitive domain, together with stereotyped movements, intense narrow interests and unusual sensory reactions. A break in routine is experienced as a genuine threat and provokes real distress. Option b is incorrect because reading faces falls under social communication, the other core domain. Difficulty interpreting expressions describes reduced social reciprocity and belongs on the first side of the diagnostic criteria rather than the repetitive side. Option c is incorrect because limited eye contact is a nonverbal social communication deficit. It is certainly part of the overall picture, though the question asks for behavior from the second domain, where routines and repetition live. Option d is incorrect because flat prosody with few gestures again describes deficits in nonverbal communication. Those features cluster with poor social reciprocity and trouble forming relationships, all of which sit outside the restricted and repetitive grouping.

Correct Answer: "I bathe her briefly in lukewarm water and cream her within three minutes."

A short lukewarm bath hydrates the skin, and sealing that water in with an emollient within three minutes stops it evaporating. Moisturizer continues twice daily even when the skin looks settled. Option a is incorrect because hot water strips lipid from an already leaky barrier and leaves the child itchier. Air drying wastes the window when damp skin can still be sealed with ointment. Option b is incorrect because brisk towel rubbing abrades inflamed skin and triggers scratching, while bubble bath is a classic irritant. Gentle patting that leaves the skin slightly damp is what the routine requires. Option d is incorrect because stopping emollient during a quiet spell invites the next flare. Maintenance moisturizing when the skin looks normal is the step families skip most often, and it prevents relapse.