The nurse is assessing the full-term Caucasian infant who is 40 hours

Pediatrics NCLEX Questions

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Question 1 of 5.

The nurse is assessing the full-term Caucasian infant who is 40 hours old. Which technique should the nurse use to evaluate the infant for jaundice?

A. Remove the infant's diaper and look at the color of the genitalia.

B. Apply pressure on the forehead for 3 seconds,release and evaluate the skin color.

C. Assess the color of the palms and compare that skin color to the color of the soles.

D. Open the infant's mouth to assess the color of the infant's tongue and palate.

Explanation: To differentiate jaundice from normal skin color apply pressure over a bony area like the forehead. A yellow blanched area indicates jaundice. Genitalia palms soles or oral mucosa are less reliable due to slower progression or darker pigmentation.

Question 2 of 5.

Which diversional activity suggested by the nurse is most appropriate for the child during the acute phase of rheumatic fever?

A. Playing with action figures

B. Playing video games

C. Reading an adventure story

D. Pounding wooden pegs with a mallet

Explanation: During the acute phase of rheumatic fever, the child is on bed rest to reduce cardiac workload. Reading an adventure story is a quiet, non-physically demanding activity appropriate for a 7-year-old, promoting rest while keeping the child engaged.

Question 3 of 5.

If the child develops shortness of breath when ambulating to the bathroom in the hospital, which intervention should the nurse add to the care plan?

A. Have the child use a bedside commode for elimination.

B. Administer oxygen after the child uses the bathroom.

C. Instruct the child to call for assistance when ambulating to the bathroom.

D. Provide a walker for the child to use when ambulating to the bathroom.

Explanation: Shortness of breath during ambulation may indicate carditis, a serious complication of rheumatic fever. Using a bedside commode minimizes physical exertion, reducing cardiac workload and the risk of worsening symptoms.

Question 4 of 5.

Which client symptoms documented by the nurse best indicate that the child is having a hypoglycemic reaction? Select all that apply.

A. The child complains of being thirsty.

B. The child's breathing is labored and prolonged.

C. The child is more hungry than usual.

D. The child complains of feeling shaky.

E. The child reports feeling light-headed.

F. The child states his or her heart is racing.

Explanation: Hypoglycemia causes shakiness, light-headedness, and tachycardia due to low blood glucose triggering the sympathetic nervous system. Thirst and hunger are less specific, and labored breathing is unrelated.

Question 5 of 5.

The nurse should plan to keep which equipment or supplies in the burned child's room in case an emergency arises?

A. An extra supply of sterile dressing

B. An endotracheal tube and oxygen supply

C. Equipment to administer pain medication

D. Additional bags of I.V. fluid

Explanation: Burn patients are at risk for airway compromise due to inhalation injury or edema. Keeping an endotracheal tube and oxygen supply available is critical for emergency airway management.