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NURSING NUR 254 Exam 4 Study Material

Maternal

• The nurse is caring for a child who has leukemia with a white blood cell (WBC) count of <

1000 mm. Which of the following should the nurse include in the child’s plan of care?

• Administer prescribed influenza vaccination
• Assign the child to a room with other children
• Allow the child to play with other children who do not have a fever
• Use sterile techniques for any procedures
• The nurse is providing a teaching session to the health care staff regarding

osteosarcoma. Which of the following statements by an attendee indicates a need for additional teaching?

• “A common clinical manifestation is limping if a weight-bearing limb is affected.”
• “The sternum is the most common site of this sarcoma.”
• “Children typically experience pain at the primary tumor site.”
• “In the early stage, the symptoms of this disease are usually attributed to normal

growing pains.”

• The nurse is caring for a child who is suspected of having a Wilm’s tumor. Which of the

following actions by the nurse indicates the need for additional training?

• Instructing the parents that the child needs to remain in bed.
• Preventing a child from playing tag in the playroom.
• Requesting a bland soft diet for the child.
• Palpating the child’s abdomen.
• The nurse is caring for a 5-year-old child who has sickle cell disease (SCD). An assessment

of the child includes the following: respirations 10 and unarousable. The child is currently on intravenous (IV) fluids and continuous IV morphine sulfate Based on the assessment information, which of the following actions should the nurse take first?

• Increase the IV fluids to decrease vaso-occlusion.
• Obtain a complete metabolic laboratory blood sample.
• Elevate the head of the bed (HOB) to increase oxygen saturation.
• Administer naloxone to reverse the effect of the morphine.
• The nurse is admitting a child who has a vaso-occlusive sickle cell crisis. Which of the

following interventions should the nurse anticipate to be prescribed for the child?

• Correction of alkalosis and reduction of energy expenditure.
• Globulins and factor VIII replacement.
• Hydration and pain management.
• Electrolyte replacement and administration of heparin.
• The nurse working in the emergency department (ED) is caring for a child who has

hemophilia and developed a swollen knee after falling off a bicycle. The nurse is teaching the child’s parents about care when similar incidents occur at home in the future. Which of the following actions should the nurse teach the parents?

• Take the child to the nearest emergency department (ED).
• Keep the child’s affected knee below the level of the heart.
• Apply an ice pack and compression dressings to the knee.
• Administer recommended dose of aspirin.

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• The newly hired nurse is talking with the nurse preceptor about the prevention of iron-

deficiency anemia in infants. Which of the following statements by the newly hired nurse is correct regarding prevention of this condition?

• “Whole cow’s milk should not be given until 1 year of age with limited daily

intake.”

• “Ferrous sulfate drops are contraindicated in infants less than 6 months of age.”
• “Iron-fortified commercial formula should be given for the first 6 months of life.”
• “Iron-fortified infant cereal should be introduced to infants at 10 months.”
• The nurse is assessing a child who has severe iron deficiency anemia. Which of the

following assessment finds should the nurse expect to observe?

• Pallor.
• Painful swelling of the hands.
• An enlarged abdomen.
• Visual disturbances.
• The nurse is caring for 4-year-old child who is 36 hours postoperative following a

removal of a Wilm’s tumor. Which of the following requires immediate follow up by the nurse?

• White blood cell (WBC) count of 15.0 mm³.
• Bowel sounds present in all 4 quadrants.
• Temperature of 100.4˚ F that occurs 1 time in a 24-hour period.
• Incision site is pink at the edges.
• The nurse is providing discharge instructions to the parents of a child who had surgical

resection of a neuroblastoma 4 days ago. Which of the following statements by the parents indicates teaching has been effective?

• “I will need to begin slowly reintroducing my child into social interaction.”
• “We will provide pain relief using pain medication and rest.”
• “A protective helmet will need to be worn until the incision is healed.”
• “An increase in temperature is expected after surgery.”
• The nurse is caring for a child who has increased intracranial pressure (ICP) and is in

stable condition. Which of the following interventions should the nurse implement to decrease ICP in the child?

• Limit number of visitors inside the child’s room.
• Keep the child positioned on the left side.
• Administer opioids for pain control.
• Administer hypertonic intravenous (IV) fluids.
• The nurse is caring for a child who has Reye’s syndrome. Which of the following should

the nurse include in the child’s plan of care?

• Change the child’s body position every 2 hours.
• Provide the child a quiet atmosphere with dimmed lighting.
• Administer salicylates for increased temperature every 4 hours as needed (PRN).
• Assess for diplopia in both of the child’s eyes.

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• The nurse is caring for a child who is suspected of having bacterial meningitis. The

results of the lumbar puncture are still pending. Which of the following actions by the nurse is the priority?

• Decrease noxious olfactory stimuli.
• Maintain a lighted environment.
• Assessing neurological status every 2-4 hours.
• Administer morphine sulfate.
• The nurse is screening infants for early warning signs of cerebral palsy. Which of the

following should the nurse recognize as 1 of the early warning signs of cerebral palsy?

• Evidence of head lag at age 1 month.
• Failure to sit up without support by age 6 months.
• Poor head control.
• Smiling by age 3 months.
• The nurse is assessing a 6-year-old for manifestations of autism spectrum disorder.

Which of the following manifestations should the nurse expect to observe in this child?

• Interest in various activities.
• Continuous eye contact.
• Monotone speech.
• Good social interaction.
• The nurse is developing a plan of care for a child diagnosed with attention-deficit

hyperactivity disorder (ADHD). Which of the following information should the nurse include in the plan of care?

• Antianxiety medications and homeschooling.
• Psychostimulant medications and behavior modification.
• Anticonvulsant medications and cognitive therapy.
• Antidepressant medications and family therapy.
• The nurse preceptor is observing a newly hired nurse care for a child who has Down

syndrome. Which of the following manifestations, if documented by the newly hired nurse, requires follow up by the nurse preceptor?

• Depressed nasal bridge.
• Protruding tongue.
• Large stature for chronological age.
• Hyperflexibility.
• The nurse is caring for a child who had a ventricular shunt placement 24 hours ago. The

child is sitting up in bed crying and has vomited a small amount on the bed linens. Which of the following actions should the nurse take first?

• Take complete set of vital signs (VS).
• Comfort the child while the linens are changed.
• Administer an antiemetic as prescribed.
• Complete a neurological assessment.

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• The nurse working in the emergency department (ED) is caring for a 2-month-old child

who presents with intraocular bleeding, bradycardia, and bulging fontanels, but no trauma to the head, face, or neck. Health history and physical examination is incongruent, and abuse is suspected. Which of the following actions should the nurse perform?

• Apply 2 L of oxygen via face mask.
• Notify child protective services (CPS).
• Ask the parents if they have a history of abuse.
• Explain the child will be able to go home shortly.
• The nurse is caring for a child who is hospitalized for 24-hour observation following a

head injury. Which of the following actions by the nurse is the priority?

• Keep the head elevated slightly.
• Checking pupil reaction every 4 hours.
• Assess for neck stiffness.
• Allowing the child to have 2 visitors at a time in the room.
• The nurse is assessing a child in a coma and notes that the child has decorticate

posturing. Which of the following findings should the nurse expect the child to demonstrate?

• Rigid extension with head arched back, arms extended by the sides, and legs

extended.

• Abnormal flexion of upper and lower extremities.
• Rigid flexion with elbows, wrists and fingers flexed, and legs extended and

rotated inward.

• Abnormal extensions of the upper extremities and flexion of lower extremities.
• The nurse is admitting a toddler who is being hospitalized following a near-drowning

accident/submersion injury. The child’s mother states to the nurse, “This is unnecessary.My child seems perfectly fine.” What is an appropriate response for the nurse to provide to the mother?

• “Complications can still occur with your child.”
• “It is important to observe your child for the development of seizure activity.”
• “We are required by law to admit your child for observation.”
• “Your child will need extra oxygen for the next 24 to 48 hours.”
• The nurse is caring for an infant who is having an active seizure. Which of the following

actions should the nurse perform when caring for the infant during a seizure?

• Place a pacifier in the infant’s mouth to protect the tongue.
• Suction any secretions out of the infant’s mouth.
• Hold the infant down in the crib to keep them safe.
• Remove any items out of the crib that can harm the infant.
• The nurse is caring for an infant with a myelomeningocele sac. Which of the following

interventions demonstrates appropriate care for the infant?

• Keep the infant in the supine position unless feeding.
• Use latex-free medical products.
• Change the dressing every 6 hours to keep the sac from drying out.
• Secure the diaper tightly on the infant.