Focus on Child Health Exam Questions
With Verified Complete Answers.
An HIV-positive woman delivers an infant. The pediatrician prescribes testing for the newborn, and the
nurse prepares for which action? - Answer Ask the laboratory to perform virologic testing
Rationale: Traditional HIV antibody measurement by ELISA or Western-blot assay is not accurate in
infants younger than 18 months because of the persistence of maternal antibodies. Because of the
potential for maternal contamination during delivery, umbilical cord blood should not be used for
testing. HIV-exposed infants should undergo virologic testing within 48 hours of birth and follow-up
testing, depending on the initial results.
A nurse providing home care instructions to a mother of a HIV-positive child discusses measures to
prevent transmission of the virus. Which statement by the mother indicates a need for further
instruction? - Answer "I'll wash up blood spills with soap and hot water and allow them to air dry."
Rationale: The correct method of cleaning up blood spills is to wash the area with soap and water, rinse
with bleach, and let the area air dry. The remaining statements by the mother reflect correct measures
to prevent transmission of the virus.
A child has been in the hospital for several days for treatment of severe vomiting related his HIV-positive
status. Which assessment finding is the best indication that the child's condition is improving? - Answer
Weight increase of 1 lb (0.45 kg) over 3 days
Rationale: Vomiting results in fluid volume deficit. The most accurate method of evaluating fluid volume
increase (the desired outcome) is weight. A temperature decrease is not reflective of fluid volume
increase. Increasing capillary refill time is indicative of a fluid volume decrease, not an increase. The
absence of mouth ulcers would allow the child to drink without pain but does not reflect a fluid volume
increase.
A girl with systemic lupus erythematosus (SLE) wants to go to the beach with her friends on the day after
their junior prom. The girl asks the nurse for guidance regarding sun exposure. The nurse should provide
which information to the girl? - Answer Waterproof sunscreen with a minimum sun protection factor
(SPF) of 15 is a necessity
,Rationale: SLE, a chronic multi-system autoimmune disease characterized by inflammation of the
connective tissue, varies in severity and is marked by remissions and exacerbations. Although the origin
of SLE is not known, genetic, environmental, hormonal, and immune response factors are likely
responsible. These factors include exposure to sun and other UV light, stress, fatigue, viruses, bacteria,
certain medications, and some food additives. Avoiding triggers that set off exacerbation is essential, so
wearing appropriate sunscreen is a necessity. The sunscreen should contain an SPF higher than 15 and
should be waterproof. The remaining options present incorrect information.
A nurse is monitoring a school-age child who is being treated for dehydration. The nurse notes that the
child's urine output has been 1 mL/kg/hr over the past 3 hours and that the specific gravity of the urine
is 1.020. Which is the appropriate nursing action? - Answer Document the findings
Rationale: Urine output of less than 2 to 3 mL/kg/hr in infants and toddlers, 1 to 2 mL/kg/hr in
preschoolers and young school-age children, and 0.5 to 1 mL/kg/hr in school-age children or adolescents
indicates dehydration. A specific gravity of the urine above 1.020 may indicate dehydration. The nurse
would document the findings, because they are normal.
Intravenous potassium chloride in 0.9% sodium chloride solution has been prescribed for a child who is
severely dehydrated. Before administering the solution, the nurse must take which priority action? -
Answer Check urine output
Rationale: Potassium chloride is not administered if the urine output is not adequate. If the child is
anuric, potassium will be retained, causing an increased potassium level. Although skin turgor, capillary
refill, and blood pressure may be checked, they are not essential assessments in this situation.
A nurse is monitoring a 3-year-old with diarrhea for signs of dehydration. The child now weighs 42 lb (19
kg), a decrease from his weight of 44 lb (20 kg) 24 hours ago. In addition to dry mucous membranes and
lack of tears, what assessment finding would the nurse find? - Answer Bilateral 1+ pedal pulses
Rationale: The minimum urine output for a child is 1 mL/kg/hour. The child weighs 42 lb, or 19 kg, so 80
mL in the last 4 hours is within the minimum range. A child with dehydration will have a rapid, weak,
thready pulse. Blood pressure may be decreased in moderate and severe dehydration, but it is a late sign
of hypovolemia. A child with dehydration will exhibit 1+ pedal pulses: difficult to palpate, weak, and
thready.
A nurse is assigned to care for a child with diarrhea. Which intervention should the nurse avoid in caring
for the child? - Answer Taking a rectal temperature every 4 hours
, Rationale: Rectal temperatures are avoided in the child with diarrhea because inserting a thermometer
in the rectum stimulates peristalsis and may damage excoriated tissue. Gloves are worn when caring for
the child. Clean gloves are sufficient; sterile gloves are not necessary in this situation. The child is turned
every 2 hours to reduce pressure on irritated skin and to prevent skin breakdown. Protective moisture
barriers, such as creams or ointments, are useful in protecting the skin from diarrhea stools.
A nurse is providing home care instructions to the mother of a child who has undergone cleft lip repair.
Which statements by the mother indicate an understanding of these instructions? Select all that apply. -
Answer "I shouldn't brush her teeth for 1 to 2 weeks."
"I should rinse her mouth with water after feeding her."
"I should watch signs of infection like drainage or fever."
Rationale: "I shouldn't brush her teeth for 1 to 2 weeks," "I should rinse her mouth with water after
feeding her," and "I should watch for signs of infection like drainage or fever" are all accurate statements.
Gentle aspiration of oral secretions may be needed to prevent respiratory complications, and bulb
syringes are often sent home with the family for removal of these secretions. After cleft lip repair the
child should be kept supine, on the side opposite the repair, or in an infant seat. The prone position
could result in contact of the suture line with the bed linens, leading to disruption of the suture line.
A newborn is found to have esophageal atresia (EA) with tracheoesophageal fistula (TEF). In which
position does the nurse immediately place the infant? - Answer Supine, with the head of the bed
elevated
Rationale: EA and TEF are congenital malformations in which the esophagus terminates before it reaches
the stomach, a fistula forms an unnatural connection with the trachea, or both. Keeping the infant
supine, with the head of the bed elevated, decreases the likelihood that gastric secretions will enter the
lungs. Placing the child in the Trendelenburg position, flat and side-lying, or prone with the head of the
bed flat is incorrect; any of these positions could result in the aspiration of gastric secretions.
A nurse is assigned to care for an infant with congenital diaphragmatic hernia (CDH). Which clinical
finding supports this diagnosis? - Answer Auscultation of cardiac sounds on the right side of the chest
Rationale: CDH is an opening in the diaphragm through which abdominal contents herniate into the
thoracic cavity during prenatal development. Clinical findings depend on the severity of the defect but
may include the presence of abdominal organs in the chest (revealed by fetal ultrasonography),
