NCLEX Practice Exam for Pediatric Nursing 2

EXPLANATION

✔Correct answer:

Bryant's traction. For a child under 2 years of age and weighing less than 12–14 kg (approximately 26–30 lbs), Bryant’s traction is the traction method of choice, particularly for conditions such as congenital hip dislocation. This type of traction involves bilateral vertical suspension of the legs at a 90-degree angle, with the buttocks slightly elevated off the bed. The purpose is to gradually stretch the soft tissues around the hip, aligning the femoral head with the acetabulum in preparation for possible closed reduction or casting.

Bryant’s traction is age-specific and weight-specific due to the mechanics required to achieve and maintain alignment using the child’s own body weight for countertraction. For a 14-month-old child weighing 11.8 kg, this method is both appropriate and safe.

Think of Bryant’s traction like gently hanging a small puppet upside down by its legs to straighten the strings that have become tangled near the hips. The puppet’s body (the child's pelvis) is lifted just enough off the surface so that gravity and tension work together to realign the joints without pulling too hard—just the right balance of lift and stretch to get everything back in place smoothly and safely.

When managing a child in Bryant’s traction, Nurse Patel must ensure continuous monitoring and safety.

• Ensure both legs are suspended vertically and maintained at a 90-degree angle from the hips.
• Check that the buttocks are just slightly off the bed to maintain proper countertraction.
• Assess skin integrity regularly, especially around the traction straps and heels, to prevent pressure injury.
• Monitor neurovascular status (color, temperature, capillary refill, pulses, sensation, and movement) of both lower extremities every 2–4 hours.
• Maintain proper alignment and positioning, avoiding twisting or movement that can disrupt traction setup.

✘Incorrect answer options:

Buck's extension traction This is a skin traction technique used mainly in older children and adolescents for short-term immobilization of fractures or for pain control. It is not appropriate for congenital hip dislocation or young children under 2 years old.

Overhead suspension traction This type is primarily used for humeral or upper extremity fractures, not for lower extremity or hip conditions.

90-90 traction Commonly used in femoral fractures in children over 6 years old, this involves skeletal traction with both the hip and knee flexed at 90 degrees. It is too invasive and inappropriate for a toddler with congenital hip dislocation.

EXPLANATION

✔Correct answer:

Start with single-grain rice cereal mixed with formula or breast milk. When introducing solid foods, the American Academy of Pediatrics (AAP) recommends starting around 6 months of age, depending on the infant’s developmental readiness—such as the ability to sit with support, good head and neck control, and showing interest in food.

Single-grain iron-fortified rice cereal is often recommended as a first food because it is easily digestible, rarely allergenic, and helps meet the infant’s growing iron needs—especially for breastfed infants. Mixing it with breast milk or formula provides a familiar taste and texture, easing the transition from liquid to solid feeding.

This controlled approach also allows caregivers to introduce one new food at a time, monitoring for signs of food allergies or intolerances (e.g., rash, vomiting, diarrhea).

Think of introducing solids like teaching a child to swim—you wouldn’t start by diving into the deep end. You begin in the shallow water (rice cereal), gradually building up to more complex strokes (other solid foods).

Nurse Carla should guide Jenny with education that supports safe and developmentally appropriate feeding practices.

• Assess the infant’s developmental readiness for solids (head control, sitting posture, interest in food).
• Instruct on starting with iron-fortified single-grain cereals mixed with breast milk or formula.
• Educate on introducing one new food every 3–5 days to monitor for allergies.
• Advise delaying introduction of highly allergenic foods until later, unless directed by pediatric guidance.
• Discourage adding solids to bottles, which can increase choking risk and interfere with satiety cues.

✘Incorrect answer options:

Begin with pureed applesauce as the initial solid. Although applesauce is a common baby food, it is not the ideal first solid due to its natural sugars and potential for allergy risk. It is typically introduced after cereals and vegetables.

Introduce egg whites early to build protein tolerance. Egg whites are a common allergen. Previously, guidelines suggested delaying them, though newer recommendations are more flexible. However, egg whites are not appropriate as a first solid and should be introduced cautiously under guidance, especially if there’s a family history of allergies.

Offer plain yogurt as the first solid option. While plain yogurt can be introduced around 6–9 months, it is not typically the first solid. Dairy products other than formula or breast milk should be introduced cautiously and later in infancy, as cow’s milk proteins can be harder to digest early on.

EXPLANATION

✔Correct answer:

Distributing reading materials tailored to the patient's age group. While reading materials may seem appropriate at first glance, relying solely on written content is the least effective teaching strategy for adolescents, particularly for a 12-year-old who is pregnant. Cognitive development at this stage, as described in Piaget’s formal operational stage, is still emerging. Many early adolescents may struggle with abstract thinking and complex decision-making, especially under stress or when navigating emotionally charged topics like parenting.

Additionally, literacy levels and engagement with printed materials can vary widely in this age group. Adolescents—especially younger teens—often benefit more from interactive, peer-supported, and visually stimulating approaches. These methods align better with their learning preferences and developmental needs by fostering engagement, emotional support, and concrete skill-building.

Giving a 12-year-old only a parenting pamphlet is like handing someone a cookbook without showing them how to cook—some may follow it, but most need to see, touch, and try it to really understand.

Nurse Rodriguez should select teaching strategies that are age-appropriate, engaging, and experiential for optimal learning outcomes.

• Incorporate hands-on learning through demonstrations and return demonstrations (e.g., diapering, feeding).
• Use audiovisual tools that combine both emotional storytelling and concrete skills to make content relatable.
• Foster a supportive environment through group sessions where teen mothers can share and learn from peers.
• Assess the adolescent’s literacy level and supplement reading materials with discussion and follow-up activities.
• Provide emotional support and build rapport to enhance receptiveness to health education.

✘Incorrect answer options:

Conducting a personal demonstration followed by a return demonstration, utilizing a live infant. This is highly effective as it uses kinesthetic learning and builds confidence through hands-on practice—ideal for young adolescents.

Facilitating a support group for teenage mothers, including both new and experienced mothers. Peer-led and peer-supported learning builds community and validation, addressing both emotional and practical concerns.

Employing audiovisual materials that illustrate emotional discussions and practical skills. Audiovisual tools are especially useful for visual and auditory learners, and help maintain engagement while making complex ideas easier to understand.

EXPLANATION

✔Correct answer:

Atropine sulfate. In pediatric emergency airway management, succinylcholine, a depolarizing neuromuscular blocker, is commonly used to induce paralysis for rapid sequence intubation (RSI). However, in children—especially those under 8 years old—succinylcholine can provoke profound bradycardia or even asystole, particularly with repeated dosing. This is due to heightened vagal tone and the drug’s stimulation of muscarinic receptors in the heart.

To prevent this, atropine sulfate, an anticholinergic agent, is routinely administered prior to or along with succinylcholine in pediatric patients. Atropine works by blocking vagal input to the heart, thus preventing bradyarrhythmias that may be triggered during intubation, suctioning, or medication administration.

This is a well-established practice in Pediatric Advanced Life Support (PALS) protocols, and failure to premedicate with atropine in this age group can result in serious cardiac complications.

Think of atropine as a “safety helmet” for the heart—it shields the heart from slowing down too much when succinylcholine gives it a sudden jolt, much like how a helmet protects the head during a sudden impact.

During pediatric intubation procedures involving succinylcholine, nurses must anticipate medication needs and monitor for cardiovascular responses.

• Prepare and administer atropine prior to or simultaneously with succinylcholine in children under 8 years old.
• Monitor ECG closely during and after administration for signs of bradycardia or arrhythmia.
• Ensure resuscitation equipment is readily available, including oxygen and advanced airway tools.
• Document time, dosage, and route of all medications administered during the intubation sequence.
• Collaborate closely with the provider and respiratory team for rapid intervention if adverse reactions occur.

✘Incorrect answer options:

Epinephrine (Adrenalin). While epinephrine is a critical medication in cardiac arrest and anaphylaxis, it is not the prophylactic drug of choice for preventing succinylcholine-induced bradycardia. It is reserved for treatment, not prevention.

Isoproterenol (Isuprel). This is a beta-adrenergic agonist that can increase heart rate, but it is not routinely used in RSI protocols. It has a short duration and is not considered first-line for pediatric bradycardia prevention.

Lidocaine hydrochloride (Xylocaine). Lidocaine is primarily used to suppress ventricular arrhythmias and occasionally to blunt the increase in intracranial pressure during intubation. It does not prevent bradycardia from succinylcholine.

EXPLANATION

✔Correct answer:

"Can you describe what your child consumed for breakfast today?" When assessing for physical neglect, especially related to nutrition, the nurse must ask objective, specific, and nonjudgmental questions that elicit factual information. Asking about what the child actually ate provides a concrete window into the child's current nutritional intake and patterns. It avoids assumptions and opens the door for a more detailed dietary history, which can help identify inadequate food provision—a key indicator of neglect.

This type of question also helps the nurse assess the quality and quantity of the child’s meals and determine whether the child’s food intake meets age-appropriate nutritional guidelines.

If you're trying to understand how well a plant is being cared for, asking "Did it get water today?" gives more helpful information than asking "Do you think it's doing okay?" Likewise, asking what the child ate gives real clues about nutritional care.

When evaluating a child for suspected physical neglect, nurses should take a holistic and sensitive approach to data collection.

• Use open-ended, non-threatening questions to gather accurate information without alarming the caregivers.
• Assess the child’s growth charts, weight trends, and physical signs of malnutrition (e.g., hair thinning, dry skin, muscle wasting).
• Collaborate with a social worker, nutritionist, or child protective services when findings suggest neglect.
• Document objective observations and statements clearly in the health record to support potential investigations.
• Offer resources or education to families if nutritional deficits are identified and not due to intentional neglect.

✘Incorrect answer options:

"Has your child consistently exhibited this level of thinness?" This question is vague and may lead to subjective answers. It may also normalize undernourishment if the parent believes the child has “always been thin,” masking potential neglect.

"Does your child display selective eating habits?" Picky eating is common in preschoolers and may distract from the caregiver’s role in providing adequate nutrition. This question places emphasis on the child’s behavior rather than parental provision of food.

"Do you believe your child receives adequate nourishment?" This is a subjective question based on the parent’s opinion and may result in biased or defensive responses, especially if the caregiver is unaware of what adequate nutrition entails.

EXPLANATION

✔Correct answer:

“How are you doing with your schoolwork and reading?” When evaluating the vision of a school-aged child like Lily, a functional assessment—how vision impacts daily activities—is often more effective than clinical questions alone. Asking about schoolwork and reading is a developmentally appropriate and indirect way to assess visual function. Children this age spend a large portion of their time in academic settings where visual acuity is crucial, especially for reading, writing, and board work.

Poor performance, avoidance of reading, or complaints about headaches or tired eyes during schoolwork can be subtle signs of refractive errors such as myopia, hyperopia, or astigmatism. This question invites the child to reflect on how their vision affects daily life and learning without needing advanced self-awareness of their vision capabilities.

It’s like asking a driver how their road trips have been lately instead of asking if their windshield is clean. The answer gives real-life clues about visibility without focusing on the glass directly.

When assessing visual health in children, nurses should incorporate open-ended and age-appropriate questions that reflect the child's daily experiences.

• Ask about school performance, reading enjoyment, and screen time habits to gather clues about vision issues.
• Observe for squinting, eye rubbing, or sitting too close to screens or books during the assessment.
• Encourage regular vision screening per pediatric guidelines, typically starting at age 3–5 and continuing annually during school years.
• Refer the child for a full ophthalmologic evaluation if visual concerns are suspected.
• Collaborate with parents and teachers to monitor for academic or behavioral signs suggestive of visual impairment.

✘Incorrect answer options:

“Do you ever mix up or have trouble telling colors apart?” This question screens specifically for color vision deficiencies, such as color blindness, which are relatively uncommon and not typically the cause of general academic or reading difficulties.

“Is it hard for you to see when the lights are dim?” While helpful in evaluating night blindness (possibly linked to vitamin A deficiency or retinal issues), this is not a primary screening question for school-aged children’s visual acuity during daytime activities.

“Do your eyes hurt or feel uncomfortable around bright lights?” This targets photophobia, which may suggest other ocular or neurological conditions but doesn't directly assess the child’s functional vision related to school performance or reading.

EXPLANATION

✔Correct answer:

Preschool age. Children in the preschool age group (approximately 3 to 6 years old) are in the preoperational stage of cognitive development, according to Jean Piaget’s theory. During this stage, they engage in egocentric and magical thinking, meaning they often believe their thoughts, wishes, or behaviors can cause events in the world around them—including their own illness or hospitalization.

As a result, they may view illness as a punishment for being bad, lying, or disobeying parents. This belief can lead to feelings of guilt, shame, and fear, making emotional support and reassurance a critical aspect of nursing care for this age group.

Imagine a preschooler who spilled their milk earlier and now has a stomachache. They might genuinely believe the stomachache happened because they were “naughty” for spilling the milk—even if there’s no connection. That’s magical thinking in action.

Nurses caring for preschool-age children should provide emotional and developmental support to reduce fear and misconceptions.

• Offer simple, age-appropriate explanations about illness and procedures without using abstract or figurative language.
• Reassure the child that the illness is not their fault and that they are not being punished.
• Encourage expression through play therapy or drawing to understand and address the child’s fears.
• Allow participation in care choices when possible to promote a sense of control and reduce anxiety.
• Engage parents in comforting routines, as familiar faces and objects reduce emotional distress.

✘Incorrect answer options:

Infancy. Infants (birth to 1 year) do not have the cognitive capacity to associate illness with behavior. Their understanding is based on sensory experiences and immediate needs such as comfort, food, and warmth.

School age. School-age children (6–12 years) begin to understand cause and effect more logically and typically no longer believe that illness is a punishment. They are more capable of understanding physical reasons for being ill.

Adolescence. Adolescents possess abstract thinking and are more likely to question the meaning or implications of their illness, but they do not attribute it to punishment. Instead, they may worry about body image, independence, or peer acceptance.

EXPLANATION

✔Correct answer:

Traditions and behaviors are often transmitted across generations. Culture is a dynamic, learned set of beliefs, values, norms, and practices that shapes how individuals and families perceive health, illness, treatment, and healing. One of the most foundational aspects of cultural influence is that traditions, behaviors, and values are passed from one generation to the next, often beginning in childhood. These intergenerational teachings affect daily health decisions, such as diet, use of traditional remedies, response to pain, attitudes toward healthcare providers, and even acceptance of medical interventions.

By recognizing this, Nurse Tasha can better understand the family's healthcare decisions in the context of their cultural values, helping to build trust, mutual respect, and culturally sensitive care. This perspective is essential in providing family-centered and holistic nursing care, especially when working with children from diverse backgrounds.

Think of culture like a family recipe passed down through generations—it evolves slightly over time, but the core ingredients and methods stay the same, shaping how each new generation "cooks" or lives their life, including how they care for health and illness.

Culturally sensitive nursing care should be intentional, respectful, and inclusive.

• Ask open-ended questions about health practices, beliefs, and values during assessment.
• Use culturally appropriate communication methods, including interpreters if needed.
• Respect cultural practices that do not interfere with medical safety or outcomes.
• Collaborate with the family to integrate their traditions with evidence-based care when possible.
• Document cultural considerations in the care plan to promote continuity and sensitivity.

✘Incorrect answer options:

A family's cultural background rarely impacts their approach to healthcare. This is incorrect; culture has a significant impact on beliefs about illness, health practices, and the use of medical services.

A child’s appearance typically reflects their cultural identity. Physical appearance may or may not align with cultural identity. Culture is more about shared values and behaviors, not outward appearance alone.

Cultural heritage defines the collective values held by a group. While partially true, this answer is too broad and does not emphasize the intergenerational transmission of culture, which is most relevant to understanding behavior and decision-making in families.

EXPLANATION

✔Correct answer:

Total serum protein level. A negative nitrogen balance occurs when the body loses more nitrogen (primarily in the form of urea from protein catabolism) than it takes in through dietary intake, which is a classic indicator of protein-energy malnutrition (PEM). This can result from inadequate intake, chronic illness, or increased metabolic demand. In this context, evaluating total serum protein is the most appropriate and direct laboratory test.

Total serum protein includes both albumin and globulin levels and provides insight into the body’s protein stores and overall nutritional status. A decreased level suggests inadequate protein synthesis, which aligns with what occurs during negative nitrogen balance. This condition affects growth, healing, immune response, and enzymatic function in children—making early identification critical.

Think of protein in the body like the bricks in a building. If more bricks are being taken out (used or broken down) than being added in (through nutrition), the building weakens. Total serum protein helps us see how many bricks are still in the structure.

When managing a pediatric patient with suspected negative nitrogen balance or malnutrition, nurses should:

• Monitor weight trends and dietary intake closely over time.
• Assess for signs of protein deficiency: muscle wasting, edema, fatigue, and delayed wound healing.
• Collaborate with the healthcare provider to initiate laboratory tests such as serum albumin, prealbumin, and total protein levels.
• Provide nutritional support or referrals to a pediatric dietitian as indicated.
• Educate caregivers about age-appropriate nutrition and caloric/protein requirements.

✘Incorrect answer options:

Total iron-binding capacity. This test evaluates the blood’s ability to bind iron with transferrin and is used primarily in the assessment of iron deficiency anemia, not protein status or nitrogen balance.

Hemoglobin level. While hemoglobin is important in detecting anemia, it does not provide direct information about protein stores or nitrogen balance.

Serum transferrin level. Transferrin is a protein that binds iron and is more related to iron metabolism. While it is a protein, it is not the most comprehensive or direct indicator for assessing overall nitrogen balance or nutritional protein status.

EXPLANATION

✔Correct answer:

The vastus lateralis muscle. The vastus lateralis muscle, located on the lateral aspect of the thigh, is the safest and most recommended site for intramuscular (IM) injections in infants less than 12 months old. This site is well-developed even in infants, has a large muscle mass, and is free of major blood vessels and nerves, reducing the risk of injury.

In a 6-month-old, the deltoid muscle is not sufficiently developed to safely accommodate most IM injections, especially those requiring larger volumes. The dorsogluteal site is contraindicated in infants due to its proximity to the sciatic nerve and superior gluteal artery, posing a risk of serious neurovascular injury. Although the ventrogluteal site is also considered safe in infants by some sources, it is generally used more confidently in children over 7 months and requires advanced anatomical landmarking, making the vastus lateralis the preferred site for ease and safety.

Giving an injection is like parking a car—you want a large, clear, and safe space with no obstacles nearby. The vastus lateralis is like a wide-open parking lot, making it the best and safest place to "park" the medication in a baby's muscle.

When preparing to give an IM injection to an infant, nurses should:

• Locate the vastus lateralis by dividing the thigh into thirds and selecting the middle third of the lateral thigh.
• Use an appropriate needle length and gauge (usually ⅝ to 1 inch, 22–25 gauge) for the infant’s size and muscle mass.
• Stabilize the limb to reduce movement and discomfort during administration.
• Use distraction techniques or sucrose solutions to reduce pain perception in infants.
• Document the site, medication, dosage, and patient response in the medical record.

✘Incorrect answer options:

The deltoid muscle. The deltoid is not well-developed in infants and is only recommended for small-volume injections in children older than 18 months.

The dorsogluteal muscle. This site is contraindicated in infants due to the risk of injuring the sciatic nerve and major blood vessels, and is no longer recommended in pediatric practice.

The ventrogluteal muscle. While this site is a safe alternative in older infants and toddlers with trained technique, it is less commonly used than the vastus lateralis in infants under 7 months due to more complex landmarking and slightly less accessible anatomy.

EXPLANATION

✔Correct answer:

Child is critically ill and younger than 3 years old. The intraosseous (IO) route is a lifesaving alternative for vascular access when intravenous (IV) access is difficult or time-consuming, especially in emergencies involving critically ill or injured children. This method involves the insertion of a needle into the bone marrow cavity, usually the proximal tibia, allowing for rapid absorption of fluids and medications directly into the systemic circulation.

This route is especially recommended for children under 6 years old, particularly those under 3 years of age, as their bone marrow is more accessible and not yet fully calcified, making insertion easier and more effective. The key indication is critical illness or life-threatening condition, such as shock, cardiac arrest, or severe dehydration, where time is of the essence.

Think of trying to water a dying plant but the regular hose (IV line) is clogged. The IO route is like creating a direct pipe into the plant’s roots (bone marrow), bypassing the broken hose and ensuring it gets water (medications/fluids) immediately.

When intraosseous access is chosen, the nurse’s role is critical in preparation, monitoring, and patient support.

• Prepare the IO insertion site using aseptic technique to minimize infection risk.
• Support the child during the procedure (if conscious) and reassure caregivers.
• Monitor for signs of complications such as infiltration, infection, or compartment syndrome.
• Ensure that medications and fluids are compatible with the IO route and administered correctly.
• Collaborate with the healthcare provider to transition to peripheral or central access as soon as feasible.

✘Incorrect answer options:

Child is younger than 3 years old. Age alone is not a sufficient reason for IO access. It is only indicated in emergent or life-threatening situations where IV access has failed or is not feasible.

Child is older than 3 years old. While IO access can be used in older children, the urgency of the situation (i.e., critical illness) is the key determinant. This option lacks that context and is therefore incomplete.

Child is critically ill and older than 3 years old. Although still appropriate for IO access, younger children, especially under 3, are more commonly managed with this method due to anatomical accessibility. This option is not the most appropriate given the scenario described.

EXPLANATION

✔Correct answer:

20 mL/kg. The standard initial fluid bolus for pediatric patients in shock is 20 mL/kg of isotonic crystalloid solution (such as normal saline or lactated Ringer’s solution). This recommendation is based on Pediatric Advanced Life Support (PALS) guidelines and is used to restore intravascular volume, improve perfusion, and support cardiac output in the early management of shock.

Shock in children may present with signs like tachycardia, delayed capillary refill, cool extremities, low urine output, and altered mental status. Because children have a higher proportion of extracellular fluid and can compensate well before sudden decompensation, timely fluid resuscitation is critical.

The 20 mL/kg bolus is typically administered over 5–20 minutes, depending on the severity of shock and patient stability. The patient’s response should be carefully monitored, and additional boluses may be given if necessary.

Think of a dehydrated plant with drooping leaves—you start by giving it a steady but substantial drink to perk it up. In the same way, the 20 mL/kg fluid bolus gives the child’s circulation a much-needed boost to stabilize their system.

Prompt and accurate administration of fluid boluses is essential in managing pediatric shock.

• Use weight-based calculations to determine the exact volume (20 mL per kilogram of body weight).
• Administer isotonic fluids such as 0.9% normal saline or lactated Ringer’s.
• Monitor for signs of improved perfusion: capillary refill, pulse quality, blood pressure, and urine output.
• Assess for signs of fluid overload, especially in patients with cardiac or renal conditions.
• Collaborate with the healthcare team for repeat boluses or escalation of care if shock persists.

✘Incorrect answer options:

10 mL/kg. This may be used for premature neonates or patients with cardiac compromise, but it is not the standard initial bolus for pediatric shock.

30 mL/kg. While total fluid resuscitation volume may eventually reach or exceed this, individual boluses are given in 20 mL/kg increments, with reassessment between doses.

15 mL/kg. This is not a standard PALS-recommended bolus volume. It falls short of the effective dose needed for initial shock management in most pediatric patients.

EXPLANATION

✔Correct answer:

This may be a temporary regression due to stress or change in routine. In early childhood development, regression is a common and often temporary reaction to stressful events or major life changes. For a 5-year-old child who had previously mastered toilet training, beginning to wet their pants again after starting nursery school is a textbook example of regression triggered by environmental stress. This does not usually indicate a pathology but rather a coping mechanism that children use when they feel overwhelmed.

Starting school, even part-time, introduces significant changes: new people, routines, expectations, and environments. The child may feel anxious, insecure, or overstimulated, leading to temporary setbacks in previously acquired skills like toilet training.

Developmentally, this is consistent with Erikson’s Initiative vs. Guilt stage, where children are learning to assert control and make decisions. A shift in routine may challenge this balance and result in behaviors such as regression.

Think of a child’s development like building a tower of blocks. If something shakes the table (like starting school), the tower may wobble, and a few blocks might fall. It doesn't mean the whole tower is broken—it just needs time and support to rebuild stability.

Nurse Thompson should guide and support the parent with understanding and practical steps to manage regression:

• Reassure the parent that regression is normal and often temporary during life transitions.
• Encourage maintaining a predictable routine at home to foster security.
• Advise using positive reinforcement rather than punishment to support desired behaviors.
• Collaborate with the child’s teacher or childcare provider to monitor behavior and transitions.
• Assess for any signs of trauma, abuse, or underlying health concerns if regression persists or worsens.

✘Incorrect answer options:

This behavior indicates a possible developmental disorder that needs immediate evaluation. While persistent or severe regression may require further evaluation, temporary setbacks following a major change (e.g., starting school) are developmentally normal and do not automatically imply a disorder.

The child should be disciplined consistently to reinforce toilet habits. Discipline in response to regression can worsen anxiety and feelings of shame, possibly exacerbating the behavior. Positive reinforcement is the recommended approach in pediatric behavioral management.

Wetting pants at this age is a sign of inadequate parenting practices. This statement is incorrect and stigmatizing. Parenting quality cannot be judged solely by a child's temporary behavior change, especially when regression is a recognized developmental response to stress.

EXPLANATION

✔Correct answer:

Heart rate, respiratory rate, and blood pressure. In the case of acute aspirin (salicylate) ingestion, vital signs are the first and most critical assessment. Aspirin toxicity can rapidly affect the cardiovascular and respiratory systems, leading to:

• Tachypnea due to stimulation of the respiratory center (resulting in respiratory alkalosis),
• Metabolic acidosis as the toxicity progresses,
• Tachycardia or hypotension in cases of fluid loss or severe toxicity.

Thus, evaluating heart rate, respiratory rate, and blood pressure allows the nurse to detect early signs of physiological compromise, guide emergency interventions, and support timely decisions regarding further diagnostics (e.g., salicylate serum levels, blood gases) and treatment (e.g., activated charcoal, sodium bicarbonate, IV fluids).

When you suspect a fire, the first step isn’t asking when the fire alarm was last tested—it’s checking if there’s smoke or flames. Similarly, in poisoning, we first look at vital signs to see if the body is already in distress.

During initial assessment of a pediatric poisoning case, nurses should:

• Quickly assess and monitor vital signs for evidence of systemic toxicity.
• Perform a focused physical exam (mental status, respiratory pattern, skin perfusion).
• Prepare for emergency interventions such as gastric decontamination or antidote administration.
• Initiate cardiac and oxygen saturation monitoring as per institutional protocol.
• Provide emotional support to both child and caregiver during the acute phase.

✘Incorrect answer options:

Recent history of exposure to communicable diseases. While relevant in general pediatric assessments, this is not a priority during an acute poisoning event. It does not contribute to the immediate management of aspirin ingestion.

Documentation of completed immunizations. Immunization history is important for routine and admission assessments but is non-urgent in a toxicologic emergency. It does not affect emergent decision-making.

Height and weight measurements. While weight is important for calculating medication dosages (e.g., activated charcoal), it can be assessed immediately after checking vital signs. It is not the first priority in the initial assessment sequence.

EXPLANATION

✔Correct answer:

Constant thoughts or fascination with death and dying. In the context of a mental health assessment, especially for an adolescent experiencing severe depression, the most alarming and immediate red flag for suicide risk is the presence of persistent thoughts about death or dying, often referred to as suicidal ideation. These thoughts may range from vague preoccupation with death to specific planning of suicide, and they reflect an internal crisis and psychological pain that requires urgent intervention.

According to the Columbia-Suicide Severity Rating Scale (C-SSRS) and the American Academy of Pediatrics, any indication that a teen is obsessed with death, talks about dying, or expresses a desire not to live must be treated as a psychiatric emergency. These are often precursors to suicidal planning or attempts and are significantly more predictive of suicide risk than general symptoms of depression alone.

Think of thoughts about death like a smoke alarm going off—it may not mean the fire has started yet, but it’s the earliest and loudest warning that something dangerous could be coming and needs attention now.

Early identification and response to suicide risk in adolescents can save lives.

• Immediately report and document any suicidal ideation or fascination with death to the healthcare team.
• Ensure a safe environment by removing access to potential means of self-harm (e.g., medications, sharp objects).
• Initiate a suicide risk assessment using validated tools like the C-SSRS.
• Do not leave the patient alone if suicidal ideation is present; arrange for continuous monitoring or hospitalization if needed.
• Provide emotional support and involve mental health specialists for crisis intervention and ongoing therapy.

✘Incorrect answer options:

Persistent symptoms of depression. While depression is a major risk factor for suicide, not all individuals with depression become suicidal. Suicidal ideation is more specific and urgent.

Frequently feeling overly tired or sleepy. Fatigue is a common symptom of depression and may affect functioning but is not directly indicative of suicidal intent or planning.

Previous use of substances like cocaine. Substance use, particularly stimulants like cocaine, can exacerbate risk, but on its own, it is less predictive of immediate suicide risk than suicidal thoughts or ideation.

EXPLANATION

✔Correct answer:

Frequent, copious diarrhea. Ulcerative colitis (UC) is a chronic inflammatory bowel disease (IBD) that primarily affects the mucosal lining of the colon and rectum, resulting in continuous lesions. The hallmark and most prevalent clinical manifestation of UC is frequent, watery diarrhea, often mixed with blood and mucus. This results from the inflammation and ulceration of the colonic mucosa, which impairs water absorption and stimulates increased motility.

In children, this diarrhea can lead to significant complications such as fluid and electrolyte imbalances, anemia, and growth delays, making early recognition and management essential. The number of bowel movements can vary from 4 to more than 10 times per day, depending on disease severity.

Imagine the lining of the colon as a sponge that absorbs excess water. In ulcerative colitis, the sponge becomes raw and damaged—so instead of absorbing, it leaks, leading to continuous, watery stools.

When managing a child with suspected or confirmed ulcerative colitis, nurses should:

• Monitor the frequency, volume, and characteristics of stools, especially presence of blood or mucus.
• Assess hydration status regularly, including vital signs, skin turgor, and urine output.
• Collaborate with the healthcare provider to initiate stool studies, lab tests (CBC, ESR, CRP), and possible colonoscopy referral.
• Administer prescribed medications such as corticosteroids, aminosalicylates (e.g., mesalamine), or immunomodulators as appropriate.
• Provide dietary support—often low-residue or elemental diets during flare-ups—and involve a pediatric dietitian if needed.

✘Incorrect answer options:

Severe abdominal cramping. While abdominal cramping does occur, it is not the most prevalent symptom. It tends to accompany bowel movements but is less specific than the frequency and nature of diarrhea.

Presence of anal fissures. Anal fissures are more commonly associated with constipation and Crohn's disease than ulcerative colitis. In UC, the disease is limited to the mucosa and doesn't typically involve the perianal area.

Notable abdominal distension. Abdominal distension can occur with severe UC or complications like toxic megacolon, but it is not a common early or primary finding. It's more concerning as a sign of acute deterioration.

EXPLANATION

✔Correct answer:

Ride a tricycle. By the age of 3 years, children typically enter the early preschool developmental stage, where gross motor skills are rapidly improving. Riding a tricycle is a milestone that reflects coordination, balance, and strength development typical for this age group. It also indicates increased independence and curiosity about the environment—hallmarks of Erikson’s initiative vs. guilt stage.

This activity demonstrates that the child can pedal, steer, and balance—complex skills that require the integration of muscular coordination and cognitive planning. Developmental screening tools such as the Denver II and CDC milestone checklists support that most 3-year-olds are expected to ride a tricycle confidently, along with climbing stairs with alternating feet and jumping in place.

Learning to ride a tricycle at age 3 is like mastering the art of using training wheels for life—it’s a safe and developmentally appropriate way to practice independence and movement before advancing to bigger challenges.

Developmental milestone assessments are essential in evaluating early childhood growth and detecting potential delays.

• Ask parents or caregivers about gross motor activities their child enjoys and can perform independently.
• Observe the child in a safe play environment to assess coordination and balance.
• Educate caregivers on age-appropriate toys and activities that support motor development, such as tricycles and outdoor play.
• Screen for signs of developmental delays using tools like the Ages and Stages Questionnaire (ASQ).
• Encourage safety measures (e.g., helmet use) during tricycle riding to prevent injury.

✘Incorrect answer options:

Tie shoelaces independently. This fine motor skill typically develops around 5–6 years of age, as it requires complex hand coordination and patience.

Use roller skates proficiently. Roller skating involves advanced balance and motor planning skills, more commonly seen in school-age children (6 years and above), not toddlers or preschoolers.

Jump rope rhythmically. While some children begin experimenting with jumping rope around age 5, rhythmic and coordinated rope jumping is generally mastered at 6–7 years old, requiring significant gross motor coordination.

EXPLANATION

✔Correct answer:

A sunken fontanelle. In infants, one of the most sensitive and observable indicators of fluid volume deficit (dehydration) is a sunken anterior fontanelle. The fontanelles are soft spots on the infant’s skull that allow for brain growth and are normally slightly concave or flat. When an infant becomes dehydrated due to fluid loss from vomiting and diarrhea, the reduction in intravascular and interstitial fluid volume leads to decreased intracranial pressure, resulting in a visibly sunken fontanelle.

This sign, especially when observed alongside dry mucous membranes, lethargy, and reduced urine output, points to moderate to severe dehydration, and immediate fluid replacement is warranted to prevent complications such as hypovolemic shock.

Think of the fontanelle like the surface of a waterbed. When the bed (body) is full of water (fluid), the surface stays firm and level. But when the water drains out, the surface sinks inward—just like a sunken fontanelle in a dehydrated baby.

Rapid assessment and intervention are crucial when dehydration is suspected in infants.

• Monitor for other signs of dehydration: sunken eyes, poor skin turgor, reduced tears, and decreased urine output.
• Document the number and consistency of stools and episodes of emesis reported by the caregiver.
• Assess weight changes, as weight loss is a key indicator of fluid volume deficit in infants.
• Initiate physician-directed rehydration therapy, starting with oral rehydration solutions or IV fluids for severe cases.
• Educate caregivers on early signs of dehydration and proper hydration techniques during illnesses.

✘Incorrect answer options:

A decreased pulse rate. Dehydrated infants more commonly present with tachycardia (increased pulse rate) as a compensatory mechanism for fluid loss. Bradycardia (decreased pulse rate) is a late and ominous sign of decompensation.

An elevated blood pressure reading. Blood pressure in infants with fluid volume deficit is typically normal or low, especially in moderate to severe dehydration. Elevated BP is not characteristic of dehydration in this age group.

A low urine specific gravity. A dehydrated infant would more likely have a high urine specific gravity, reflecting concentrated urine due to fluid conservation. Low specific gravity is associated with overhydration or renal impairment, not dehydration.

EXPLANATION

✔Correct answer:

Renal anomalies. Low-set ears in an infant are a notable dysmorphic feature that can be a clinical clue to underlying renal (kidney) anomalies. During fetal development, the ears and kidneys develop simultaneously from adjacent embryologic tissue (the mesoderm). Because of this parallel development, abnormalities in one structure may indicate malformations in the other.

Low-set ears may be present in various genetic syndromes—such as Trisomy 13, 18, or 21, or VACTERL association—many of which are associated with renal defects like hydronephrosis, renal agenesis, or multicystic dysplastic kidney. As part of a thorough newborn assessment, identifying low-set ears should prompt further evaluation, including a renal ultrasound, to rule out or confirm urologic involvement.

Think of the ears and kidneys like two apps that download together from the same package—if one didn’t install correctly, there’s a good chance the other one might have issues too.

Early identification of dysmorphic features allows for timely referral and management of potentially serious anomalies.

• Document physical findings such as ear placement, shape, and symmetry during the newborn exam.
• Notify the healthcare provider if dysmorphic features like low-set ears are present.
• Anticipate orders for renal imaging (e.g., ultrasound) to assess kidney structure and function.
• Support parents by explaining the significance of the finding and the need for further testing.
• Monitor for other anomalies, as renal issues may be part of a larger congenital syndrome.

✘Incorrect answer options:

Otogenous tetanus. This is an extremely rare form of tetanus acquired via ear infections or trauma. It is not associated with congenital ear positioning.

Tracheoesophageal fistula. This condition involves abnormal connection between the trachea and esophagus. While it may appear in syndromic presentations, low-set ears are not a hallmark feature.

Congenital heart defects. These may be associated with certain syndromes that also include low-set ears, but heart anomalies are not directly linked to ear placement in isolation, unlike renal anomalies.

EXPLANATION

✔Correct answer:

Eustachian tubes. The Eustachian tubes are the primary anatomical structures responsible for children's increased susceptibility to otitis media (middle ear infection). In infants and young children, these tubes are shorter, more horizontal, and more flexible than in adults. This structural difference makes it easier for pathogens from the nasopharynx (such as during a cold or upper respiratory infection) to travel into the middle ear and for fluid to become trapped.

When the Eustachian tube becomes blocked—often due to inflammation or mucus—it can no longer ventilate the middle ear effectively. This leads to negative pressure, fluid accumulation, and a favorable environment for bacterial growth. The Eustachian tube’s immature function in early childhood is the central reason otitis media is most prevalent in children under age 5.

Think of the Eustachian tubes in children like short, flat water slides connecting the nose to the middle ear—because they're so small and level, it’s easy for mucus and germs from a cold to slide right in and get stuck, causing fluid buildup and infection. In adults, the "slide" is longer and angled downward, so things are more likely to drain out instead of backing up into the ear.

When teaching parents about otitis media, it's important to emphasize anatomical and behavioral risk factors.

• Explain the structure and function of the Eustachian tube in young children.
• Encourage strategies to reduce risk, such as breastfeeding, avoiding secondhand smoke, and not bottle-feeding while the child is lying flat.
• Educate parents on early signs of otitis media—ear pulling, irritability, fever, and poor feeding.
• Discuss the importance of completing the full course of antibiotics if prescribed.
• Provide guidance on when to seek medical attention and the role of tympanostomy tubes in recurrent cases.

✘Incorrect answer options:

Nasopharynx. While the nasopharynx is the origin of pathogens in otitis media, it is not the structural reason for children's vulnerability. It is the Eustachian tube that connects the nasopharynx to the middle ear and facilitates transmission.

Tympanic membrane. This structure is affected by otitis media (e.g., bulging, red, or perforated), but it is not the cause of the infection.

External ear canal. This canal leads to the tympanic membrane and is associated with otitis externa, not otitis media, which involves the middle ear space.

EXPLANATION

✔Correct answer:

A prior episode of throat infection in the past few weeks. Rheumatic fever is an autoimmune inflammatory disease that can develop as a delayed sequela of an untreated or inadequately treated group A beta-hemolytic streptococcal (GABHS) pharyngitis (strep throat). It most commonly affects children between 5 and 15 years of age. The disease typically occurs 2 to 4 weeks after the initial infection and may involve the heart (carditis), joints (polyarthritis), skin (erythema marginatum), and central nervous system (Sydenham’s chorea).

The most significant risk factor in the health history is a recent throat infection. This aligns with the pathophysiological basis of rheumatic fever, in which the immune system, while responding to the strep infection, mistakenly targets its own tissues due to molecular mimicry between streptococcal antigens and human tissues.

Think of the immune system like a guard dog trained to attack a specific intruder (the streptococcus bacteria). However, if someone else (the body’s own tissues) shows up wearing something similar to the intruder’s outfit, the dog might attack the wrong person. This mistaken identity is what happens in rheumatic fever—our immune system attacks healthy tissues thinking they’re harmful.

When assessing and managing a pediatric patient with suspected rheumatic fever, nurses should consider the following key actions:

• Ask about recent sore throats or diagnoses of strep throat within the past 1 to 5 weeks.
• Monitor for signs of carditis (e.g., new heart murmur, tachycardia, chest pain) and joint pain or swelling.
• Obtain a throat culture or rapid antigen detection test, and review previous antibiotic therapy.
• Collaborate with the healthcare provider to initiate prophylactic antibiotic therapy if rheumatic fever is diagnosed.
• Provide education to caregivers about completing full antibiotic courses and the importance of early treatment of future sore throats.

✘Incorrect answer options:

Fever that began approximately three days prior to admission. While fever is a common symptom, it is non-specific and does not provide insight into the underlying etiology of rheumatic fever. Rheumatic fever often presents after the initial streptococcal infection has resolved, not during it.

Notable decrease in appetite over recent days. Decreased appetite is a general symptom of many illnesses and is not diagnostic or specific to rheumatic fever. It lacks clinical specificity in identifying the root cause.

Complaints of vomiting occurring over the last two days. Vomiting is not a typical manifestation of rheumatic fever and is more suggestive of gastrointestinal disturbances. This does not support a connection with prior streptococcal infection.

EXPLANATION

✔Correct answer:

Establishing a stable personal identity. According to Erik Erikson’s theory of psychosocial development, adolescence (approximately ages 12–18) is characterized by the stage of “Identity vs. Role Confusion.” During this period, the primary psychosocial task is for the adolescent to develop a coherent and stable sense of self—including beliefs, values, sexual orientation, and future goals.

This is a time of significant cognitive, emotional, and social change. Adolescents explore different roles and ideologies, seek peer approval, and test boundaries. Success in this stage leads to the development of fidelity—the ability to live by society’s standards and a strong personal identity. Failure to resolve identity issues may lead to confusion, poor self-esteem, and difficulty in future relationships or occupational roles.

Imagine adolescence as building your personal “blueprint.” Before building a house (your adult life), you need to figure out what kind of house you want—where it’s located, what it looks like, and how it functions. That blueprint is your identity, and if it's not clear, the house may not turn out stable.

In supporting an adolescent's psychosocial development, the nurse should:

• Provide a safe, nonjudgmental environment to encourage self-expression and exploration of identity.
• Respect the adolescent's privacy and confidentiality when appropriate.
• Involve the adolescent in decision-making regarding their care to promote autonomy.
• Assess for signs of role confusion or identity crises, including risky behaviors or peer pressure influences.
• Encourage supportive peer and family relationships to reinforce a positive sense of self.

✘Incorrect answer options:

Cultivating a sense of industry. This task aligns with the school-age stage (6–12 years) in Erikson’s model, where children focus on competence through academic and social achievement.

Attaining intimate relationships. This is the key task of young adulthood (18–40 years) in Erikson’s stage of “Intimacy vs. Isolation.” It comes after establishing a personal identity in adolescence.

Fostering a sense of initiative. This is the developmental task for the preschool age (3–6 years), where children learn to initiate activities and assert control over their environment through play and social interaction.

EXPLANATION

✔Correct answer:

Shake the container thoroughly to ensure even distribution of the medication particles. A suspension is a liquid medication in which solid particles are dispersed but not dissolved. These particles tend to settle at the bottom over time. Therefore, before administering a suspension, it is critical to shake the container well to evenly redistribute the medication and ensure the patient receives the accurate dose and therapeutic effect.

Failing to shake a suspension properly can lead to inconsistent dosing—for example, the first dose may be too weak, and later doses too concentrated. This could compromise treatment effectiveness or increase the risk of adverse effects.

Think of a bottle of salad dressing where the oil and herbs separate when left standing. You have to shake it well before pouring to make sure every serving has the same flavor—just like suspensions need shaking to deliver the correct medication dose.

Accurate preparation of suspension medications is essential to ensure therapeutic effectiveness and patient safety.

• Always check the medication label for instructions such as “Shake well before use.”
• Gently but thoroughly shake the bottle to ensure homogeneity of the suspension.
• Measure the dose using an appropriate oral syringe or medication cup for accuracy.
• Educate caregivers or patients about shaking the suspension each time before use.
• Store suspensions as directed—some require refrigeration, others do not.

✘Incorrect answer options:

Dilute the suspension with normal saline solution. Suspensions should not be diluted unless explicitly ordered by a physician or pharmacist, as it may alter the concentration and efficacy of the medication.

Dilute the suspension with a 5% dextrose solution. Like normal saline, dextrose solution is not appropriate for dilution of suspensions unless under specific instruction. It can affect the stability or absorption of the drug.

Crush any remaining particles using a mortar and pestle. Crushing is not appropriate for suspensions, as they are already formulated in liquid form for oral use. Crushing could alter dosing accuracy and drug integrity.

EXPLANATION

✔Correct answer:

A firm, non-tender mass located in the abdominal area. Wilms’ tumor, also known as nephroblastoma, is the most common renal malignancy in children, typically diagnosed between ages 2 and 5. The classic clinical finding during a physical assessment is a firm, unilateral, non-tender abdominal mass, often discovered incidentally by a parent or healthcare provider during bathing or routine examination.

This tumor originates from the kidney and tends to grow rapidly, but it is often painless in the early stages, which is why many children present with minimal symptoms aside from the mass. Although some children may eventually develop hematuria, hypertension, or abdominal pain, the presence of a palpable, non-tender mass is the most consistent early indicator and should raise immediate suspicion.

Importantly, manipulating the mass should be done with extreme caution, as excessive handling can risk tumor rupture and metastasis.

Finding a Wilms’ tumor is like feeling a smooth rock under a blanket—it’s firm and noticeable, but not painful to the touch, which makes it easily missed unless someone is paying close attention.

Physical assessment and careful handling are critical in children with suspected or diagnosed Wilms’ tumor.

• Gently palpate the abdomen and document the location, size, and characteristics of any mass noted.
• Avoid deep or repeated palpation to reduce the risk of tumor rupture and spread.
• Monitor for signs of associated symptoms such as hematuria, hypertension, or fatigue.
• Support the family with education about the condition, diagnostic process, and treatment options (surgery, chemotherapy, radiation).
• Coordinate prompt referral to pediatric oncology and surgical teams for evaluation and intervention.

✘Incorrect answer options:

Visible blood in the urine. While hematuria may occur in some children with Wilms’ tumor, it is not a consistent or early symptom and does not occur in all cases.

Pain or discomfort while urinating. Dysuria is more common with urinary tract infections or bladder-related conditions, not Wilms’ tumor, which originates in the kidney and is typically painless.

Episodes of nausea accompanied by vomiting. These symptoms may appear later in the disease or if the tumor has metastasized or is causing obstruction, but they are not typical initial signs.

EXPLANATION

✔Correct answer:

The child has mild intellectual disability but is capable of learning. An IQ of 65 falls within the range of mild intellectual disability, which is typically defined as an IQ between 50–70. Children in this range often develop more slowly than their peers but can acquire functional academic skills, such as reading, writing, and basic math, usually up to a 6th-grade level by adulthood. They are often described as “educable” and can participate in social activities, perform simple jobs, and achieve a level of independence with appropriate support and structured learning.

At 5 years old, this child may show delays in speech, comprehension, and problem-solving, but can still benefit from individualized education plans (IEPs), early intervention, and therapeutic support. Nurse Thompson should recognize the child’s potential to learn, emphasizing a strengths-based and developmentally appropriate approach in the care plan.

Think of learning with a mild intellectual disability like walking on a path that’s a bit bumpier and slower—but still heading in the right direction. With support, the child can reach many of the same destinations as peers, just at a different pace.

Nursing care should focus on promoting development, independence, and family education.

• Use simple language, repetition, and visual aids when communicating with the child.
• Encourage self-care tasks like dressing and feeding with supervision and support.
• Collaborate with occupational and speech therapists to enhance developmental progress.
• Involve family and caregivers in setting realistic goals and providing consistent routines.
• Advocate for early educational interventions and access to community resources.

✘Incorrect answer options:

The child's intelligence is within the lower limits of normal. Normal IQ generally ranges from 85 to 115. An IQ of 65 is below the normal range and qualifies as a mild intellectual disability.

The child has moderate intellectual disability but can be trained in self-care skills. Moderate intellectual disability corresponds to an IQ between 35–49, which is lower than 65. These individuals often require more intensive support and are classified as “trainable” rather than “educable.”

The child is entirely reliant on others for all aspects of care. This describes someone with profound intellectual disability (IQ below 20–25). A child with an IQ of 65 does not require total dependence and can achieve partial independence with proper guidance.

EXPLANATION

✔Correct answer:

“How do you feel about your physical appearance?” In adolescents, particularly girls around the age of 12, issues like body image dissatisfaction, peer pressure, and media influence often play a significant role in disordered eating behaviors. Asking “How do you feel about your physical appearance?” is the most appropriate and focused question to explore potential psychosocial and emotional contributors to Ava’s nutritional status.

This open-ended question can help Nurse Janelle assess whether Ava is experiencing body image concerns, low self-esteem, or possibly symptoms of an eating disorder such as anorexia nervosa or bulimia. According to Erikson’s psychosocial development theory, adolescents are in the stage of identity vs. role confusion, where self-image and peer acceptance are especially influential. Understanding Ava's self-perception is key to identifying social or emotional stressors affecting her eating behaviors.

Asking Ava how she feels about her appearance is like checking the roots of a plant when its leaves are wilting—it helps uncover deeper issues that may be affecting overall health, not just what's visible on the surface.

A psychosocial approach is essential when assessing nutrition-related concerns in adolescents.

• Establish a private and trusting environment to promote honest responses.
• Assess for additional signs of disordered eating: meal skipping, excessive exercise, or distorted body image.
• Screen for anxiety, depression, or social isolation if body image concerns are present.
• Collaborate with mental health providers, dietitians, and the pediatrician as needed.
• Educate the family on healthy body image and nutrition without reinforcing shame or guilt.

✘Incorrect answer options:

“Can you tell me what your usual daily activities look like?” This question provides general lifestyle information but does not specifically address nutrition or social influences on eating habits.

“Do you have any food allergies I should know about?” This is medically relevant, but it focuses on physiologic limitations, not psychosocial factors influencing appetite or weight loss.

“What types of food do you enjoy eating most?” While useful in a dietary history, this question assesses preference, not the underlying emotional or social pressures that could be contributing to restrictive eating.

EXPLANATION

✔Correct answer:

A noticeable increase in urine output. In acute poststreptococcal glomerulonephritis (APSGN), one of the hallmark issues is glomerular inflammation, which leads to reduced kidney filtration, sodium and water retention, and often oliguria (low urine output). An early sign of recovery is a return of diuresis, or increased urine output, as the kidneys begin to regain function and inflammation subsides. This improved urine output also helps relieve other symptoms like hypertension and edema.

In clinical practice, tracking intake and output (I&O) is a vital part of nursing care for patients with APSGN. Increased urine production typically precedes other signs of systemic improvement and indicates that glomerular perfusion and filtration are improving—a key milestone in renal recovery.

Think of the kidneys like a clogged drain. When it's blocked, water builds up in the sink (the body), but once the drain starts working again, the water flows out freely. That first sign of drainage—more urine—is the earliest indicator the system is improving.

Monitoring renal function is critical in managing APSGN and detecting improvement.

• Measure and document urine output every shift to detect changes in renal function.
• Monitor for decreasing edema and blood pressure as secondary signs of fluid balance restoration.
• Support hydration while avoiding fluid overload; follow fluid restriction orders carefully.
• Reinforce the importance of completing any prescribed antibiotics to prevent recurrence.
• Educate the family on the expected course of recovery and warning signs of deterioration.

✘Incorrect answer options:

A marked improvement in appetite. Appetite typically improves later in recovery, once fluid overload and metabolic waste buildup have resolved. It is not an early or reliable indicator of renal improvement.

A significant rise in energy levels. Energy levels may improve gradually, but they are often influenced by various factors including nutrition, emotional state, and general illness recovery—making this a subjective and late sign of improvement.

A reduction in diarrheal episodes. Diarrhea is not a hallmark symptom of APSGN. If present, it may be coincidental or related to another condition, and its resolution is not directly linked to renal recovery.

EXPLANATION

✔Correct answer:

Immediately inform the healthcare provider. The anterior fontanel, also known as the “soft spot” on an infant’s head, typically closes between 12 and 18 months of age. By the time a child reaches 2 years old, the fontanel should be completely closed in the majority of cases. If the anterior fontanel remains open at this age, it may suggest underlying pathological conditions, such as hypothyroidism, hydrocephalus, Down syndrome, or rickets (often linked to vitamin D deficiency or metabolic disorders).

Nurse Patel’s most appropriate response is to immediately notify the healthcare provider for further evaluation. While this may not always indicate a serious problem, it warrants a detailed assessment including laboratory tests, imaging, and developmental evaluations to rule out systemic causes or delays in bone ossification.

Think of the skull bones like puzzle pieces that slowly connect as a child grows. By age 2, the main center piece (the anterior fontanel) is usually locked in place. If it’s still open, it’s like noticing a missing puzzle piece—it doesn’t always mean something is wrong, but it definitely needs to be checked out.

When an open anterior fontanel is observed beyond the normal closure age, nurses should:

• Measure and document head circumference and compare with pediatric growth charts.
• Monitor for signs of increased intracranial pressure (e.g., bulging fontanel, vomiting, irritability, lethargy).
• Assess for developmental milestones and overall growth patterns.
• Provide a calm explanation to the caregiver and emphasize the need for further evaluation—not immediate alarm.
• Collaborate with the healthcare provider for appropriate referrals, such as endocrinology or neurology.

✘Incorrect answer options:

Assess for other potential indicators of abuse. While thorough assessment is essential, an open anterior fontanel is not typically an indicator of abuse. Abuse would be suspected with physical trauma, inconsistent history, or behavioral signs—not delayed fontanel closure.

Document this as an expected finding for the child's age. This is incorrect because an open anterior fontanel after 18 months is generally considered abnormal and requires further evaluation.

Inquire about any familial history of Tay-Sachs disease. Tay-Sachs disease is a genetic neurodegenerative disorder not directly related to delayed fontanel closure. It presents with motor weakness, developmental regression, and a cherry-red spot on the retina—not an open fontanel as a key sign.

EXPLANATION

✔Correct answer:

From 1 week up to 1 year, with highest risk between 2 and 4 months. Sudden Infant Death Syndrome (SIDS) is the unexpected and unexplained death of an otherwise healthy infant, typically during sleep. It is the leading cause of death in infants between 1 month and 1 year of age, with the peak incidence occurring between 2 and 4 months. This is a critical period of neurologic and cardiorespiratory development when infants are especially vulnerable to environmental stressors during sleep.

The exact cause of SIDS is still not fully understood, but current evidence points to a combination of immature respiratory control, sleep positioning, and environmental factors such as soft bedding, overheating, and secondhand smoke exposure.

Nurse Alondra should emphasize safe sleep practices—such as placing the baby on their back to sleep, using a firm mattress, avoiding loose bedding or stuffed toys in the crib, and room-sharing without bed-sharing—to reduce the risk of SIDS during this critical window.

Think of the first few months of a baby’s life like a fragile circuit board still being assembled—during this time, extra care is needed to prevent overloads. That’s why the 2–4 month period is most critical for safe sleep habits.

Teaching safe sleep practices is a key component of anticipatory guidance for parents and caregivers.

• Educate caregivers to always place the infant on their back to sleep, for both naps and nighttime.
• Encourage use of a firm sleep surface with a fitted sheet and no soft objects or loose bedding.
• Discourage co-sleeping, but recommend room-sharing for at least the first 6 months.
• Promote breastfeeding, which has been shown to reduce the risk of SIDS.
• Warn against exposure to tobacco smoke, alcohol, and illicit substances, which increase SIDS risk.

✘Incorrect answer options:

Between 1 and 2 years of age. SIDS is rare after 1 year of age. At this stage, other causes of sudden death would be considered.

Between 6 months and 1 year, peaking around 10 months. While SIDS can occur up to 12 months, the highest risk is much earlier, around 2 to 4 months.

Between 6 and 8 weeks of age. Although this falls within the risk window, it does not represent the peak risk period, which is slightly later—between 2 and 4 months.

EXPLANATION

✔Correct answer:

To control and reduce excessive protein loss in the urine. The hallmark of nephrotic syndrome is massive proteinuria, primarily the loss of albumin due to increased permeability of the glomerular basement membrane. This leads to hypoalbuminemia, edema, and fluid shifts. Corticosteroids, such as prednisone, are the first-line treatment because they stabilize the glomerular filtration barrier by reducing immune-mediated damage and altering the inflammatory process in the glomeruli.

By decreasing inflammation and modulating immune activity, corticosteroids effectively reduce glomerular permeability, thereby limiting further protein loss in the urine. Most children with minimal change nephrotic syndrome—the most common type in this age group—respond favorably to corticosteroid therapy.

Imagine the kidneys like a coffee filter that’s supposed to let only water through. In nephrotic syndrome, the filter has big holes, and the coffee grounds (proteins) are leaking out. Corticosteroids help patch up the holes so only the right stuff passes through again.

Managing nephrotic syndrome involves close monitoring and supportive care while corticosteroids work to reduce proteinuria.

• Monitor daily weights, abdominal girth, and urine protein levels to assess response to treatment.
• Teach parents about the importance of medication adherence and the expected duration of corticosteroid therapy.
• Monitor for corticosteroid side effects such as mood changes, increased appetite, weight gain, and immune suppression.
• Implement infection control precautions, as corticosteroids can increase infection risk.
• Promote a low-sodium, adequate-protein diet to help manage edema and maintain nutritional status.

✘Incorrect answer options:

To increase the child’s blood pressure to a safer level. Children with nephrotic syndrome typically present with normal or slightly elevated blood pressure, and hypertension, if present, is managed with antihypertensives—not corticosteroids.

To reduce inflammation within the kidneys. While corticosteroids do reduce inflammation, this is not the primary therapeutic goal in nephrotic syndrome; the main focus is reducing proteinuria by restoring the integrity of the glomerular membrane.

To help prevent infections that take advantage of a weakened immune system. Corticosteroids actually suppress the immune system, making patients more susceptible to infections rather than preventing them. Preventing infections in these patients requires environmental precautions and sometimes prophylactic antibiotics—not steroids.