A mother brings her 8 mo. old baby boy to clinic bc he has been vomitting and had
diarrhea for last 3 days. Which assessment is most important for nurse to make?
a. Assess infant abdomen for tenderness
b. Determine if the infant was exposed to a virus
c. Measure the infant’s pulse
d. Evaluate the infant’s cry
2. While obtaining the vital signs of a 10 year old who had a tonsillectomy this morning,
the nurse observes the child swallowing every 2-3 minutes. Which assessment should
the nurse implement?
a. Inspect the posterior oropharynx
b. Assess for teeth clenching or grinding
c. Touch the tonsillar pillars to stimulate the gag reflex
d. Ask the child to speak to evaluate change in voice tone
3. The parents of a 3-year old boy who has Duchenne muscular dystrophy ask, “How can
our son have this disease? We are wondering if we should have any more children.”
What information should the nurse provide to parents?
a. This is an inherited X-linked recessive disorder, which
primarily affects male children in the family
b. The striated muscle groups of males can be impacted by a lack of the
protein dystrophin in their mothers
c. The male infant had a viral infection that went unnoticed and untreated so
muscle damage was incurred
d. Birth trauma with a breech vaginal birth causes damage to the spinal cord,
thus weakening the muscles
4. A 2-week-old female infant is hospitalized for the surgical repair of an umbilical hernia.
After returning to the postoperative neonatal unit, her RR and HR have increased
during the last hour. Which intervention should the nurse implement?
a. Notify the HCP of these findings
b. Administer a PRN analgesic prescription
c. Record the findings in the child’s record
d. Wrap the infant tightly and rock in r
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