1. A mother brings her 8 mo. old baby boy to clinic because he has been vomiting 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

It is essential to establish if the infant is dehydrated because the extent of dehydration, if severe it

can lead to metabolic acidosis, seizures, and death. One of the first signs of dehydration is

tachycardia, so measurement of the child’s heart rate (A) is essential. The underlying cause of

dehydration may be associated with abdominal tenderness (B) or viral exposure (D), but

determining the etiology is not the most urgent assessment to obtain. A child who is severely

dehydrated may have a weaker cry than normal, but this symptom is difficult to measure (C) and

is usually a later symptom.

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

DMD is inherited from an X-linked recessive gene, and affects males most

exclusively (A), and about one-third of all cases occur from new mutations. DMD is

characterized by progressive weakness and muscle wasting of skeletal muscle, not

striated muscle, and dystrophin is a protein found in skeletal muscle (B) that is

absent in children with DMD. DMD does not occur as a result of (C or D).

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?