which of the following parameters would be least reliable when assessing the perfusion status of a 2 year old child with possible shock
Logo

Nursing Elites

HESI LPN

HESI Pediatrics Quizlet

1. Which of the following parameters would be LEAST reliable when assessing the perfusion status of a 2-year-old child with possible shock?

Correct answer: B

Rationale: Systolic blood pressure is the least reliable parameter when assessing the perfusion status of a 2-year-old child with possible shock. In pediatric patients, especially young children, blood pressure may not decrease until significant shock has already occurred, making it a late indicator of inadequate perfusion. Depending solely on systolic blood pressure to evaluate perfusion status in this age group can lead to a delay in appropriate interventions. Distal capillary refill time, skin color, and temperature changes, and the presence of peripheral pulses are more sensitive and early indicators of perfusion status in pediatric patients. Monitoring distal capillary refill provides information on peripheral perfusion, while changes in skin color and temperature can signal circulatory compromise. Evaluating the presence or absence of peripheral pulses offers insights into vascular perfusion. These parameters offer more reliable and prompt feedback on a child's perfusion status compared to systolic blood pressure.

2. A 2-year-old child with a diagnosis of gastroesophageal reflux disease (GERD) is being discharged. What dietary instructions should the nurse provide?

Correct answer: C

Rationale: Avoiding gluten is not typically necessary for managing gastroesophageal reflux disease (GERD) in children. The correct dietary instruction for a 2-year-old with GERD would be to avoid high-fat foods. High-fat foods can relax the lower esophageal sphincter, leading to increased reflux symptoms. While spicy foods and dairy products may also trigger reflux in some individuals, the primary focus should be on avoiding high-fat foods due to their direct impact on the lower esophageal sphincter, which exacerbates GERD symptoms.

3. A nurse is reviewing the immunization schedule of an 11-month-old infant. What immunizations does the nurse expect the infant to have previously received?

Correct answer: B

Rationale: By 11 months of age, the recommended vaccines for infants include diphtheria, pertussis, tetanus, and polio. These vaccines are part of the routine immunization schedule to protect infants from serious infectious diseases. Choice A is incorrect because measles is not typically administered at this age. Choice C is incorrect because rubella and tuberculosis are not part of routine infant immunizations. Choice D is incorrect because measles, mumps, and rubella are usually given as a combination vaccine later in childhood, not at 11 months of age.

4. .A nurse is performing a physical examination on an infant with Down syndrome. For what anomaly should the nurse assess the child?

Correct answer: C

Rationale: Abnormal heart sounds could indicate a congenital heart defect, which is common in infants with Down syndrome.

5. A nurse is caring for an infant born with exstrophy of the bladder. What does the nurse determine is the greatest risk for this infant?

Correct answer: A

Rationale: Infection is the greatest risk for an infant with exstrophy of the bladder due to the exposure of the bladder and surrounding tissues. The exposed bladder increases the risk of infection as it lacks the protective covering of the skin. Dehydration (Choice B) may occur but is not the greatest risk compared to infection. Urinary retention (Choice C) is less likely due to the nature of the condition. Intestinal obstruction (Choice D) is not directly associated with exstrophy of the bladder.

Similar Questions

The parents of a 2-year-old child tell the nurse that they are having difficulty disciplining their child. What is the nurse’s most appropriate response?
A parent of a 2-year-old child tells a nurse at the clinic, 'Whenever I go to the store, my child has a screaming tantrum, demanding a toy or candy on the shelves. How can I deal with this situation?' What is the nurse’s best response?
A 6-year-old child with asthma is admitted to the hospital with an acute exacerbation. What is the priority nursing intervention?
A nurse plans to talk to the parents of a toddler about toilet training. What should the nurse explain is the most important factor in the process of toilet training?
A child has undergone surgery using steel bar placement to correct pectus excavatum. What position would the nurse instruct the parents to avoid?

Access More Features

HESI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

HESI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All HESI courses Coverage
  • 30 days access

Other Courses