513 Module 2

When completing an assessment for dehydration on a pre-school child, the nurse would assess for all of the following except:

Anterior fontanelle The anterior fontanelle usually closes by 18 months old.

The nurse caring for a hospitalized child with failure to thrive (FTT) will focus first on:

Assisting the child to attain adequate nutrition to demonstrate weight gain Regardless of the cause of the FTT, the nurse must implement interventions to aid the child in getting enough calories to gain weight.

When caring for an infant with severe dehydration due to vomiting and diarrhea, the nurse would: (Select all that apply)

Provide meticulous skincare Allow the mother to continue to breastfeed Monitor intake and output Place in contact isolation Skin breakdown and rashes common due to diarrhea, mothers are encouraged to continue breastfeeding (and formula too), monitoring intake and output is important to follow fluid balance and putting a child with diarrhea in isolation prevents spreading to others on the unit.

The primary goal for a nurse when caring for a child with cognitive impairment is to:

Promote optimum development It is important to provide stimulation that will aid in cognitive impairment.

A 2-week-old infant with Down syndrome is being seen in the clinic. The mother tells the nurse that the infant is difficult to hold. "The baby is like a rag doll and doesn't cuddle up to me as my other babies did." The nurse interprets the infant's behavior as a:

Result of the physical characteristics of Down syndrome Children with Down syndrome have hypotonia and feel floppy.

The nurse is evaluating an infant brought to the clinic with severe diarrhea. What signs and symptoms indicate that the infant has severe dehydration?

Tachycardia, capillary refill greater than 3 seconds, intense thirst Severe dehydration is greater than 10% loss of body weight. The body responds with a faster pulse rate, decreased perfusion, and intense thirst.

The nurse has measured the urinary output for 12 hours for a child weighing 15 kg as 225 mL. What is the nurse's priority?

Document the results 1 mL/kg/hour x 12 hours = 225 mL/12 hours. This is an expected minimum urine output. There is nothing to notify the healthcare provider with, nor a reason to give a bolus.

When assessing a child for dehydration, the best location to assess tissue turgor will be:

Just below the clavicle This is the best location for a child.

A 15-year-old boy with special needs is attending high school. Which nursing intervention by the school nurse will be most beneficial to his education?

Serving on his individualized education plan (IEP) committee Serving on the IEP committee and advocating for the child's rights and services to be received is very important.

The nurse is planning to care for a young, nonverbal patient with an autism spectrum disorder. In order to plan the best care for the child, which question is most important for the nurse to ask the child's parents?

"What are some of your child's rituals that we can incorporate into daily care?" Knowing what is familiar to the child will give him a sense of control.