Exam 4 PEDI

The pediatric nurse educator provides a teaching session to the nursing staff regarding juvenile idiopathic arthritis (JIA). Which action by a nursing staff member in the care of a child with JIA indicates a need for further education?

Emphasizes the importance of rising quickly in the mornings Rationale: The nursing plan of care for juvenile idiopathic arthritis (JIA) focuses on the status of affected joints. Isometric exercises and passive range of motion exercises will prevent contractures and deformities. Nonsteroidal antiinflammatory medications are used to treat joint stiffness and pain. The child may need more time than average to begin morning activities.

The nurse notes documentation that a child is exhibiting an inability to flex the leg when the thigh is flexed anteriorly at the hip. Which condition does the nurse suspect?

Meningitis Rationale: Meningitis is an infectious process of the central nervous system caused by bacteria and viruses. The inability to extend the leg when the thigh is flexed anteriorly at the hip is a positive Kernig's sign, noted in meningitis. Kernig's sign is not seen specifically with spinal cord injury, intracranial bleeding, or decreased cerebral blood flow.

A child has a right femur fracture caused by a motor vehicle crash and is placed in skin traction temporarily until surgery can be performed. During assessment, the nurse notes that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take?

Notify the health care provider (HCP). Rationale: An absent pulse to an extremity of the affected limb after a bone fracture could mean that the child is developing or experiencing compartment syndrome. This is an emergency situation, and the HCP should be notified immediately. Administering analgesics would not improve circulation. The skin traction should not be released without an HCP's prescription. Applying ice to an extremity with absent perfusion is incorrect. Ice may be prescribed when perfusion is adequate to decrease swelling.

A 7-year-old child is seen in a clinic, and the health care provider documents a diagnosis of primary nocturnal enuresis. The nurse should provide which information to the parents?

Primary nocturnal enuresis is usually outgrown without therapeutic intervention. Rationale: Primary nocturnal enuresis occurs in a child who has never been dry at night for extended periods. The condition is common in children, and most children eventually outgrow bed-wetting without therapeutic intervention. The child is unable to sense a full bladder and does not awaken to void. The child may have delayed maturation of the central nervous system. The condition is not caused by a psychiatric problem.

The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the parent about the child's symptoms?

Projectile vomiting Rationale: In pyloric stenosis, hypertrophy of the circular muscles of the pylorus causes narrowing of the pyloric canal between the stomach and the duodenum. Clinical manifestations of pyloric stenosis include projectile vomiting, irritability, hunger and crying, constipation, and signs of dehydration, including a decrease in urine output.

The nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. Which statement by the parents indicates their understanding of the plan?

"Circumcision has been delayed to save tissue for surgical repair." Rationale: Hypospadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. In hypospadias, the urethral orifice is located below the glans penis along the ventral surface. The infant should not be circumcised because the dorsal foreskin tissue will be used for surgical repair of the hypospadias. Options 1, 2, and 3 are unrelated to this disorder.

Which question should the nurse ask the parents of a child suspected of having glomerulonephritis?

"Has the child had a sore throat or a throat infection in the last few weeks?" Rationale: Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Group A β-hemolytic streptococcal infection is a cause of glomerulonephritis. Often, a child becomes ill with streptococcal infection of the upper respiratory tract and then develops symptoms of acute poststreptococcal glomerulonephritis after an interval of 1 to 2 weeks. The assessment data in options 1, 2, and 3 are unrelated to a diagnosis of glomerulonephritis.

The parents of a child with juvenile idiopathic arthritis call the clinic nurse because the child is experiencing a painful exacerbation of the disease. The parents ask the nurse if the child can perform range-of-motion exercises at this time. The nurse should make which response?

"Have the child perform simple isometric exercises during this time." Rationale: Juvenile idiopathic arthritis is an autoimmune inflammatory disease affecting the joints and other tissues, such as articular cartilage. During painful episodes of juvenile idiopathic arthritis, hot or cold packs and splinting and positioning the affected joint in a neutral position help reduce the pain. Although resting the extremity is appropriate, beginning simple isometric or tensing exercises as soon as the child is able is important. These exercises do not involve joint movement.

The nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which statement by one of the parents indicates an understanding of the use of the harness?

"I can remove the harness to bathe my infant." Rationale: The harness should be worn 23 hours a day and can be removed only to check the skin and for bathing. The hips and buttocks should be supported carefully when the infant is out of the harness. The harness does not need to be removed for diaper changes or feedings.

A 4-year-old child sustains a fall at home. After an x-ray examination, the child is determined to have a fractured arm and a plaster cast is applied. The nurse provides instructions to the parents regarding care for the child's cast. Which statement by the parents indicates a need for further instruction?

"I can use lotion or powder around the cast edges to relieve itching." Rationale: Teaching about cast care is essential to prevent complications from the cast. The parents need to be instructed not to use lotion or powders on the skin around the cast edges or inside the cast. Lotions or powders can become sticky or caked and cause skin irritation. Options 1, 3, and 4 are appropriate statements.

The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by a parent indicates a need for further teaching?

"I need to be sure to apply lotion on the skin under the brace." Rationale: The use of lotions or powders should be avoided with a brace because they can become sticky or cake under the brace, causing irritation. The actions in the remaining options are appropriate interventions for the use of a brace on a child.

Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot made at birth. Which statement by the parents indicates a need for further teaching regarding this disorder?

"I need to bring my infant back to the clinic in 1 month for a new cast." Rationale: Clubfoot is a complex deformity of the ankle and foot that includes forefoot adduction, midfoot supination, hindfoot varus, and ankle equinus; the defect may be unilateral or bilateral. Treatment for clubfoot is started as soon as possible after birth. Serial manipulation and casting are performed at least weekly. If sufficient correction is not achieved in 3 to 6 months, surgery usually is indicated. Because clubfoot can recur, all children with clubfoot require long-term interval follow-up until they reach skeletal maturity to ensure an optimal outcome.

The nurse reviews the record of a child who is suspected to have glomerulonephritis. Which statement by the child's parent should the nurse expect that is associated with this diagnosis?

"I noticed his urine was the color of coca-cola lately." Rationale: Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Gross hematuria, resulting in dark, smoky, cola-colored or brown-colored urine, is a classic symptom of glomerulonephritis. Blood urea nitrogen levels and serum creatinine levels may be elevated, indicating that kidney function is compromised. A mild to moderate elevation in protein in the urine is associated with glomerulonephritis. Hypertension is also common due to fluid volume overload secondary to the kidneys not working properly.

The nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction?

"I should apply lotion under the brace to prevent skin breakdown." Rationale: A brace may be prescribed to treat scoliosis. Braces are not curative, but may slow the progression of the curvature to allow skeletal growth and maturity. The use of lotions or powders under a brace should be avoided because they can become sticky and cake under the brace, causing irritation. Options 1, 2, and 4 are appropriate interventions in the care of a child with a brace.

The nurse is reinforcing instructions to the mother of a child who has a plaster cast applied to the left arm. Which statement by the mother indicates a need for further teaching?

"I will have to use a heat lamp to help the cast dry." Rationale: The mother needs to be instructed not to use a heat lamp to help the cast dry because of the risk associated with a burn injury from the heat lamp. The statements in the remaining options indicate understanding of instructions.

The nurse is implementing a teaching plan for a 4-month-old child who has been diagnosed with developmental dysplasia of the hip. The child will be placed in the Pavlik harness. Which statement by the family indicates that they understand the care of their child while placed in the Pavlik harness?

"I will watch for any redness or skin irritation where the straps are applied and call the health care provider for red areas." Rationale: If stabilization of the hip is required, a cast is initially applied. This is kept in place for 3 to 6 months until the hip is stabilized. After this is completed, and if further treatment is required, a Pavlik harness is the treatment of choice next. A Pavlik harness is a removable abduction brace. The brace must be checked every 1 to 2 weeks for adjustment of the straps. The use of double diapering is not recommended for developmental dysplasia of the hip (DDH) because of the possibility of hip extension. Because there are straps applied to the child's skin, it is important to check the skin of the child frequently.

The nurse provided discharge instructions to the parents of a 2-year-old child who had an orchiopexy to correct cryptorchidism. Which statement by the parents indicates the need for further instruction?

"I'll let him decide when to return to his play activities." Rationale: Cryptorchidism is a condition in which 1 or both testes fail to descend through the inguinal canal into the scrotal sac. Surgical correction may be necessary. All vigorous activities should be restricted for 2 weeks after surgery to promote healing and prevent injury. This prevents dislodging of the suture, which is internal. Normally, 2-year-olds want to be active; allowing the child to decide when to return to his play activities may prevent healing and cause injury. The parents should be taught to monitor the temperature, provide analgesics as needed, and monitor the urine output.

The nurse has reinforced teaching for a school-age child who was given a brace to wear for the treatment of scoliosis. The nurse determines that the child needs further teaching if the child makes which statement?

"This brace will correct my curve." Rationale: Bracing can halt the progression of most curvatures, but it is not curative for scoliosis. The statements in the remaining options represent correct understanding on the part of the child.

The clinic nurse is assessing a child suspected of having juvenile rheumatoid arthritis (JRA). Which assessment findings should the nurse expect to note in a child who has been diagnosed with JRA? Select all that apply.

- Morning stiffness -Painful, stiff, and swollen joints -Limited range of motion of the joints -History of late-afternoon temperature Rationale: Clinical manifestations associated with JRA include intermittent joint pain that lasts longer than 6 weeks and painful, stiff, and swollen joints that are warm to the touch, with limited range of motion. The child will complain of morning stiffness and may protect the affected joint or refuse to walk. Systemic symptoms include malaise, fatigue, lethargy, anorexia, weight loss, and growth problems. A history of a late-afternoon fever with temperature spiking up to 105°F (40.6°C) will also be part of the clinical manifestations. Hematuria is not specifically associated with JRA.

The nurse prepares a list of home care instructions for the parents of a child who has a plaster cast applied to the left forearm. Which instructions should be included on the list? Select all that apply.

-Keep small toys and sharp objects away from the cast. -Elevate the extremity on pillows for the first 24 to 48 hours after casting to prevent swelling. -Contact the health care provider (HCP) if the child complains of numbness or tingling in the extremity. Rationale: While the cast is drying, the palms of the hands are used to lift the cast. If the fingertips are used, indentations in the cast could occur and cause constant pressure on the underlying skin. Small toys and sharp objects are kept away from the cast, and no objects (including padded objects) are placed inside the cast because of the risk of altered skin integrity. The extremity is elevated to prevent swelling, and the HCP is notified immediately if any signs of neurovascular impairment develop. A heating pad is not applied to the cast or fingers. Cold fingers could indicate neurovascular impairment, and the HCP should be notified.

The nurse is performing an assessment on a child admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which assessment findings should the nurse expect to observe? Select all that apply.

-Pallor - Edema -Anorexia -Proteinuria Rationale: Nephrotic syndrome is a kidney disorder characterized by massive proteinuria, hypoalbuminemia, edema, elevated serum lipids, anorexia, and pallor. The child gains weight.

Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select all that apply.

-Providing a low-fat, well-balanced diet -Teaching the child effective hand-washing techniques -Instructing the parents to avoid administering medications unless prescribed Rationale: Hepatitis is an acute or chronic inflammation of the liver that may be caused by a virus, a medication reaction, or another disease process. Because hepatitis can be viral, standard precautions should be instituted in the hospital. The child should be discouraged from sharing toys, so playtime in the playroom with other children is not part of the plan of care. The child will be allowed to return to school 1 week after the onset of jaundice, so indefinite home schooling would not need to be arranged. Jaundice is an expected finding with hepatitis and would not warrant notification of the HCP. Provision of a low-fat, well-balanced diet is recommended. Parents are cautioned about administering any medication to the child because normal doses of many medications may become dangerous owing to the liver's inability to detoxify and excrete them. Hand washing is the most effective measure for control of hepatitis in any setting, and effective hand washing can prevent the immunocompromised child from contracting an opportunistic type of infection.

A child is brought to the emergency department, and diagnostic x-rays of the child reveal that a fracture is present. The mother states that the child was rollerblading and attempted to break a fall with an outstretched arm. A plaster of Paris cast is applied to the arm. Which instructions should the nurse provide the mother? Select all that apply.

-The cast will mold to the body part. -The cast should be dry in about 6 hours. -Keep the cast elevated on pillows for the first day. -Make sure that the child can frequently wiggle the fingers. -The cast needs to be kept dry because it will begin to disintegrate when wet.

Which nursing actions apply to the care of a child who is having a seizure? Select all that apply.

-Time the seizure. -Stay with the child. -Loosen clothing around the child's neck. -Place the child in a lateral side-lying position. Rationale: During a seizure, the nurse should stay with the child to reduce the risk of injury and allow for observation and timing of the seizure. The child is not restrained because this could cause injury to the child. The child is placed on his or her side in a lateral position. Nothing is placed in the child's mouth during a seizure because this could injure the child's mouth, gums, or teeth. Positioning on the side prevents aspiration because saliva drains out of the corner of the child's mouth. The nurse should loosen clothing around the child's neck and ensure a patent airway.

The nurse is creating a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply.

-Time the seizure. -Stay with the child. -Move furniture away from the child. Rationale: A seizure is a disorder that occurs as a result of excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. During a seizure, the child is placed on his or her side in a lateral position. Positioning on the side prevents aspiration because saliva drains out the corner of the child's mouth. The child is not restrained because this could cause injury to the child. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for observation and timing of the seizure.

An infant is brought to the child care clinic for a follow-up visit. The nurse notes that the infant is wearing this apparatus. The nurse documents that the infant is wearing which device? Refer to Figure.

A Pavlik harness for the treatment of congenital hip dislocation Rationale: A Pavlik harness is a device that is used to treat congenital hip dislocation. It keeps the hips and knees flexed, the hips abducted, and the femoral head in the acetabulum. The Pavlik harness is worn continuously for 3 to 6 months. It promotes the development of muscle and cartilage, resulting in a stable hip.

The parents of a child recently diagnosed with cerebral palsy ask the nurse about the limitations of the disorder. The nurse responds by explaining that the limitations occur as a result of which pathophysiological process?

A chronic disability characterized by impaired muscle movement and posture Rationale: Cerebral palsy is a chronic disability characterized by impaired movement and posture resulting from an abnormality in the extrapyramidal or pyramidal motor system. Meningitis is an infectious process of the central nervous system. Encephalitis is an inflammation of the brain that occurs as a result of viral illness or central nervous system infection. Down syndrome is an example of a congenital condition that results in moderate to severe intellectual disabilities.

The nurse is assisting a health care provider (HCP) during the examination of an infant with developmental hip dysplasia. The HCP performs the Ortolani maneuver. The nurse determines that the infant exhibits a positive response to this maneuver if which finding is noted?

A palpable click during abduction of the affected hip Rationale: In the Ortolani maneuver, the examiner abducts both hips. A positive finding is a palpable click on the affected side during abduction. Crying is expected. Asymmetry and reduced range of motion of the affected hip are not positive signs of this maneuver.

An adolescent is seen in the emergency department for a suspected sprain of the ankle. X-rays have been obtained, and a fracture has been ruled out. Which instruction should the nurse provide to the adolescent regarding home care for treatment of the sprain?

Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 to 48 hours. Rationale: The injured area should be wrapped immediately to support the joint and control the swelling. Ice is applied to reduce the swelling and should be applied for not longer than 30 minutes every 4 to 6 hours for the first 24 to 48 hours. The joint should be immobilized and elevated, but strict bed rest for a period of 7 days is not required. A dependent position will cause swelling in the affected area.

The nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which assessment finding should the nurse expect to note documented in the infant's record regarding this condition?

Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table Rationale: Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table is noted in hip dysplasia. Asymmetrical abduction of the affected hip when an infant is placed supine with the knees and hips flexed would also be an assessment finding in hip dysplasia in infants beyond the newborn period. An apparent short femur on the affected side is noted, as well as limited range of motion.

The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. When analyzing the results of the urinalysis, which should the nurse most likely expect to note?

Bacteriuria Rationale: Epispadias is a congenital defect involving abnormal placement of the urethral orifice of the penis. The urethral opening is located anywhere on the dorsum of the penis. This anatomical characteristic facilitates entry of bacteria into the urine. Options 1, 2, and 4 are not characteristically noted in this condition.

A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP?

Bradycardia Rationale: Head injury is the pathological result of any mechanical force to the skull, scalp, meninges, or brain. A head injury can cause bleeding in the brain and result in increased ICP. In a child, early signs include a slight change in level of consciousness, headache, nausea, vomiting, visual disturbances (diplopia), and seizures. Late signs of increased ICP include a significant decrease in level of consciousness, bradycardia, decreased motor and sensory responses, alterations in pupil size and reactivity, posturing, Cheyne-Stokes respirations, and coma.

A child must wear a brace for correction of scoliosis. The nurse creates a plan of care knowing the child is at risk for which problem?

Breaks in skin integrity Rationale: Braces for treatment of scoliosis usually are worn 16 to 23 hours a day. The skin should be kept clean and dry and inspected for signs of redness or breakdown. Therefore, breaks in skin integrity are the client problem that should be included in this child's plan of care. The brace assists with posture, so mobility is not an issue. The brace does not compromise the respiratory status, so oxygenation is not decreased. The child will not have a risk for delayed growth and development because normal developmental milestones can be met while wearing a brace.

The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented?

Bright red blood and mucus in the stools Rationale: Intussusception is a telescoping of 1 portion of the bowel into another. The condition results in an obstruction to the passage of intestinal contents. A child with intussusception typically has severe abdominal pain that is crampy and intermittent, causing the child to draw in the knees to the chest. Vomiting may be present, but is not projectile. Bright red blood and mucus are passed through the rectum and commonly are described as currant jelly-like stools. Watery diarrhea and ribbon-like stools are not manifestations of this disorder.

A child is placed in skeletal traction for treatment of a fractured femur. The nurse creates a plan of care and should include which intervention?

Check the health care provider's (HCP's) prescriptions for the amount of weight to be applied. Rationale: When a child is in traction, the nurse would check the HCP's prescription to verify the prescribed amount of traction weight. The nurse would maintain the correct amount of weight as prescribed, ensure that the weights hang freely, check the ropes for fraying and ensure that they are on the pulleys appropriately, monitor the neurovascular status of the involved extremity, and monitor for signs and symptoms of immobilization. The nurse would provide therapeutic and diversional play activities for the child.

The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record?

Choking with feedings Rationale: In esophageal atresia and tracheoesophageal fistula, the esophagus terminates before it reaches the stomach, ending in a blind pouch, and a fistula is present that forms an unnatural connection with the trachea. Any child who exhibits the "3 Cs"—coughing and choking with feedings and unexplained cyanosis—should be suspected to have tracheoesophageal fistula. Options 1, 2, and 4 are not specifically associated with tracheoesophageal fistula.

A lumbar puncture is performed on a child suspected to have bacterial meningitis, and cerebrospinal fluid (CSF) is obtained for analysis. The nurse reviews the results of the CSF analysis and determines that which results would verify the diagnosis?

Cloudy CSF, elevated protein, and decreased glucose levels Rationale: Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. Meningitis is diagnosed by testing CSF obtained by lumbar puncture. In the case of bacterial meningitis, findings usually include an elevated pressure; turbid or cloudy CSF; and elevated leukocyte, elevated protein, and decreased glucose levels.

A child who sustained a fractured ankle has a short leg cast applied, and the nurse provides home care instructions to the mother. The mother returns to the emergency department 16 hours later because the child is complaining of severe pain. The nurse notes that the child's toes are cool, pale, and puffy and that the child is agitated and crying loudly. The mother states, "I gave her the pain medication you sent with us just like you told us, and I have kept her foot up on two pillows since we left, except when she gets up to go to the bathroom. I don't understand why she hurts so much. Do something!" What is the most likely clinical situation that occurred?

Compartment syndrome Rationale: Compartment syndrome occurs as a result of pressure buildup within a tissue compartment bound by anatomical structures such as fascia. With a fracture, this pressure increase may occur as a result of the intense inflammatory response or severe bleeding caused by the bone injury, even when diligent nursing care has been provided. Pain disproportionate to the injury despite analgesic administration is the classic sign of compartment syndrome. The nurse should constantly assess for this complication and should instruct the caregiver about the manifestations associated with this complication.

The nurse is caring for an infant with a diagnosis of bladder exstrophy. To protect the exposed bladder tissue, the nurse should plan which intervention?

Cover the bladder with a nonadhering plastic wrap. Rationale: In bladder exstrophy, the bladder is exposed and external to the body. In this disorder, one must take care to protect the exposed bladder tissue from drying, while allowing the drainage of urine. This is accomplished best by covering the bladder with a nonadhering plastic wrap. The use of petroleum jelly gauze should be avoided because this type of dressing can dry out, adhere to the mucosa, and damage the delicate tissue when removed. Dry sterile dressings and dressings soaked in solutions (that can dry out) also damage the mucosa when removed.

An infant born with an imperforate anus returns from surgery after requiring a colostomy. The nurse assesses the stoma and notes that it is red and edematous. Based on this finding, which action should the nurse take?

Document the findings. Rationale: A fresh colostomy stoma would be red and edematous, but this would decrease with time. The colostomy site then becomes pink without evidence of abnormal drainage, swelling, or skin breakdown. The nurse should document these findings because this is a normal expectation. Options 1, 3, and 4 are inappropriate and unnecessary interventions.

The nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse should monitor for which sign of a serious complication associated with this type of traction?

Elevated temperature Rationale: The most serious complication associated with skeletal traction is osteomyelitis, an infection involving the bone. Organisms gain access to the bone systemically or through the opening created by the metal pins or wires used with the traction. Osteomyelitis may occur with any open fracture. Clinical manifestations include complaints of localized pain, swelling, warmth, tenderness, an unusual odor from the fracture site, and an elevated temperature. The remaining options are not specifically associated with osteomyelitis.

The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder?

Failure to pass meconium stool in the first 24 hours after birth Rationale: Imperforate anus is the incomplete development or absence of the anus in its normal position in the perineum. During the newborn assessment, this defect should be identified easily on sight. However, a rectal thermometer or tube may be necessary to determine patency if meconium is not passed in the first 24 hours after birth. Other assessment findings include absence or stenosis of the anal rectal canal, presence of an anal membrane, and an external fistula to the perineum. Options 1, 2, and 4 are findings noted in intussusception.

The clinic nurse reviews the record of an infant and notes that the health care provider has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant?

Foul-smelling ribbon-like stools --> Hirschsprung's disease is a congenital anomaly also known as congenital aganglionosis or aganglionic megacolon. It occurs as the result of an absence of ganglion cells in the rectum and other areas of the affected intestine. Chronic constipation beginning in the first month of life and resulting in pellet-like or ribbon-like stools that are foul-smelling is a clinical manifestation of this disorder. Delayed passage or absence of meconium stool in the neonatal period is also a sign. Bowel obstruction, especially in the neonatal period; abdominal pain and distention; and failure to thrive are also clinical manifestations. Options 1, 2, and 3 are not associated specifically with this disorder.

The nurse performing an admission assessment on a 2-year-old child who has been diagnosed with nephrotic syndrome notes that which most common characteristic is associated with this syndrome?

Generalized edema Rationale: Nephrotic syndrome is defined as massive proteinuria, hypoalbuminemia, hyperlipemia, and edema. Other manifestations include weight gain; periorbital and facial edema that is most prominent in the morning; leg, ankle, labial, or scrotal edema; decreased urine output and urine that is dark and frothy; abdominal swelling; and blood pressure that is normal or slightly decreased.

A neighborhood nurse is attending a soccer game at a local middle school. One of the students falls off the bleachers and sustains an injury to the left arm. The nurse quickly attends to the child and suspects that the child's arm may be broken. Which nursing action would be the priority before transferring the child to the hospital emergency department?

Immobilize the arm. Rationale: When a fracture is suspected, it is imperative that the area be splinted and immobilized before the injured person is transferred or moved. The nurse should remain with the child and provide realistic reassurance. Although it may be necessary to contact the child's pediatrician, this is not the priority. It is not necessary to notify the radiology department because this would be the responsibility of the emergency department staff when the child arrives if it is determined that the child needs a radiograph. The child should not be told that permanent damage will not occur.

An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time?

Left lateral position --> Rationale: A cleft lip is a congenital anomaly that occurs as a result of failure of soft tissue or bony structure to fuse during embryonic development. After cleft lip repair, the nurse avoids positioning an infant on the side of the repair or in the prone position because these positions can cause rubbing of the surgical site on the mattress. The nurse positions the infant on the side lateral to the repair or on the back upright and positions the infant to prevent airway obstruction by secretions, blood, or the tongue. From the options provided, placing the infant on the left side immediately after surgery is best to prevent the risk of aspiration if the infant vomits.

A 1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip. On assessment, the nurse understands that which finding should be noted in this condition?

Limited range of motion in the affected hip Rationale: In developmental dysplasia of the hip, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Asymmetrical and restricted abduction of the affected hip, when the child is placed supine with the knees and hips flexed, would be an assessment finding in developmental dysplasia of the hip in infants beyond the newborn period. Other findings include an apparent short femur on the affected side, asymmetry of the gluteal skinfolds, and limited range of motion in the affected extremity.

The nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which precautionary intervention should be included in the plan of care?

Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics. Rationale: Meningitis is an infectious process of the central nervous system caused by bacteria and viruses; it may be acquired as a primary disease or as a result of complications of neurosurgery, trauma, infection of the sinus or ears, or systemic infections. A major priority of nursing care for a child suspected to have meningitis is to administer the antibiotic as soon as it is prescribed. The child also is placed on respiratory isolation precautions for at least 24 hours while culture results are obtained and the antibiotic is having an effect. Enteric precautions and neutropenic precautions are not associated with the mode of transmission of meningitis. Enteric precautions are instituted when the mode of transmission is through the gastrointestinal tract. Neutropenic precautions are instituted when a child has a low neutrophil count.

A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem?

Metabolic alkalosis Rationale: Vomiting causes the loss of hydrochloric acid and subsequent metabolic alkalosis. Metabolic acidosis would occur in a child experiencing diarrhea because of the loss of bicarbonate. Diarrhea might or might not accompany vomiting. Hyperactive bowel sounds are not associated with vomiting.

The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the health care provider's (HCP's) prescriptions and should contact the HCP to question which prescription?

Nasotracheal suction as needed. Rationale: A basilar skull fracture is a type of head injury. Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture: Because of the nature of the injury, there is a possibility that the catheter will enter the brain through the fracture, creating a high risk of secondary infection. Fluid balance is monitored closely by daily weight determination, intake and output measurement, and serum osmolality determination to detect early signs of water retention, excessive dehydration, and states of hypertonicity or hypotonicity. The child is maintained on NPO (nothing by mouth) status or restricted to clear liquids until it is determined that vomiting will not occur. An intravenous line is maintained to administer fluids or medications, if necessary.

An alert child, who is crying loudly, is brought to the hospital emergency department for a simple fracture to the lower right arm that occurred after a fall off a bicycle. What is the nurse's priority assessment?

Neurovascular Rationale: A simple fracture is a fracture of the bone across its entire shaft with some possible displacement but without breaking the skin. The priority assessment is the neurovascular status in the affected arm. The affected arm should be immobilized. Skin integrity is a higher priority in a compound fracture since there is an open wound. The level of consciousness is already established, as the child is alert and crying.

A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse should take which action?

Notify the health care provider (HCP). Rationale: Scoliosis is a three-dimensional spinal deformity that usually involves lateral curvature, spinal rotation resulting in rib asymmetry, and hypokyphosis of the thorax. A complication after surgical treatment of scoliosis is superior mesenteric artery syndrome. This disorder is caused by mechanical changes in the position of the child's abdominal contents, resulting from lengthening of the child's body. The disorder results in a syndrome of emesis and abdominal distention similar to that which occurs with intestinal obstruction or paralytic ileus. Postoperative vomiting in children with body casts or children who have undergone spinal fusion warrants attention because of the possibility of superior mesenteric artery syndrome. Options 1, 2, and 3 are incorrect.

The nurse is assisting a health care provider (HCP) examining a 3-week-old infant with developmental dysplasia of the hip. What test or sign should the nurse expect the HCP to assess?

Ortolani's maneuver Rationale: In developmental dysplasia of the hip, the head of the femur is seated improperly in the acetabulum or hip socket of the pelvis. Ortolani's maneuver is a test to assess for hip instability and can be done only before 4 weeks of age. The examiner abducts the thigh and applies gentle pressure forward over the greater trochanter. A "clicking" sensation indicates a dislocated femoral head moving into the acetabulum. Babinski's sign is abnormal in anyone older than 2 years of age and indicates central nervous system abnormality. The Moro reflex is normally present at birth but is absent by 6 months; if still present at 6 months, there is an indication of neurological abnormality. The palmar-plantar grasp is present at birth and lessens within 8 months.

A child with cerebral palsy is in a management program to achieve maximum potential for locomotion, self-care, and socialization in school. The nurse works with the child to meet these goals by performing which action?

Placing the child on a wheeled scooter board Rationale: The correct option provides the child with maximum potential in locomotion, self-care, and socialization. While lying on the abdomen, the child can move around independently anywhere the child wants to go and can interact with others as desired. Orthoses need to be used all the time to aid locomotion. Children with cerebral palsy (CP) need to be mainstreamed as much as cognitive ability permits to provide for maximum socialization and normalization. Not all children with CP are intellectually challenged. Just as children without CP sit up and use assistive devices when eating, so should children with CP.

A child is diagnosed with Reye's syndrome. The nurse creates a nursing care plan for the child and should include which intervention in the plan?

Providing a quiet atmosphere with dimmed lighting Rationale: Reye's syndrome is an acute encephalopathy that follows a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver. In Reye's syndrome, supportive care is directed toward monitoring and managing cerebral edema. Decreasing stimuli in the environment by providing a quiet environment with dimmed lighting would decrease the stress on the cerebral tissue and neuron responses. Hearing loss and urine output are not affected. Changing the body position every 2 hours would not affect the cerebral edema directly. The child should be positioned with the head elevated to decrease the progression of the cerebral edema and promote drainage of cerebrospinal fluid.

Russell's traction is prescribed for a child with a lower leg fracture. The mother of the child asks the nurse about the purpose of the traction. The nurse explains to the mother that which is the primary action of this type of traction?

Reduces or realigns a fracture site Rationale: Russell's traction uses skin traction to realign a fracture in the lower extremity and to immobilize the hip and knee in a flexed position. It is important to keep the hip flexion at the prescribed angle to prevent fracture malalignment. The traction may also relieve pain by reducing muscle spasms, but this is not the primary reason for this traction. The child can still move in bed with some restriction as a result of the traction. Traction is never used to restrain a child.

The nurse is caring for a child who fractured the ulna bone and had a cast applied 24 hours ago. The child tells the nurse that the arm feels like it is falling asleep. Which nursing action is appropriate?

Report the findings to the health care provider. Rationale: A child's complaint of pins and needles or of the extremity falling asleep needs to be reported to the health care provider. These complaints indicate the possibility of circulatory impairment and paresthesia. Paresthesia is a serious concern because paralysis can result if the problem is not corrected. The five Ps of vascular impairment are pain, pallor, pulselessness, paresthesia, and paralysis. Prompt intervention is critical if neurovascular impairment is to be prevented.

An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority nursing intervention in the preoperative period?

Reposition the infant frequently. Rationale: Hydrocephalus occurs as a result of an imbalance of cerebrospinal fluid absorption or production that is caused by malformations, tumors, hemorrhage, infections, or trauma. It results in head enlargement and increased intracranial pressure (ICP). In infants with hydrocephalus, the head grows at an abnormal rate, and if the infant is not repositioned frequently, pressure ulcers can occur on the back and side of the head. An egg crate mattress under the head is also a nursing intervention that can help to prevent skin breakdown. Proteinuria is not specific to hydrocephalus. Stimulus should be kept at a minimum because of the increase in ICP. It is not necessary to check the blood pressure every 15 minutes.

The nurse is planning care for a child with hemolytic-uremic syndrome who has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to implement which measure?

Restrict fluids as prescribed. Rationale: Hemolytic-uremic syndrome is thought to be associated with bacterial toxins, chemicals, and viruses that result in acute kidney injury in children. Clinical manifestations of the disease include acquired hemolytic anemia, thrombocytopenia, renal injury, and central nervous system symptoms. A child with hemolytic-uremic syndrome undergoing peritoneal dialysis because of anuria would be on fluid restriction. Pain is not associated with hemolytic-uremic syndrome, and potassium would be restricted, not encouraged, if the child is anuric. Peritoneal dialysis does not require an arteriovenous fistula (only hemodialysis).

The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet?

Rice Rationale: Celiac disease also is known as gluten enteropathy or celiac sprue and refers to intolerance to gluten, the protein component of wheat, barley, rye, and oats. The important factor to remember is that all wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn, rice, or millet. Vitamin supplements—especially the fat-soluble vitamins, iron, and folic acid—may be needed to correct deficiencies. Dietary restrictions are likely to be lifelong.

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing?

Rigid extension and pronation of the arms and legs Rationale: Decerebrate (extension) posturing is characterized by the rigid extension and pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe decorticate (flexion) posturing.

The nurse develops a plan of care for a child at risk for tonic-clonic seizures. In the plan of care, the nurse identifies seizure precautions and documents that which item(s) need to be placed at the child's bedside?

Suctioning equipment and oxygen Rationale: A seizure results from the excessive and unorganized neuronal discharges in the brain that activate associated motor and sensory organs. A type of generalized seizure is a tonic-clonic seizure. This type of seizure causes rigidity of all body muscles, followed by intense jerking movements. Because increased oral secretions and apnea can occur during and after the seizure, oxygen and suctioning equipment are placed at the bedside. A tracheotomy is not performed during a seizure. No object, including a padded tongue blade, is placed into the child's mouth during a seizure. An emergency cart would not be left at the bedside, but would be available in the treatment room or nearby on the nursing unit.

The clinic nurse is assessing jaundice in a child with hepatitis. Which anatomical area would provide the best data regarding the presence of jaundice?

The nail beds Rationale: Jaundice, if present, is best assessed in the sclera, nail beds, and mucous membranes. Generalized jaundice appears in the skin throughout the body. Option 4 is an inappropriate area to assess for the presence of jaundice.

The nurse provides feeding instructions to a parent of an infant diagnosed with gastroesophageal reflux disease. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis?

Thicken the feedings by adding rice cereal to the formula. Rationale: Gastroesophageal reflux is backflow of gastric contents into the esophagus as a result of relaxation or incompetence of the lower esophageal or cardiac sphincter. Small, more frequent feedings with frequent burping often are prescribed in the treatment of gastroesophageal reflux. Feedings thickened with rice cereal may reduce episodes of emesis. If thickened formula is used, cross-cutting of the nipple may be required.

A 9-year-old child fractures the left tibia along an epiphyseal line while using a skateboard. What is the nurse's priority concern during future growth?

Uneven leg growth Rationale: The epiphyseal line is the area that is responsible for longitudinal bone growth. A fracture affecting this area places the child at risk for uneven future growth if proper healing does not occur. The epiphyses are located at the proximal and distal ends of a bone and are the insertion sites for muscles. The diaphysis is the shaft or main longitudinal portion of a long bone. The metaphysis is an area of flaring of bone, located between the epiphysis and the diaphysis. Paralysis, pressure ulcer, and infection are not priority concerns for future growth. Paralysis and neurovascular status are priority concerns during the immediate period postinjury, but not during future growth.