NursingCareATI1-11,35,42

DTRs are graded from

0 to 4+, where 0 denotes no response and 4+ is a hyperactive, exaggerated response. The normal response to DTR testing is 2+

TEMPERATURE

2.1 Temperature by age EXPECTED LEVEL RECOMMENDED ROUTES 3 MONTHS 37.5˚ C (99.5˚ F) ● Axillary ● Rectal (if exact measurement necessary) 6 MONTHS 1 YEAR 37.7˚ C (99.9˚ F) 3 YEARS 37.2˚ C (99.0˚ F) ● Axillary ● Tympanic ● Oral (if child cooperative) ● Rectal (if exact measurement necessary) 5 YEARS 37.0˚ C (98.6˚ F) 7 YEARS 36.8˚ C (98.2˚ F) ● Oral ● Axillary ● Tympanic 9 YEARS 36.7˚ C (98.1˚ F) 11 YEARS 13 YEARS 36.6˚ C (97.9˚ F)

A normal respiratory rate for a toddler is between

25 and 30 breaths per minute; for children between the ages of 3 and 6 years, it averages between 21 and 25; and for children between the ages of 8 and 10 years, it averages 19 to 20.

Gross motor skills by age

3-YEAR-OLD Rides a tricycle Jumps off bottom step Stands on one foot for a few seconds 4-YEAR-OLD Skips and hops on one foot Throws ball overhead Catches ball reliably 5-YEAR-OLD Jumps rope Walks backward with heel to toe Throws and catche

Foster family:

A child or children who have been placed in an approved living environment away from the family of origin, usually with one or two parents

CIRCULAT ORY SYSTEM

A comprehensive assessment of the circulatory system includes assessment of pulses, capillary refill time, neck veins, clubbing of fingers, peripheral cyanosis, edema, blood pressure, and respiratory status. Heart sounds ● Auscultation should be done in both a sitting and reclining position. ● S1 and S2 heart sounds should be clear and crisp. S1 is louder at the apex of the heart. S2 is louder near the base of the heart. Physiologic splitting of S2 and S3 heart sounds are expected findings in some children. Sinus arrhythmias that are associated with respirations are common. Pulses ● Infants: Brachial, temporal, and femoral pulses should be palpable, full, and localized. ● Children and adolescents: Pulse locations and expected findings are the same as those in adults.

fontanel

A sunken fontanel is typically associated with dehydration. At 6 months of age, the anterior fontanel is about 2 inches (4-5 centimeters) in diameter with a diamond shape and then becomes smaller as the infant gets older. It usually closes by 12 to 18 months of age (the average being 14 months). The posterior fontanel may not be palpable at birth, but if it is, it is usually less than ½ inch (1 centimeter) in diameter and closes between 2 and 3 months of age.

A nurse is providing preconception teaching with a client who has phenylketonuria (PKU). Which of the following information should the nurse include in the teaching? A. Follow a low‑phenylalanine diet once pregnancy is confirmed. B. The client will undergo testing of phenylalanine levels one to two times per week throughout pregnancy. C. Increase intake of dietary proteins prior to conception. D. The client will require a cesarean section birth due to the likelihood of having a fetus with macrosomia.

A. A client who has PKU should follow a low‑phenylalanine diet for at least 3 months prior to conception and throughout the pregnancy. B. CORRECT: A client who has PKU will have her phenylalanine levels monitored one to two times per week throughout pregnancy. C. A client who has PKU should decrease her dietary intake of protein prior to conception. D. A client who has PKU is at no higher risk of fetal macrosomia and will not require a cesarean birth.

A nurse is caring for a child who is dying. Which of the following are findings of impending death? (Select all that apply.) A. Heightened sense of hearing B. Tachycardia C. Difficulty swallowing D. Sensation of being cold E. Cheyne‑Stokes respirations

A. A decrease in the senses of smell, sight, and hearing are physical manifestations of approaching death. B. Bradycardia is a physical manifestation of approaching death. C. CORRECT: Difficulty swallowing is a physical finding of approaching death. D. A client's sensation of heat when the body feels cool is a physical manifestation of approaching death. E. CORRECT: Cheyne‑Stokes respirations are an abnormal breathing pattern with periods of apnea that is a physical finding of impending death.

A nurse is preparing to administer immunizations to a 4-month-old infant. Which of the following is an appropriate action for the nurse to take in providing atraumatic care? A. Administer 81 mg of aspirin. B. Use the Z-track method when injecting. C. Ask the parents to leave the room during the injection. D. Provide sucrose solution on the pacifier.

A. A dministering aspirin to the infant can increase his risk for developing Reye syndrome. This is not an appropriate action for the nurse to take. B. U sing the Z-track method is not recommended with immunizations. This is not an appropriate action for the nurse to take. C. S eparating the parents from the infant can produce anxiety in the infant. This is not an appropriate action for the nurse to take. D. CORRECT: Allowing an infant to suck on a pacifier with sucrose solution can decrease pain with immunizations and is an appropriate action for the nurse to take in providing atraumatic care.

A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and is to undergo phototherapy. Which of the following actions should the nurse include in the plan of care? A. Reposition the newborn every 4 hr. B. Lotion the newborn's skin twice per day. C. Check the newborn's temperature every 8 hr. D. Remove the newborn's eye mask during feedings.

A. A newborn undergoing phototherapy should be repositioned every 2 hr. B. A newborn undergoing phototherapy should not have lotion applied to the skin because it can cause burns. C. A newborn undergoing phototherapy should have their temperature monitored every 4 hr. D. CORRECT: A newborn undergoing phototherapy should have the eye mask removed for each feeding to allow for bonding and assessment of the newborn's eyes.

A nurse is teaching the parent of a newborn how to treat the newborn's plagiocephaly. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should put my baby to sleep on her belly during her afternoon nap." B. "I should ensure my baby's head is in the same position each time she sleeps." C. "I should have my baby wear the prescribed helmet 23 hours a day." D. "I should allow my baby to sleep in her infant swing."

A. A newborn who has plagiocephaly should not be placed in the prone position to sleep. B. A newborn's head should not be placed in the same position each time she sleeps. C. CORRECT: A newborn who has plagiocephaly should wear the prescribed helmet 23 hr/day. D. A newborn who has plagiocephaly should not be allowed to sleep in an infant swing.

A nurse is teaching a parent about complicated grief. Which of the following statements should the nurse make? A. "It is considered complicated grief if you are still grieving 6 months after your loss." B. "Personal activities are affected when experiencing complicated grief." C."Parents will experience complicated grief together." D."Complicated grief self‑resolves in 12 months."

A. A parent who is still experiencing intense grieving after 1 year should be evaluated for complicated grief. B. CORRECT: A parent who is experiencing complicated grief experiences intense emotions that affect personal activities. C. Parents grieve differently, and not all parents experience complicated grief. D. A nurse should refer the parent to an expert in grief counseling if complicated grief is identified.

A nurse is checking the vital signs of a 3‑year‑old child during a well‑child visit. Which of the following findings should the nurse report to the provider? A. Temperature 37.2˚ C (99.0˚ F) B. Heart rate 106/min C. Respirations 30/min D. Blood pressure 88/54 mm Hg

A. A temperature of 37.2˚ C (99.0˚ F) is within the expected reference range for a 3‑year‑old child and should not be reported to the provider. B. A heart rate of 106/min is within the expected reference range for a 3‑year‑old child and should not be reported to the provider. C. CORRECT: Respirations of 30/min is above the expected reference range for a 3‑year‑old child and should be reported to the provider. D. A blood pressure of 90/52 mm Hg is within the expected reference range for a 3‑year‑old child and should not be reported to the provider.

A nurse is assessing a 12-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? A. Closed anterior fontanel B. Eruption of six teeth C. Birth weight doubled D. Birth length increased by 50%

A. By the age of 12 to 18 months, the infant's anterior fontanel should close. B. By the age of 12 months, the infant should have six to eight teeth erupted. C. CORRECT: By the age of 12 months, the infant's birth weight should have tripled. Therefore, the nurse should report this finding to the provider. D. By the age of 12 months, the infant's birth length should increase by 50%

A nurse is performing a developmental screening on a 3-year-old child. Which of the following skills should the nurse expect the child to perform? A. Ride a tricycle B. Hop on one foot C. Jump rope D. Throw a ball overhead

A. CORRECT: A 3-year-old child should be able to ride a tricycle. B. A 4-year-old child should be able to hop on one foot. C. A 5-year-old child should be able to jump rope. D. A 4-year-old child should be able to throw a ball overhead.

A nurse is providing anticipatory guidance to the parents of a toddler. Which of the following should the nurse include? (Select all that apply.) A. Develop food habits that will prevent dental caries. B. Meeting caloric needs results in an increased appetite. C. Expression of bedtime fears is common. D. Expect behaviors associated with negativism and ritualism. E. Annual screenings for phenylketonuria are important.

A. CORRECT: Because the toddler is developing taste preferences, the development of food habits that will prevent dental caries should be included in the anticipatory guidance. B. Toddlers often experience physiologic anorexia and become fussy eaters because of a decreased appetite. C. CORRECT: Expression of bedtime fears is common for toddlers and should be included in the anticipatory guidance. D. CORRECT: Negativism and ritualism are exhibited by toddlers as they seek autonomy, and associated behaviors should be included in the anticipatory guidance. E. Screening for phenylketonuria occurs in the newborn, not the toddler.

A nurse is performing a neurological assessment on an adolescent. Which of the following is an appropriate reaction by the adolescent when the nurse checks the trigeminal cranial nerve? (Select all that apply.) A. Clenching teeth together tightly B. Recognizing sour tastes on the back of the tongue C. Identifying smells through each nostril D. Detecting facial touches with eyes closed E. Looking down and in with the eyes

A. CORRECT: Clenching teeth together tightly is an appropriate reaction by the adolescent when checking the trigeminal cranial nerve. B. Recognizing sour tastes on the back of the tongue is an appropriate reaction by the adolescent when checking the glossopharyngeal cranial nerve. C. Identifying smells through each nostril is an appropriate reaction by the adolescent when checking the olfactory cranial nerve. D. CORRECT: Detecting facial touches with eyes closed is an appropriate reaction by the adolescent when checking the trigeminal cranial nerve. E. Looking down and in with the eyes is an appropriate reaction by the adolescent when checking the trochlear cranial nerve

A nurse is conducting a well-child visit with a 5-year-old child. Which of the following immunizations should the nurse plan to administer to the child? (Select all that apply.) A. Diphtheria, tetanus, pertussis (DTaP) B. Inactivated poliovirus (IPV) C. Measles, mumps, rubella (MMR) D. Pneumococcal (PCV) E. Haemophilus influenzae type B (Hib)

A. CORRECT: DTaP is a recommended immunization for 4- to 6-year-olds, and should be administered by the nurse. B. CORRECT: IPV is a recommended immunization for 4- to 6-year-olds, and should be administered by the nurse. C. CORRECT: MMR is a recommended immunization for 4- to 6-year-olds, and should be administered by the nurse. D. PCV is given as a series of immunizations in the first 15 months of life, and is not recommended for 4- to 6-year-olds. E. Hib is given as a series of immunizations in the first 15 months of life, and is not recommended for 4- to 6-year-olds.

A nurse is preparing a toddler for an intravenous catheter insertion using atraumatic care. Which of the following actions should the nurse take? (Select all that apply.) A. Explain the procedure using the child's favorite toy. B. Ask the parents to leave during the procedure. C. Perform the procedure with the child in his bed. D. Allow the child to make one choice regarding the procedure. E. Apply lidocaine and prilocaine cream to three potential insertion sites.

A. CORRECT: Explaining the procedure using the child's favorite toy can assist the child to manage fears and provides atraumatic care. B. The parents should be allowed to remain for procedures to offer comfort to the child. C. Safe places, such as the child's bed, should be avoided. D. CORRECT: Allowing the child to make choices offers a sense of control over the situation and should be used to provide atraumatic care. E. CORRECT: A topical analgesic, such as lidocaine and prilocaine cream, decreases pain and should be used to provide atraumatic care.

A nurse is caring for a toddler in a clinic. Which of the following actions should the nurse take? (See the chart for additional client information.) DEMOGRAPHICS 15 months old Female IMMUNIZATION RECORD HepB: 1 month, 2 months, 12 months Rotavirus: 2 months, 4 months, 6 months DTaP: 2 months, 4 months, 6 months Hib: 2 months, 4 months, 12 months IPV: 2 months, 4 months, 6 months MM R: 12 months Varicella: 12 months HepA: 12 months NURSES NOTES Temperature: 37.8° C (100.1° F) Sore throat Family history of seizures A. Administer DTaP vaccine. B. Administer rotavirus vaccine. C. Hold immunizations until fever subsides. D. Administer hepatitis A vaccine.

A. CORRECT: Five diphtheria, tetanus, and acellular pertussis immunizations are given during childhood, with one at 15 months of age. B. T his child completed the three-dose rotavirus vaccine series at age 6 months. C. T emperature of 37.8° C (100.1° F) is not a contraindication to administering immunizations. D. T wo hepatitis A immunizations are given during childhood, with the second one 6 to 18 months after the first.

A nurse is planning to administer recommended immunizations to a 4-year-old child. Which of the following vaccines should the nurse plan to give? (Select all that apply.) A. Inactivated poliovirus (IPV) B. Haemophilus influenzae type b (Hib) C. Measles, mumps, rubella (MMR) D. Varicella (VAR) E. Hepatitis B (HepB) F. Diphtheria, tetanus, and acellular pertussis (DTaP)

A. CORRECT: Four doses of IPV are given during childhood with a dose given at 4 years of age. B. T he series of Hib vaccines is complete by the age of 15 months. C. CORRECT: Two doses of MMR are given during childhood with a dose given at 4 years of age. D. CORRECT: Two doses of VAR are given during childhood with a dose given at 4 years of age. E. T he series of HepB vaccines is complete by the age of 18 months. F. CORRECT: Five doses of DTaP are given during childhood with a dose given at 4 years of age.

A nurse is providing teaching about expected changes during puberty to a group of parents of early adolescent girls. Which of the following statements by one of the parents indicates an understanding of the teaching? A. "Girls usually stop growing about 2 years after menarche." B. "Girls are expected to gain about 65 pounds during puberty." C."Girls experience menstruation prior to breast development." D."Girls typically grow more than 10 inches during puberty."

A. CORRECT: Girls usually stop growing about 2 years after menarche. This statement by the parent indicates and understanding of the teaching. B. Girls are expected to gain 7 to 25 kg (15.5 to 55 lb) during puberty. This statement by the parent does not indicate an understanding of the teaching. C. Breast development is usually the first manifestation of sexual maturity in girls, and appears before menstruation. This statement by the parent does not indicate an understanding of the teaching. D. Girls typically grow 5 to 20 cm (2 to 8 in) during puberty. This statement by the parent does not indicate an understanding of the teaching

A nurse often cares for children who are dying. Which of the following are appropriate actions for the nurse to take to maintain professional effectiveness? (Select all that apply.) A. Remain in contact with the family after their loss. B. Develop a professional support system. C. Take time off from work. D. Suggest that a hospital representative attend the funeral. E. Demonstrate feelings of sympathy toward the family.

A. CORRECT: Maintaining contact with the family after their loss is an act of support for the family. B. CORRECT: Developing professional support systems is a strategy the nurse can use to maintain effectiveness when working with the client who is dying and their family. C. CORRECT: Taking time off from work is a strategy the nurse can use to maintain effectiveness when working with the client who is dying. D. Nurses should be encouraged to participate in funeral rituals as an act of support for the family. E. A nurse should develop the ability for empathy when dealing with dying clients

A nurse is planning care for an infant who is experiencing pain. Which of the following interventions should the nurse include the plan of care? (Select all that apply.) A. Offer a pacifier. B. Use guided imagery. C. Use swaddling. D. Initiate a behavioral contract. E. Encourage kangaroo care.

A. CORRECT: Nonnutritive sucking is a therapeutic nonpharmacological strategy for pain management with infants. B. Guided imagery is a nonpharmacological strategy used with children. C. CORRECT: Swaddling the infant is a therapeutic nonpharmacological strategy for pain management. D. Behavioral contracts are a nonpharmacological strategy used with children. E. CORRECT: Skin‑to‑skin touch is a relaxation technique and should be encouraged for infants who have pain

A nurse is planning to administer recommended immunizations to a 2-month-old infant. Which of the following vaccines should the nurse plan to give? (Select all that apply.) A. Rotavirus (RV) B. Diphtheria, tetanus, and acellular pertussis (DTaP) C. Haemophilus influenzae type b (Hib) D. Hepatitis A (HepA) E. Pneumococcal conjugate (PCV13) F. Inactivated poliovirus (IPV)

A. CORRECT: RV is given as a two-or threedose series starting at 2 months of age. B. CORRECT: DTaP is given as a five-dose series starting at 2 months of age. C. CORRECT: Hib is given as a three-or fourdose series starting at 2 months of age. D. HepA is given as a two-dose series starting at 12 months of age. E. CORRECT: PCV13 is given as a four-dose series starting at 2 months of age. F. CORRECT: IPV is given as a four-dose series starting at 2 months of age.

A nurse is conducting a well-child visit with a child who is scheduled to receive the recommended immunizations for 11- to 12-year olds. Which of the following immunizations should the nurse administer? (Select all that apply.) A. Trivalent inactivated influenza (TIV) B. Pneumococcal (PCV) C. Meningococcal (MCV4) D. Tetanus and diphtheria toxoids and pertussis (Tdap) E. Rotavirus (RV)

A. CORRECT: TIV is a recommended immunization for 11- to 12-year-olds, and should be administered by the nurse. B. PCV is recommended as a series of immunizations in the first 15 months of life. C. CORRECT: MCV4 is a recommended immunization for 11- to 12-year-olds, and should be administered by the nurse. D. CORRECT: Tdap is a recommended immunization for 11- to 12-year-olds, and should be administered by the nurse. E. RV is recommended as a series of immunizations in the first 6 months of life

A nurse is performing a developmental screening on a 10-month-old infant. Which of the following fine motor skills should the nurse expect the infant to perform? (Select all that apply.) A. Grasp a rattle by the handle B. Try building a two-block tower C. Use a crude pincer grasp D. Place objects into a container E. Walks with one hand held

A. CORRECT: The infant should be able to grasp a rattle by the handle at the age of 10 months. B. The infant should try building a two-block tower at the age of 12 months. C. CORRECT: The infant should be able to use a crude pincer grasp at the age of 9 months. D. The infant should be able to place objects into a container at the age of 11 months. E. The infant should be able to walk with one hand held at the age of 12 months.

A nurse is preparing to assess a preschool‑age child. Which of the following is an appropriate action by the nurse to prepare the child? A. Allow the child to role‑play using miniature equipment. B. Use medical terminology to describe what will happen. C. Separate the child from her parent during the examination. D. Keep medical equipment visible to the child.

A. CORRECT: The nurse should allow the child to role‑play or manipulate actual or miniature equipment to reduce anxiety and fear related to the examination. B. The nurse should use neutral words and avoid overestimating the child's understanding of words when describing what will happen. C. The nurse should encourage parental presence during the examination. D. The nurse should keep medical equipment out of sight unless showing or using it on the child.

A nurse is performing family assessment. Which of the following should the nurse include? (Select all that apply.) A. Medical history B. Parents' education level C. Child's physical growth D. Support systems E. Stressors

A. CORRECT: The nurse should include a medical history on the parents, siblings, and grandparents when performing a family assessment. B. CORRECT: The nurse should include the family structure, which includes family members, family size, roles/position within the family, and occupation and education of family members, when performing a family assessment. C. The nurse should include the child's physical growth when performing an individual assessment on the child. D. CORRECT: The nurse should include support systems to determine the availability of extended family, work and peer relationships, and social systems and community resources to assist the family in meeting needs when performing a family assessment. E. CORRECT: The nurse should include stressors, both expected and unexpected, when performing a family assessment.

A nurse is providing education about age-appropriate activities for the parents of a 6-year-old child. Which of the following activities should the nurse include in teaching? A. Jumping rope B. Playing card games C. Solving jigsaw puzzles D. Joining competitive sports

A. CORRECT: The nurse should recommend activities such as playing hopscotch, jumping rope, riding bicycles, and joining organized sports. B. Playing card games is not an appropriate activity for a 6-year-old child. C. Solving jigsaw puzzles is not an appropriate activity for a 6-year-old child. D. Joining an organized competitive sport is an appropriate activity for a child who is 9 to 12 years old.

A nurse is providing anticipatory guidance to the parent of a 13‑year‑old adolescent. Which of the following screenings should the nurse recommend for the adolescent? (Select all that apply.) A. Body mass index B. Blood lead level C. 24‑hr dietary recall D. Weight E. Scoliosis

A. CORRECT: The nurse should recommend that the adolescent have a body mass index screening annually. B. Blood lead level screenings are recommended for children at the age of 1 and 2 years, and for children between the ages of 3 and 6 years who have not previously been screened. C. A 24‑hr dietary recall is not a routine screening for an adolescent. D. CORRECT: The nurse should recommend that the adolescent have a weight screening annually. E. CORRECT: The nurse should recommend that the adolescent have a scoliosis screening annually

A nurse is assisting a group of parents of adolescents to develop skills that will improve communication within the family. The nurse hears one parent state, "My son knows he better do what I say." Which of the following parenting styles is the parent exhibiting? A. Authoritarian B. Permissive C. Authoritative D. Passive

A. CORRECT: This parent is exhibiting an authoritarian parenting style. The parent controls the adolescent's behaviors and attitudes through unquestioned rules and expectations. B. This parent is not exhibiting a permissive parenting style. Using this style, the parent exerts little or no control over the adolescent's behaviors, and consults the adolescent when making decisions. C. This parent is not exhibiting an authoritative parenting style. Using this style, the parent directs the adolescent's behavior by setting rules and explaining the reason for each rule setting. D. This parent is not exhibiting a passive parenting style. Using this style, the parent is uninvolved, indifferent, and emotionally removed

A nurse is providing teaching about age-appropriate activities to the parent of a 2 year old. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will send my child's favorite stuffed animal when she will be napping away from home." B. "My child should be able to stand on one foot for a second." C."The soccer team my child will be playing on starts practicing next week." D."I should expect my child to be able to draw circles."

A. CORRECT: Transitional objects, such as a favorite stuffed animal, provide a sense of security for toddlers. This is an age-appropriate activity for a 2 year old. B. This is not an age-appropriate activity for a 2 year old. It requires good gross motor skills and is appropriate for a 2½-year-old child. C. Toddlers continue to develop gross motor skills and prefer parallel play where they play alongside of, instead of with, other children. This will make the concept of team soccer challenging for the toddler. D. This is not an age-appropriate activity for a 2 year old. It requires good fine motor coordination. Drawing circles is appropriate for a 2½-year-old child.

A nurse is caring for a preschoolage child who says she needs to leave the hospital because her doll is scared to be at home alone. Which of the following characteristics of preoperational thought is the child exhibiting? A. Egocentrism B. Centration C. Animism D. Magical thinking

A. Egocentrism occurs when the child is unable to see another person's perspective. B. Centration occurs when the child focuses on one aspect of something instead of considering the whole. C. CORRECT: Animism occurs when the child gives living qualities to inanimate objects, such as a doll feeling scared. D. Magical thinking occurs when the child believes their thoughts cause an event to occur.

A nurse is preparing to administer medication to a toddler. Which of the following actions should the nurse take? (Select all that apply.) A. Identify the toddler by asking the parent. B. Tell the parent to administer the medication. C. Calculate the safe dosage. D. Ask the toddler what toy he wants to hold during administration. E. Offer juice after the medication.

A. For safe medication administration, confirm two identifiers by looking at the identification band or having the toddler state his name and date of birth. B. The nurse should assess the preferred level of involvement of the parents prior to medication administration. C. CORRECT: For safe medication administration, the nurse should calculate safe dosage prior to administering medication. D. CORRECT: Offering choices to the toddler is an example of atraumatic care. E. CORRECT: Offering juice after the medication is an example of atraumatic care.

A nurse is teaching a course about safety during the schoolage years to a group of parents. Which of the following information should the nurse include in the course? (Select all that apply.) A. Gating stairs at the top and bottom B. Wearing helmets when riding bicycles or skateboarding C. Riding safely in bed of pickup trucks D. Implementing firearm safety E. Wearing seat belts

A. Gating stairs at the top and bottom should not be included in the teaching. This is appropriate information to include when teaching about safety during infant and toddler years. B. CORRECT: When teaching about safety in the schoolage years, the nurse should include information about wearing helmets when riding bicycles or skateboarding. C. The nurse should teach that it is never safe to ride in the bed of a pickup truck. D. CORRECT: The nurse should include information about implementing firearm safety when teaching about safety in the school-age years. E. CORRECT: The nurse should include information about wearing seat belts when teaching about safety in the school-age years

A nurse is assessing a newborn who has congenital hypothyroidism. Which of the following findings should the nurse expect? (Select all that apply.) A. Hypertonicity B. Cool extremities C. Short neck D. Tachycardia E. Hyperreflexia

A. Hypertonicity is not an expected finding in a newborn who has congenital hypothyroidism. B. CORRECT: Cool extremities are an expected finding in a newborn who has congenital hypothyroidism. C. CORRECT: A short neck is an expected finding in a newborn who has congenital hypothyroidism. D. T achycardia is not an expected finding in a newborn who has congenital hypothyroidism. E. Hyperreflexia is not an expected finding in a newborn who has congenital hypothyroidism.

A nurse is assessing an infant. Which of the following are manifestations of pain in an infant? (Select all that apply.) A. Pursed lips B. Loud cry C. Lowered eyebrows D. Rigid body E. Pushes away stimulus

A. Infants who experience pain have their mouth open in a squarish shape. B. CORRECT: Infants who experience pain exhibit a loud cry. C. CORRECT: Infants who experience pain lower and draw together their eyebrows. D. CORRECT: Infants who experience pain exhibit a rigid body. E. Infants who experience pain exhibit a local reflex to withdraw from the stimulus.

A nurse is discussing prepubescence and preadolescence with a group of parents of school-age children. Which of the following information should the nurse include in the discussion? A. Initial physiologic changes appear during early childhood. B. Changes in height and weight occur slowly during this period. C. Growth differences between boys and girls become evident. D. Signs of sexual maturation become highly visible in boys

A. Initial physiologic changes appear toward the end of middle childhood, around the age of 9 years. B. Changes in height and weight occur rapidly during this time period. C. CORRECT: The nurse should include in the discussion that growth differences between boys and girls become evident. D. Visible signs of sexual maturation are minimal in boys

A nurse is reviewing the medical record of a newborn who has necrotizing enterocolitis (NEC). Which of the following findings is a risk factor for NEC? A. Macrosomia B. Transient tachypnea of the newborn (TTN) C. Maternal gestational hypertension D. Gestational age 36 weeks

A. M acrosomia does not place a newborn at risk for NEC. B. TTN does not place a newborn at risk for NEC. C. M aternal gestational hypertension does not place a newborn at risk for NEC. D. CORRECT: A gestational age of 36 weeks, or a preterm birth, places a newborn at risk for NEC.

A nurse is teaching a parent of an infant about administration of oral medications. Which of the following should the nurse include in the teaching? (Select all that apply.) A. Use a universal dropper for medication administration. B. Ask the pharmacy to add flavoring to the medication. C. Add the medication to a formula bottle before feeding. D. Use the nipple of a bottle to administer the medication. E. Hold the infant in an semireclining position.

A. Medication has different viscosities, and droppers do not have a standard opening. A universal dropper is not an accurate way to measure medications. B. CORRECT: Multiple flavorings are available to add to medications and can assist in masking the taste. C. Because an infant might not finish an entire bottle of formula, it is not recommended to add medication to the bottle. D. CORRECT: Administering medications through an empty nipple can assist with successful administration of the medication. E. CORRECT: For successful medication administration, the infant should be held in a semireclining position, similar to feeding.

A nurse is planning care for a child following a surgical procedure. Which of the following interventions should the nurse include in the plan of care? A. Administer NSAIDs for pain greater than 7 on a scale of 0 to 10. B. Administer intranasal analgesics PRN. C. Administer IM analgesics for pain. D. Administer IV analgesics on a schedule.

A. NSAIDs are used for mild to moderate pain. B. Intranasal analgesics are used for clients older than 18 years. C. IM analgesics are not recommended for pain management in children. D. CORRECT: IV analgesics should be administered on a schedule to achieve optimal pain management

A nurse is teaching a parent about parallel play in children. Which of the following statements should the nurse include in the teaching? A. "Children sit and observe others playing." B. "Children exhibit organized play when in a group." C."The child plays alone." D."The child plays independently when in a group."

A. Onlooker play is when a child sits and observes others playing. B. Cooperative play is when a child exhibits organized play in a group. C. Solitary play is when a child plays alone. D. CORRECT: Parallel play is when the toddler plays independently but is among other children in a group.

A nurse is caring for a child who has a terminal illness and reviews palliative care with an assistive personnel (AP). Which of the following statements by the AP indicates understanding of this review? A. "I'm sure the family is hopeful that the new medication will stop the illness." B. "I'll miss working with this client now that only nurses will be caring for him." C."I will get all the client's personal objects out of his room." D."I will listen and respond as the family talks about their child's life."

A. Palliative care is provided when there is no longer hope for a disease cure. B. Palliative care focuses on providing consistency among the interprofessional team to offer supportive care and a normal environment. C. Palliative care focuses on offering support and a normal environment as the dying process occurs. D. CORRECT: Palliative care focuses on the process of dying and grieving, which includes using therapeutic communication.

A nurse is caring for an infant who needs otic medication. Which of the following is an appropriate action for the nurse to take? A. Hold the infant in an upright position. B. Pull the pinna downward and straight back. C. Hyperextend the infant's neck. D. Ensure that the medication is cool.

A. Position the infant supine or prone for administration of otic medication. B. CORRECT: Pulling the pinna downward and straight back will straighten the ear canal to allow medication to flow into the ear. C. Hyperextending the infant's neck could occlude the airway and should not be performed during otic medication administration. D. Allowing the otic medication to warm up to room temperature is recommended to provide atraumatic care

A nurse on a pediatric unit is caring for a toddler. Which of the following behaviors is an effect of hospitalization? (Select all that apply.) A. Believes the experience is a punishment B. Experiences separation anxiety C. Displays intense emotions D. Exhibits regressive behaviors E. Manifests disturbance in body image

A. Preschool children believe hospitalization is a punishment. B. CORRECT: Separation anxiety is a potential effect of hospitalization in a toddler. C. CORRECT: Intense emotions are a potential effect of hospitalization in a toddler. D. CORRECT: Behavior regression is a potential effect of hospitalization in a toddler. E. Body image disturbances can be seen in adolescents who are hospitalized.

A nurse is caring for a preschooler. Which of the following is an expected behavior of a preschool‑age child? A. Describing manifestations of illness B. Relating fears to magical thinking C. Understanding cause of illness D. Awareness of body functioning

A. Preschool‑age children have limited ability to describe manifestations of illness. B. CORRECT: Preschool‑age children are egocentric and relate fears to magical thinking. C. Preschool‑age children have limited understanding of cause‑and‑effect relationship, but understand what illness feels like. D. Awareness of body functioning is a behavior of an adolescent.

A nurse is teaching a class about puberty in boys. Which of the following should the nurse include as the first manifestation of sexual maturation? A. Pubic hair growth B. Vocal changes C. Testicular enlargement D. Facial hair growth

A. Pubic hair appears during early puberty, but is not the first manifestation of sexual maturation in males. B. Vocal changes occur after the appearance of pubic hair, typically in early to midpuberty, and are not the first manifestation of sexual maturation in males. C. CORRECT: Testicular enlargement is the first manifestation of sexual maturation in males. D. Facial hair growth typically appears about 2 years after pubic hair, and is not the first manifestation of sexual maturation in males

A nurse is preparing an education program for a group of parents of preschool-age children about promoting optimum nutrition. Which of the following information should the nurse include in the teaching? A. Saturated fats should equal 20% of total daily caloric intake. B. Average calorie intake should be 1,800 calories per day. C. Daily intake of fruits and vegetables should total 2 servings. D. Healthy diets include a total of 8 g protein each day.

A. Saturated fats should be less than 10% of total caloric intake. B. CORRECT: Preschool-age children should consume an average of 1,800 calories/day. C. Preschool-age children should consume a total of 5 servings of fruits and vegetables per day. D. Healthy diets include 13 to 19 g protein each day.

A nurse is teaching a group of parents about separation anxiety. Which of the following information should the nurse include in the teaching? A. It is often observed in the school‑age child. B. Detachment is the stage exhibited in the hospital. C. It results in prolonged issues of adaptability. D. Kicking a stranger is an example

A. Separation anxiety is commonly observed in the toddler. B. The detachment stage is rarely seen in the hospital setting. C. Children are adaptable and permanent issues are rare. D. CORRECT: Physical aggression toward strangers is a behavior seen in the protest stage of separation anxiety.

A nurse is caring for an adolescent whose mother expresses concerns about her child sleeping such long hours. Which of the following conditions should the nurse inform the mother as requiring additional sleep during adolescence? A. Sleep terrors B. Rapid growth C. Elevated zinc levels D. Slowed metabolism

A. Sleep terrors occur most often in preschool‑age children, and do not contribute to the adolescent's need for additional sleep. B. CORRECT: Rapid growth during the adolescent years results in the need for additional sleep. C. Zinc levels do not typically elevate during the adolescent years, and do not contribute to the adolescent's need for additional sleep. Zinc is often identified as deficient due to inadequate dietary intake during adolescence. D. An increased metabolism contributes to the adolescent's need for additional sleep.

A nurse is providing education about introducing new foods to the parents of a 4-month-old infant. The nurse should recommend that the parents introduce which of the following foods first? A. Strained yellow vegetables B. Iron-fortified cereals C. Pureed fruits D. Whole milk

A. Strained yellow vegetables are not the best source of needed nutrients and should not be the first food introduced. B. CORRECT: Iron-fortified cereals are the first solid food introduced due to the high iron content. The order of introducing solid foods after this is variable. C. Pureed fruits are not the best source of needed nutrients and should not be the first food introduced. D. Whole milk is not the best source of needed nutrients and should not be the first food introduced.

A nurse is preparing to administer the varicella vaccine to an adolescent. Which of the following questions should the nurse ask to determine whether there is a contraindication to administering the vaccine? A. "Do you have an allergy to eggs?" B. "Have you ever had encephalopathy following immunizations?" C. "Are you currently taking corticosteroid medication?" D. "Have you ever had an anaphylactic reaction to yeast?"

A. T he varicella vaccine is contraindicated for clients who have an allergy to gelatin or neomycin. B. DTaP vaccine is contraindicated for clients who have a history of encephalopathy within 7 days following prior doses of the vaccine. C. CORRECT: Varicella vaccine is contraindicated for clients who have been taking corticosteroids or other medications that affect the immune system for 2 weeks or longer. D. HepB vaccine is contraindicated for clients who have had an anaphylactic reaction to yeast.

A nurse is completing a pain assessment of an infant. Which of the following pain scales should the nurse use? A. FACES B. FLACC C. Oucher D. Non‑communicating children's pain checklist

A. The FACES pain assessment scale is recommended for children 3 years or older. B. CORRECT: The FLACC pain assessment scale is recommended for infants and children between 2 months and 7 years of age. C. The Oucher pain assessment scale is recommended for children between the ages of 3 and 13 years. D. The non‑communicating children's pain checklist is recommended for non‑communicating children between the ages of 3 and 18 years.

A nurse is assessing a 6‑month‑old infant. Which of the following reflexes should the infant exhibit? A. Moro B. Plantar grasp C. Stepping D. Tonic neck

A. The Moro reflex is exhibited by infants from birth to the age of 4 months. B. CORRECT: The plantar grasp is exhibited by infants from birth to the age of 8 months. C. The stepping reflex is exhibited by infants from birth to the age of 4 weeks. D. The tonic neck reflex is exhibited by infants from birth to the age of 3 to 4 months.

A nurse is providing teaching to the parent of a preschool-age child about methods to promote sleep. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will sleep in the bed with my child if she wakes up during the night." B. "I will let my child stay up an additional 2 hours on weekend nights." C."I will let my child watch television for 30 minutes just before bedtime each night." D."I will keep a dim lamp on in my child's room during the night."

A. The child should not be allowed to sleep in the same bed as the parent. B. The parent should maintain a consistent bedtime routine and avoid allowing the child to stay up past a reasonable hour. C. Watching television prior to bed can cause the child to resist and delay sleep. D. CORRECT: Leaving a light on in the child's room is an appropriate method to promote sleep for a preschool-age child.

A nurse is preparing to administer an intramuscular (IM) injection to a child. Which of the following muscle groups is contraindicated? A. Deltoid B. Ventrogluteal C. Vastus lateralis D. Dorsogluteal

A. The deltoid muscle can be used once developed for IM injections in children for medication containing up to 1 mL fluid. B. The ventrogluteal muscle can be used for IM injections in children for medication containing up to 2 mL fluid. C. The vastus lateralis muscle can be used for intramuscular injections in children for medication containing up to 2 mL fluid. D. CORRECT: The dorsogluteal site has major nerves and blood vessels and is not a recommended site for IM injections for children.

A nurse manager on a pediatric floor is preparing an education program on working with families for a group of newly hired nurses. Which of the following should the nurse include when discussing the developmental theory? A. Describes that stress is inevitable B. Emphasizes that change with one member affects the entire family C. Provides guidance to assist families adapting to stress D. Defines consistencies in how families change

A. The family stress theory describes that stress is inevitable. B. The family systems theory emphasizes that change with one member affects the entire family. C. The family stress theory provides guidance to assist families adapting to stress. D. CORRECT: The nurse should include that the developmental theory defines consistencies in how families change.

A nurse is conducting a well-baby visit with a 4-month-old infant. Which of the following immunizations should the nurse plan to administer to the infant? (Select all that apply.) A. Measles, mumps, rubella (MMR) B. Polio (IPV) C. Pneumococcal vaccine (PCV) D. Varicella E. Rotavirus vaccine (RV)

A. The first MMR vaccine is given between the ages of 12 and 15 months. B. CORRECT: The nurse should administer an IPV vaccine to a 4-month-old infant. C. CORRECT: The nurse should administer a PCV vaccine to a 4 month-old infant. D. The first varicella vaccine is given at a minimum age of 12 months. E. CORRECT: The nurse should administer an RV vaccine to a 4-month-old infant.

A nurse is planning to administer the influenza vaccine to a toddler. Which of the following actions should the nurse take? A. Administer subcutaneously in the abdomen. B. Use a 20-gauge needle. C. Divide the medication into two injections. D. Place the child in the supine position.

A. The influenza vaccination is administered IM. B. A 22- to 25-gauge needle is recommended for IM injections. C. The total volume of the influenza vaccination is 0.5 mL, which can be administered in the vastus lateralis. D. CORRECT: The vastus lateralis is recommended for administering IM medications. Placing the toddler in a supine position is the appropriate action for the nurse to take.

A nurse is assessing a child's ears. Which of the following is an expected finding? A. Light reflex is located at the 2 o'clock position. B. Tympanic membrane is red in color. C. Bony landmarks are not visible. D. Cerumen is present bilaterally.

A. The light reflex should be located around the 5 or 7 o'clock position. B. The tympanic membrane should be a pearly pink, or gray color. C. Bony landmarks should be visible. D. CORRECT: The presence of cerumen bilaterally is an expected finding.

A nurse is performing a developmental screening on an 18 month old. Which of the following skills should the toddler be able to perform? (Select all that apply.) A. Build a tower with six blocks B. Throw a ball overhand C. Walk up and down stairs D. Draw circles E. Use a spoon without rotation

A. The toddler should build a tower with six blocks at the age of 2 years. B. CORRECT: An 18 month old should be able to throw a ball overhand. C. The toddler should be able to walk up and down stairs by placing both feet on each step at the age of 2 years. D. The toddler should be able to draw circles at the age of 2½ years. E. CORRECT: An 18 month old should be able to use a spoon without rotation.

A nurse is assessing a 2½-year-old toddler at a well-child visit. Which of the following findings should the nurse report to the provider? A. Height increased by 7.5 cm (3 in) in the past year. B. Head circumference exceeds chest circumference. C. Anterior and posterior fontanels are closed. D. Current weight equals four times the birth weight.

A. Toddler height should increase by 7.5 cm (3 in) each year. Therefore, the nurse should not report this finding to the provider. B. CORRECT: The head and chest circumference should be equal by 1 to 2 years of age, with the chest circumference continuing to increase in size until it exceeds the head circumference. Therefore, the nurse should report this finding to the provider. C. The posterior fontanel closes by the age of 6 to 8 weeks, and the anterior fontanel closes by 12 to 18 months. Therefore, the nurse should not report this finding to the provider. D. The current weight should be four times the birth weight at the age of 2½ years. Therefore, the nurse should not report this finding to the provider.

A nurse is teaching a parent of a preschool child about factors that affect the child's perception of death. Which of the following factors should the nurse include in the teaching? A. Preschool children have no concept of death. B. Preschool children perceive death as temporary. C. Preschool children often regress to an earlier stage of behavior. D. Preschool children experience fear related to the disease process.

A. Toddlers have no concept of death. B. CORRECT: Preschool children perceive death as temporary because they have no concept of time. C. Toddlers often regress to an earlier stage of behavior. D. School‑age children experience fear related to the disease process.

A nurse is providing teaching about dental care and teething to the parent of a 9-month-old infant. Which of the following statements by the parent indicates an understanding of the teaching? A. "I can give my baby a warm teething ring to relieve discomfort." B. "I should clean my baby's teeth with a cool, wet wash cloth." C."I can give Advil for up to 5 days while my baby is teething." D."I should place diluted juice in the bottle my baby drinks while falling asleep."

A.Teething pain can be relieved using frozen teething rings or an ice cube wrapped in a wash cloth. B. CORRECT: It is appropriate to use a cool, wet wash cloth for cleaning the infant's teeth. C. Ibuprofen (Advil) should not be used for more than 3 days. D. To prevent early childhood caries, infants should not be given bottles while falling asleep

EARS

Alignment: The top of the auricles should meet in an imaginary horizontal line that extends from the outer canthus of the eye. External ear ● The external ear should be free of lesions and nontender. ● The ear canal should be free of foreign bodies or discharge. ● Cerumen is an expected finding. Internal ear ● In infants and toddlers, pull the pinna down and back to visualize the tympanic membrane. ● In children older than 3 years of age, pull the pinna up and back to visualize. ● The ear canal should be pink with fine hairs. ● The tympanic membrane should be pearly pink, or gray. ● The light reflex should be visible. ● Umbo (tip of the malleolus) and manubrium (long process or handle) are the bony landmarks that should be visible. Hearing ● Newborns should have intact acoustic blink reflexes to sudden sounds. ● Infants should turn toward sounds. ● Older children can be screened by whispering a word from behind to see whether they can identify the word.

GRIE F AND MOURNING

Anticipatory grief: when death is expected or a possible outcome Complicated grief: extends for more than 1 year following the loss ● Intense thoughts ● Distressing yearning ● Feelings of loneliness ● Distressing emotions and feelings ● Disturbances in personal activities, such as sleep ● Can require referral to an expert in grief counseling Parental grief ● Intense, long-lasting, and complex ● Secondary losses related to the death of the child, such as absence of hope and dreams, disruption of the family unit, loss of identity as a parent ● Differences in maternal and paternal grief Sibling grief ● Differs from adult/parental grief ● Reactions depend on age and developmental stage

infant abnormalhead findings

Any abnormal finding should have further evaluation. For the newborn who has swelling and ecchymosis of the presenting part of the head likely has what is called caput succedaneum. This area feels soft and may extend across suture lines. It usually resolves on its own in the first few days of life. Another head abnormality in newborns is a cephalhematoma. Caused by a subperiosteal hemorrhage, it usually reabsorbs within the first few weeks of life without treatment. The soft, spongy hemorrhage is usually only over one bone.

Infants and children of certain ethnicities who are dark-skinned or Asian may have Mongolian spots.

Assess for these bluish-gray macular areas on the sacrum or buttocks. These spots usually fade over the first year. It is important to recognize Mongolian spots as such and not mistake them for bruises. Café au lait spots are another skin color variation common in infants. They are usually large round or oval patches that are light brown in color and are a normal finding unless they are larger than 1.5 cm and there are more than 6 present. This finding requires further evaluation.

Pain Management

Assessment of pain depends on the child's cognitive, emotional, and physical development. Atraumatic care is the use of interventions that minimize or eliminate physical and psychological distress. Pain is managed by atraumatic, nonpharmacological, and pharmacological interventions.

Marijuana exposure

Associated with a decrease in newborn birth weight and length, fetal growth

Extended family:

At least one parent, one or more children, and other individuals (might not be related)

Blended family (also called reconstituted):

At least one stepparent, stepsibling, or half-sibling

Scoliosis test for adolescents

Between 10 and 12 years of age for females and ages 13 to 14 for males, you should begin to screen your patient for scoliosis using the forward bend test

Intravenous NURSING CONSIDERATIONS

Bolus ● Rapid pain control in approximately 5 min ● Use for medications such as morphine, hydromorphone ● Continuous: provides steady blood levels Patient-controlled analgesia (PCA) ● Self-administration of pain medication ● Can be basal, bolus, or combination ● Has lockouts to prevent overdosing Family-controlled analgesia ● Same concept as PCA ● Parent or caregiver manages the child's pain

A nurse is preparing to administer LAIV, HPV2, and MenACWY to a 12 year-old female client. Use the AT I Active Learning Template: Medication to complete this item. COMPLICATIONS: Include adverse effects for each vaccine.

COMPLICATIONS LAIV ●● Allergic reaction ●● Vomiting and/or diarrhea ●● Cough ●● Fever ●● Headache ●● Myalgia ●● Nasal congestion/runny nose HPV2 ●● Allergic reaction ●● Redness, swelling and tenderness at the injection site ●● Temperature of 37.7° C (99.9° F) or higher ●● Headache ●● Fatigue ●● Nausea, vomiting, abdominal pain ●● Myalgia ●● Fainting (shortly after receiving the vaccine) MenACWY ●● Allergic reaction ●● Redness and tenderness at the injection site ●● Fever

Increased intracranial pressure

Caused by shunt malformation or hydrocephalus MANIFESTATIONS: High‑pitched cry, lethargy, vomiting, bulging fontanels and/or widening cranial suture lines, increased head circumference NURSING ACTIONS ●● Prepare for surgery for shunt or shunt revision. ●● Use gentle movements when performing ROM exercises. ●● Minimize environmental stressors (noise, lights, frequent visitors). ●● Assess and manage pain. PARENT EDUCATION: Teach the parents manifestations of shunt malfunction and hydrocephalus and to report them

IMM UNIZATIO NS

Centers for Disease Control and Prevention (CDC) recommendations for healthy adolescents 13 to 18 years old (www.cdc.gov) include catch-up doses of any recommended immunizations not received at 11 to 12 years old. ● Yearly seasonal influenza vaccine: Trivalent inactivated influenza vaccine or live, attenuated influenza vaccine by nasal spray. ● 16 to 18 years: Meningococcal (MCV4) booster is recommended if first dose was received between the ages of 13 and 15 years. A booster dose is not needed if the first dose is received at age 16 or older

THORAX AND LUNGS

Chest shape ● Infants: Shape is almost circular with anteroposterior diameter equaling the transverse or lateral diameter. ● Children and adolescents: The transverse diameter to anteroposterior diameter changes to 2:1. Ribs and sternum: More soft and flexible in infants; symmetric and smooth, with no protrusions or bulges Movement ● Symmetric, no retractions ● Infants: Irregular rhythms are common. ● Children younger than 7 : More abdominal movement is seen during respirations. Breath sounds ● Inspiration is longer and louder than expiration ● Vesicular, or soft, swishing sounds, are heard over most of the lungs Breasts ● Newborns: Breasts can be enlarged during the first few days. ● Children and adolescents: Nipples and areolas are darker pigmented and symmetric. ◯ Females: Breasts typically develop between 10 to 14 years of age. The breasts should appear asymmetric, have no masses, and be palpable. ◯ Males can develop gynecomastia, which is unilateral or bilateral breast enlargement that occurs during puberty

When the child is a toddler.

Children in this age group are concrete thinkers who interpret your statements literally Toddlers love dolls and puppets, so incorporate these props into the examination, demonstrating each step on the doll and letting the toddler practice on the doll. It is very helpful to let a toddler touch and play with the equipment before performing the examination. If the child remains uncooperative despite your best efforts, perform the examination as quickly as possible.

complications of newborns and infants.

Complications include phenylketonuria (PKU), meningocele, necrotizing enterocolitis (NEC), respiratory distress syndrome (RDS), congenital hypothyroidism, substance‑exposed infants, hyperbilirubinemia, chromosomal abnormalities, neonatal seizures, complications of premature infants, newborn sepsis, failure to thrive (FTT ), and plagiocephaly.

Orthopedic issues

Corrections of associated potential problems such as clubfoot, scoliosis, and other malformations of the feet and legs NURSING ACTIONS ●● Monitor for manifestations of infection. ●● Administer pain medications. ●● Prepare the newborn and family for surgery if needed. ●● Provide cast care if cast is present. ●● Monitor for neurosensory deficits. PARENT EDUCATION ●● Educate the parents about findings of infection. ●● Educate the parents about cast and splint care if necessary.

A nurse is reviewing pain assessment tools with a group of newly licensed nurses. What should the nurse include in the teaching? DESCRIPTION OF SKILL: Describe four pain tools used with pediatric clients.

DESCRIPTION OF SKILL FLACC (2 months to 7 years) ● Pain rated on a scale of 0 to 10. ● Assess behaviors of the child. ● Face (F) ◯ 0: Smile or no expression ◯ 1: Occasional frown or grimace, withdrawn ◯ 2: Frequent or constant frown, clenched jaw, quivering chin ● Legs (L) ◯ 0: Relaxed or normal position ◯ 1: Uneasy, restless, tense ◯ 2: Kicking or legs drawn up ● Activity (A) ◯ 0: Lying quietly, moves easily, normal position ◯ 1: Squirming, shifting, tense ◯ 2: Arched, ridged, or jerking ● Cry (C) ◯ 0: No cry ◯ 1: Moans or whimpers, occasional complaints ◯ 2: Crying, screaming, sobbing, frequent complaints ● Consolability (C) ◯ 0: Content or relaxed ◯ 1: Reassured by occasional touching or hugging. Able to distract ◯ 2: Difficult to console or comfort FACES (3 years and older) ● Pain rated on a scale of 0 to 5 using a diagram of six faces. ● Substitute 0, 2, 4, 6, 8, 10 for 0 to 5 to convert to the 0 to 10 scale. ● Explain each face to the child. ◯ 0: No hurt ◯ 1: Hurts a bit ◯ 2: Hurts a little more ◯ 3: Hurts even more ◯ 4: Hurts a whole lot ◯ 5: Hurts worst ● Ask the child to choose a face that best describes how they are feeling Oucher (3 to 13 years) ● Pain rated on a scale of 0 to 5 using six photographs. ● Substitute 0, 2, 4, 6, 8, 10 for 0 to 5 to convert to the 0 to 10 scale. ● Have the child organize the photographs in order of no pain to the worst pain. ◯ 0: No hurt ◯ 1: Hurts a bit ◯ 2: Hurts a little more ◯ 3: Hurts even more ◯ 4: Hurts a whole lot ◯ 5: Hurts worst ● Ask the child to choose a picture that best describes how they are feeling. Numeric scale (5 years and older) ● Pain rated on a scale of 0 to 10. ● Explain to the child that 0 means "no pain" and 10 means "worst pain." ● Have the child verbally report a number or point on a visual scale their pain level. Non‑communicating children's pain checklist (3 to 18 years) ● Behaviors are observed for 10 min. ● Six subcategories are scored on a scale 0 to 3. ● Subcategories are vocal, social, facial, activity, body and limbs, and physiological, each with observable behaviors to be scored. ◯ 0: Not at all ◯ 1: Just a little ◯ 2: Fairly often ◯ 3: Very often ● Cutoff scores: ◯ 11 or more indicates moderate to severe pain. ◯ 6 to 10 indicates mild pain.

A nurse is conducting a well-child visit with a 2-year-old toddler. DEVELOPMENTAL STAGE: Identify the toddler's developmental stage according to Piaget and Erikson. NUTRITION: List three concepts to include in teaching with the family. INJURY PREVENTION: Identify two injury prevention methods to include in teaching with the family for each of the following categories. ● Bodily harm ● Drowning ● Burns ● Falls

DEVELOPMENTAL STAGE ● Piaget: Preoperational stage ● Erikson: Autonomy vs. shame and doubt NUTRITION ● May switch from whole milk to low fat milk after the age of 2 years. ● Trans fatty acids and saturated fats should be avoided. ● Diet should include 1 cup of fruit daily. ● Limit fruit juice to 4 to 6 oz per day. ● Cut food into small, bite-size pieces to prevent choking. ● Do not allow drinking or eating during play activities or while lying down. INJURY PREVENTION ● Bodily harm ◯ Keep sharp objects out of reach. ◯ Lock firearms in a cabinet or box. ◯ Teach toddler stranger safety. ◯ Do not leave toddler unattended with animals. ● Drowning ◯ Do not leave toddler unattended in bathtub. ◯ Keep toilet lids closed. ◯ Begin teaching toddler water safety and to swim. ◯ Keep bathroom doors closed. ● Burns ◯ Check bath water temperature prior to toddler contact with water. ◯ Set hot water heaters to less than 49° C (120° F) . ◯ Keep pot handles pointed to back of stove when cooking. ◯ Cover electrical outlets. ◯ Keep working smoke detectors in the home. ◯ Apply sunscreen when toddler will be outside. ● Falls ◯ Keep doors and windows locked. ◯ Place crib mattresses in lowest position with rails all the way up. ◯ Use safety gates at the top and bottom of stairs.

A nurse is preparing an educational program for a group of parents of infants. DEVELOPMENTAL STAGE: Identify the infant's developmental stage according to Piaget and Erikson. COGNITIVE DEVELOPMENT: List two cognitive developmental tasks the infant should accomplish in the first year of life. AGE-APPROPRIATE ACTIVITIES: List five activities appropriate for infants. INJURY PREVENTION: Identify two injury prevention methods in each of the following categories. ● Aspiration ● Poisoning ● Drowning ● Suffocation

DEVELOPMENTAL STAGE ● Piaget: Sensorimotor stage ● Erikson: Trust vs. mistrust COGNITIVE DEVELOPMENT ● Infants progress from reflexive to simple repetitive to imitative activities. ● Separation: Learning to separate themselves from other objects in the environment. ● Object permanence: Understanding that an object still exists when it is out of view. ● Mental representation: Ability to recognize and use symbols. AGE-APPROPRIATE ACTIVITIES ● Rattles ● Soft stuffed toys ● Teething toys ● Nesting toys ● Playing pat-a-cake ● Playing with balls ● Reading books ● Mirrors ● Brightly colored toys ● Playing with blocks INJURY PREVENTION ● Aspiration ◯ Avoid small objects. ◯ Hold infant for feedings; do not prop bottles. ◯ Provide age-appropriate toys. ◯ Check clothing for hazards such as loose buttons. ● Poisoning ◯ Keep toxins and plants out of reach. ◯ Place safety locks on cabinets where cleaners/ chemicals are stored. ◯ Use a carbon monoxide detector in the home. ◯ Keep medications in childproof containers and out of reach. ● Drowning ◯ Do not leave unattended around any water source. ◯ Secure fencing around swimming pool. ◯ Keep bathroom door closed. ● Suffocation ◯ Avoid plastic bags. ◯ Ensure crib mattress fits snugly. ◯ Remove crib mobiles by 4 to 5 months of age. ◯ Keep pillows out of the crib. ◯ Place on back to sleep.

A nurse is providing anticipatory guidance to the parents of a school-age child. DEVELOPMENTAL STAGE: Identify the child's developmental stage according to Piaget and Erikson. PHYSICAL DEVELOPMENT: Identify three facts relevant to the child's physical development. NUTRITION: List three strategies the family can implement to reduce the risk of obesity

DEVELOPMENTAL STAGE ● Piaget: concrete operations ● Erikson: industry vs. inferiority PHYSICAL DEVELOPMENT ● Will gain 2 to 3 kg (4.4 to 6.6 lb) per year. ● Will grow about 5 cm (2 in) per year. ● Bladder capacity is variable with each child. ● Immune system improves. ● Bones continue to ossify. NUTRITION ● Avoid using food as a reward. ● Emphasize physical activity. ● Ensure a balanced diet is consumed. ● Teach children to select healthy foods and snacks. ● Avoid eating fast foods frequently. ● Avoid skipping meals. ● Model healthy behaviors

A nurse is preparing an educational program for a group of parents of adolescents. DEVELOPMENTAL STAGE: Identify adolescent developmental stages according to Piaget and Erikson. COGNITIVE DEVELOPMENT: List five cognitive developmental tasks the adolescent should accomplish. INJURY PREVENTION: Identify three injury prevention methods in each of the following categories. ● Bodily harm ● Motor vehicle injuries

DEVELOPMENTAL STAGE ● Piaget: formal operations ● Erikson: identity vs. role confusion COGNITIVE DEVELOPMENT ● Able to think through more than two categories of variables concurrently ● Capable of evaluating the quality of own thinking ● Able to maintain attention for longer periods of time ● Highly imaginative and idealistic ● Increasingly capable of using formal logic to make decisions ● Think beyond current circumstances ● Understand how the actions of an individual influence others INJURY PREVENTION ● Bodily injury ◯ Keep firearms unloaded and in a locked cabinet or box. ◯ Teach proper use of sporting equipment prior to use. ◯ Insist on helmet use and/or pads when roller skating, skateboarding, bicycling, riding scooters, skiing, and snowboarding. ◯ Be aware of changes in mood. Continuously monitor adolescents at risk for self‑harm. ● Motor vehicle injuries ◯ Encourage attendance at drivers' education courses. ◯ Emphasize the need for adherence to seat belt use. ◯ Discourage use of cell phones while driving and enforce laws regarding use. ◯ Teach the dangers of combining substance abuse with driving. ● Role model desired behavior.

Deep tendon reflexes

Deep tendon reflexes should demonstrate the following. ● Partial flexion of the lower arm at the biceps tendon ● Partial extension of the lower arm at the triceps tendon ● Partial extension of the lower leg at the patellar tendon ● Plantar flexion of the foot at the Achilles tendon

NONPHARMACOLOGICAL MEA SURES

Distraction ● Use play, radio, a computer game, or a movie. ● Tell jokes or a story to the child. Relaxation ● Hold or rock the infant or young child. ● Assist older children into a comfortable position. ● Assist with breathing techniques. Guided imagery ● Assist the child in an imaginary experience. ● Have the child describe the details. Positive self-talk: Have the child say positive things during a procedure or painful episode. Behavioral contracting ● Use stickers or tokens as rewards. ● Give time limits for the child to cooperate. ● Reinforce cooperation with a reward. Containment ● Swaddle the infant. ● Place rolled blankets around the child. ● Maintain proper positioning. Nonnutritive sucking ● Offer pacifier with sucrose before, during, and after painful procedures. ● Offer nonnutritive sucking during episodes of pain. Kangaroo care: skin-to-skin contact between infants and parents Complementary and alternative medicine ● Offer foods, vitamins, or supplements. ● Offer massage or chiropractic options. ● Review energy-based treatments such as magnets. ● Discuss mind-body techniques such as hypnosis, homeopathy, or naturopathy.

Infant reflexes

EXPECTED FINDING EXPECTED AGE SUCKING AND ROOTING REFLEXES Elicited by stroking an infant's cheek or the edge of an infant's mouth. The infant turns her head toward the side that is touched and starts to suck. Birth to 4 months PALMAR GRASP Elicited by placing an object in an infant's palm The infant grasps the object. Birth to 3 months PLANTAR GRASP Elicited by touching the sole of an infant's foot The infant's toes curl downward. Birth to 8 months MORO REFLEX Elicited by allowing the head and trunk of an infant in a semi‑sitting position to fall backward to an angle of at least 30° The infant's arms and legs symmetrically extend, then abduct while fingers spread to form C shape. Birth to 4 months STARTLE REFLEX Elicited by clapping hands or by a loud noise The newborn abducts arms at the elbows, and the hands remain clenched. Birth to 4 months TONIC NECK REFLEX (FENCER POSITION) Elicited by turning an infant's head to one side The infant extends the arm and leg on that side and flexes the arm and leg on the opposite side. Birth to 3 to 4 months BABINSKI REFLEX Elicited by stroking the outer edge of the sole of an infant's foot up toward the toes The infant's toes fan upward and out. Birth to 1 year STEPPING Elicited by holding an infant upright with his feet touching a flat surface The infant makes stepping movements. Birth to 4 weeks

PSYCHOSO CIAL DE VELO PMENT

Erikson: autonomy versus shame and doubt ● Independence is paramount for toddlers, who are attempting to do everything for themselves. ● Toddlers often use negativism, or negative responses, as they begin to express their independence. ● Ritualism, or maintaining routines and reliability, provides a sense of comfort for toddlers as they begin to explore the environment beyond those most familiar to them.

PSYCHOSOCIAL DEVELOPMENT

Erikson: trust vs. mistrust (birth to 1 year) ● Achieving this task is based on the quality of the caregiver-infant relationship and the care received by the infant. ● The infant begins to learn delayed gratification. Failure to learn delayed gratification leads to mistrust. ● Trust is developed by meeting comfort, feeding, stimulation, and caring needs. ● Mistrust develops if needs are inadequately or inconsistently met, or if needs are continuously met before being vocalized by the infant.

EYES

Eyebrows should be symmetric and evenly distributed from the inner to the outer canthus. Eyelids should close completely and open to allow the lower border and most of the upper portion of the iris to be seen. Eyelashes should curve outward and be evenly distributed with no inflammation around any of the hair follicles. Conjunctiva ● Palpebral is pink. ● Bulbar is transparent. Lacrimal apparatus is without excessive tearing, redness, or discharge. Sclera should be white. Corneas should be clear. Pupils should be ● Round ● Equal in size ● Reactive to light ● Accommodating Irises should be round with the permanent color manifesting around 6 to 12 months of age. Visual acuity ● Can be difficult to assess in children younger than 3 years of age. ● Visual acuity in infants can be assessed by holding an object in front of the eyes and checking to see whether the infant is able to fix on the object and follow it. ● Use the tumbling E or HOTV test to check visual acuity of children who are unable to read letters and numbers. ● Older children should be tested using a Snellen chart or symbol chart. Peripheral visual fields should be ● Upward 50° ● Downward 70° ● Nasally 60° ● Temporally 90° Extraocular movements ● Might not be symmetric in newborns. ● Corneal light reflex should be symmetric. ● Cover/uncover test should demonstrate equal movement of the eyes. ● Six cardinal fields of gaze should demonstrate no nystagmus. Color vision ● Should be assessed using the Ishihara color test or the Hardy-Rand-Rittler test. ● The child should be able to correctly identify shapes, symbols, or numbers. Internal exam ● Red reflex should be present in infants. ● Arteries, veins, optic discs, and maculae can be visualized in older children and adolescents.

Failure to thrive

FTT is inadequate growth resulting from the inability to obtain or use calories required for growth. It is usually described in an infant who falls below the 5th percentile for weight (and possibly for height), or who has a pattern of consistent weight loss. ●● Inadequate caloric intake ●● Inadequate absorption ●● Increased metabolism ●● Defective utilization

EXPECTED FIN DINGS

Findings vary based on type of seizure. Clonic: Slow rhythmic jerking movements; one to three movements per second ●● Focal: Involves face, or upper or lower extremities on one side of the body; can involve neck or trunk; newborn is conscious during seizure ●● Multifocal: Can migrate randomly from one part of the body to another; movements can start at different times Tonic: Extension, stiffening movements ●● Generalized: Extension of all limbs; upper limbs maintain a stiffly flexed position ●● Focal: Sustained posturing of one limb; asymmetric posturing of trunk or neck Subtle: Most common in premature newborns, often overlooked ●● Horizontal eye deviation, repetitive blinking, fluttering of eyelids, staring ●● Sucking or other oral/buccal/tongue movements ●● Arm movements resembling swimming or rowing ●● Leg movements resembling pedaling ●● Apnea is common Myoclonic: Rapid jerks that involve flexor muscle groups ●● Focal: Involves upper extremity flexor muscles; no changes in EEG ●● Multifocal: Asynchronous twitching of several parts of the body; no changes in EEG ●● Generalized: Bilateral jerks of upper and lower limbs; associated with EEG discharges

Cerebellar function (children and adolescents)

Finger to nose test: Rapid coordinated movements Heel to shin test: Able to run the heel of one foot down the shin of the other leg while standing Romberg test: Able to stand with slight swaying while eyes are closed

Normal breath sounds vary according to the area of the lungs auscultated.

For example, anteriorly over the trachea, you should hear a loud, high-pitched, hollow sound called a bronchial breath sound. It is abnormal to hear this sound over peripheral lung tissue, that is, away from the trachea and the large bronchi. Over the mainstem bronchi, which are relatively large-diameter airways, you should hear medium-pitched and quieter sounds, called bronchovesicular breath sounds. Note that the areas over which bronchovesicular breath sounds are expected are small, but are present both anteriorly and posteriorly. Over most of the lung tissue, you should hear soft, fine, breezy, low-pitched sounds called vesicular breath sounds. They are normally heard over peripheral lung tissue.

Infant Skin inspection

For light-skinned infants, the overall color of the skin should be pink. Skin folds may appear red or irritated, though, since these areas are often moist. Infants, especially during the newborn period, might have tiny white papules called milia on the cheeks, forehead, nose, and chin. Let the parents know that milia will go away on their own, and encourage them not to rub vigorously or break the intact skin. Another irregularity you might note on the forehead or the back of the neck is a "stork bite," a telangiectatic nevi that is irregularly shaped and red or pink. This type of lesion typically fades during the first year. Lastly, note the condition of the peri-anal skin in the diaper area for any redness, rashes, or open lesions.

Motor skill development by a ge

GROSS MOTOR SKILLS FINE MOTOR SKILLS 15 MONTHS Walks without help Creeps up stairs Uses a cup well Builds a tower of two blocks 18 MONTHS Runs clumsily; falls often Throws a ball overhand Jumps in place with both feet Pulls and pushes toys Manages a spoon without rotation Turns pages in a book, two or three at a time Builds tower of three or four blocks 2 YEARS Walks up and down stairs by placing both feet on each step Builds a tower of six or seven blocks Turns pages of books one at a time 2.5 YEARS Jumps across the floor and off a chair or step using both feet Stands on one foot momentarily Takes a few steps on tiptoe Draws circles Has good hand-finger coordination

Motor skill development by age

GROSS MOTOR SKILLS FINE MOTOR SKILLS 1 MONTH Demonstrates head lag Has a strong grasp reflex 2 MONTHS Lifts head off mattress when prone Holds hands in an open position Grasp reflex fading 3 MONTHS Raises head and shoulders off mattress when prone Only slight head lag No longer has a grasp reflex Keeps hands loosely open 4 MONTHS Rolls from back to side Grasps objects with both hands 5 MONTHS Rolls from front to back Uses palmar grasp dominantly 6 MONTHS Rolls from back to front Holds bottle 7 MONTHS Bears full weight on feet Sits, leaning forward on both hands Moves objects from hand to hand 8 MONTHS Sits unsupported Begins using pincer grasp 9 MONTHS Pulls to a standing position Creeps on hands and knees instead of crawling Has a crude pincer grasp Dominant hand preference evident 10 MONTHS Changes from a prone to a sitting position Grasps rattle by its handle 11 MONTHS Cruises or walks while holding onto something Walks with one hand held Places objects into a container Neat pincer grasp 12 MONTHS Sits down from a standing position without assistance Tries to build a two-block tower without success Can turn pages in a book

Subcutaneous

Give anywhere there is adequate subcutaneous tissue. Common sites are the lateral aspect of the upper arm, abdomen, and anterior thigh. ● Inject volumes of less than 0.5 mL. ● Use a 1 mL syringe with a 26- to 30-gauge needle. ● Insert at a 90° angle. Use a 45° angle for children who are thin. ● Check policy for aspiration practices.

toddler head

Head circumference should be measured annually until about 3 years of age to determine whether or not growth is adequate for proper brain development. A larger-than-normal head is associated with hydrocephalus, while a smaller-than-normal head is associated with microcephaly or various genetic factors.

Infants (2 days -1 year) GENERAL MEASUREMENTS OF FULL-TERM NEWBORN

Head circumference: The head circumference averages between 33 and 35 cm (13 and 14 in). Crown to rump length: The crown to rump length is 31 to 35 cm (12.5 to 14 in), approximately equal to head circumference. Length: Head to heel length averages 48 to 53 cm (19 to 21 in). Weight: Newborn weight averages 2,700 to 4,000 g (6 to 9 lb). Newborns will lose up to 10% of their birth weight by 3 to 4 days of age. This is due to fluid shifts, loss of meconium, and limited intake, especially in infants who are breastfed. The birth weight is usually regained by the tenth to fourteenth day of life, depending on the feeding method used.

FAMILY ASSESSMENT

History: Medical history for parents, siblings, and grandparents Structure: Family members (mother, father, son) Developmental tasks: Tasks a family works on as the child grows (parents with a school-age child helping her to develop peer relations) Family characteristics: Cultural, religious, and economic influences on behavior, attitudes, and actions Family stressors: Expected (birth of a child) and unexpected (illness, divorce, disability, or death of a family member) events that cause stress Environment: Availability of and family interactions with community resources Family support system: Availability of extended family, work and peer relationships, as well as social systems and community resources to assist the family in meeting needs or adapting to a stressor

Palpation:

Hypotonic or lax muscle tone is called flaccidity, while increased or hypertonic muscle tone is spasticity.

Cranial nerves: expected findings

INFANTS CHILDREN AND ADOLESCENTS I OLFACTORY Difficult to test Identifies smells through each nostril individually II OPTIC Looks at face and tracks with eyes Has intact visual acuity, peripheral vision, and color vision III OCULOMOTOR Blinks in response to light Has pupils that are reactive to light Has no nystagmus and PERRLA is intact IV TROCHLEAR Looks at face and tracks with eyes Has the ability to look down and in with eyes V TRIGEMINAL Has rooting and sucking reflexes Is able to clench teeth together Detects touch on face with eyes closed VI ABDUCENS Looks at face and tracks with eyes Is able to see laterally with eyes VII FACIAL Has symmetric facial movements Has the ability to differentiate between salty and sweet on tongue Has symmetric facial movements VIII ACOUSTIC Tracks a sound Blinks in response to a loud noise Does not experience vertigo Has intact hearing IX GLOSSOPHARYNGEAL Has an intact gag reflex Has an intact gag reflex Is able to taste sour sensations on back of tongue X VAGUS Has no difficulties swallowing Speech clear, no difficulties swallowing Uvula is midline XI SPINAL ACCESSORY Moves shoulders symmetrically Has equal strength of shoulder shrug against examiner's hands XII HYPOGLOSSAL Has no difficulties swallowing Opens mouth when nares are occluded Has a tongue that is midline Is able to move tongue in all directions with equal strength against tongue blade resistance

Beractant CLASSIFICATION: Lung surfactant

INTENDED EFFECT: It is prescribed for newborns who are premature and have RDS. It restores surfactant and improves respiratory compliance. NURSING CONSIDERATIONS ●● Perform a respiratory assessment including ABGs, respiratory rhythm, and rate and color before and after administration of agent. ●● Provide suction to the newborn prior to administration of the medication. ●● Assess endotracheal tube placement. ●● Avoid suctioning of the endotracheal tube for 1 hr after administration of the medication.

Phenobarbital CLASSIFICATION: Anticonvulsant

INTENDED EFFECT: It is prescribed to decrease CNS irritability and control seizures for newborns who are susceptible to seizures. NURSING CONSIDERATIONS ●● Assess IV site frequently. ●● Check for any medication incompatibilities. ●● Decrease environmental stimuli. ●● Cluster cares for newborns to minimize stimulation. ●● Swaddle the newborn to reduce self‑stimulation and protect the skin from abrasions. ●● Monitor and maintain fluids and electrolytes. ●● Administer frequent, small feedings of high‑calorie formula. The newborn can require gavage feedings. ●● Elevate the newborn's head during and following feedings, and burp the newborn to reduce vomiting and aspiration.

Communal family:

Individuals who share common ownership of property and goods, and exchange services without monetary consideration

Spine

Infants: Spines should be without dimples or tufts of hair. They should be midline with an overall C-shaped lateral curve. Toddlers appear squat with short legs and protuberant abdomens. Preschoolers appear more erect than toddlers. Children should develop the cervical, thoracic, and lumbar curvatures like that of adults. Adolescents should remain midline (no scoliosis noted).

Topical/transdermal NURSING CONSIDERATIONS

Lidocaine and prilocaine is available in a cream or gel. ● Used for any procedure in which the skin will be punctured (IV insertion, biopsy) 60 min prior to a superficial puncture and 2.5 hr prior to a deep puncture. ● Place an occlusive dressing over the cream after application. ● Prior to procedure, remove the dressing and clean the skin. Indication of an adequate response is reddened or blanched skin. ● Demonstrate to the child that the skin is not sensitive by tapping or scratching lightly. ● Instruct parents to apply medication at home prior to the procedure. Fentanyl ● Use for children older than 12 years of age. ● Use to provide continuous pain control. Onset of 12 to 24 hr and a duration of 72 hr. ● Use an immediate-release opioid for breakthrough pain. ● Treat respiratory depression with naloxone

MOUTH AND THROAT

Lips ● Darker pigmented than facial skin ● Smooth, soft, moist, and symmetric Gums ● Coral pink ● Tight against the teeth Mucous membranes ● Without lesions ● Moist, pink, smooth, and glistening Tongue ● Infants can have white coatings on their tongues from milk that can be easily removed. Oral candidiasis coating is not easily removed. ● Children and adolescents should have pink, symmetric tongues that they are able to move beyond their lips. Teeth ● Infants should have six to eight teeth by 1 year of age. ● Children and adolescents should have teeth that are white and smooth, and begin replacing the 20 deciduous teeth with 32 permanent teeth. Hard and soft palates: Intact, firm, and concave Uvula: Intact and moves with vocalization Tonsils ● Infants: Might not be able to visualize ● Children: Barely visible to prominent, same color as surrounding mucosa, Speech ● Infants: Strong cry ● Children and adolescents: Clear and articulate

LYMPH NODES

Lymph nodes should be nonpalpable. Lymph nodes that are small, palpable, nontender, and mobile can be an expected finding in children.

DIA GNOSTI C TESTS

MATERNAL TESTING DURING PREGNANCY ●● Elevated alpha‑fetoprotein levels in maternal serum ●● Chorionic villi sampling ●● Amniocentesis ●● Ultrasound NEWBORN TESTING ●● MRI ●● Ultrasound ●● CT scan ●● Neurologic evaluation

Traditional nuclear family:

Married couple and their biologic children (only full brothers and sisters)

Substance‑exposed infants

Maternal substance use during pregnancy consists of any use of alcohol or drugs. Intrauterine drug exposure can cause anomalies, neurobehavioral changes, and evidence of withdrawal in the neonate. These changes depend on the specific drug or combination of drugs used, dosage, route of administration, metabolism and excretion by the mother and her fetus, timing of exposure, and length of exposure.

RIS K FA CTO RS

Metabolic: Hyperglycemia, hypoglycemia, PKU, hypocalcemia, hypomagnesemia Toxic: Uremia, kernicterus Prenatal infection: Toxoplasmosis, syphilis, cytomegalovirus, herpes, hepatitis Postnatal infection: Bacterial or viral meningitis, sepsis, brain abscess Trauma during birth: Hypoxia, intracranial hemorrhage, subarachnoid or subdural hemorrhage, intraventricular hemorrhage Miscellaneous: Degenerative disease, narcotic withdrawal, stroke (fetal, perinatal, or neonatal), benign familial newborn seizures

PHYSI CAL ASSESSMENT FINDINGS

Monitor the neonate for abstinence syndrome (withdrawal) and increased wakefulness using the neonatal abstinence scoring system that assesses for and scores the following. ●● CNS: increased wakefulness, a high‑pitched, shrill cry, incessant crying, irritability, tremors, hyperactive with an increased Moro reflex, increased deep‑tendon reflexes, increased muscle tone, abrasions and/or excoriations on the face and knees, and convulsions ●● Metabolic, vasomotor, and respiratory: nasal congestion with flaring, frequent yawning, skin mottling, tachypnea greater than 60/min, sweating, and temperature greater than 37.2° C (99° F) or temperature greater than 38.3° C (101° F) ●● Gastrointestinal: poor feeding, regurgitation (projectile vomiting), diarrhea, and excessive, uncoordinated, and constant sucking

In infant: The nails should be smooth, pink, and convex. While inspecting the hands, be sure to assess the palmar creases.

Multiple creases across the palm are normal, whereas a single crease, called a simian crease, is abnormal and is associated with Down syndrome

A nurse is planning care for a client who is nearing the end of life. What interventions should the nurse include in the plan of care? NURSING INTERVENTIONS: Describe at least eight nursing interventions to be used.

NURSING INTERVENTIONS ● Allow an opportunity for anticipatory grieving, which affects the way a family will cope with the death of a child. ● Provide consistency among nursing staff caring for the client and family. ● Encourage parents to remain with the client. ● Attempt to maintain a normal environment. ● Communicate with the client honestly and respectfully. ● Encourage independence. ● Stay with the client as much as possible. ● Administer analgesics to control pain. ● Provide privacy. ● Soften lights. ● Offer soft music if desired. ● Assist with arranging religious or cultural rituals desired by the client and family. ● Assist the client with unfinished tasks. ● Provide support for the family and client.

A nurse is planning to initiate IV access for a toddler. What actions should the nurse plan to take? NURSING INTERVENTIONS: Describe 10 atraumatic care interventions.

NURSING INTERVENTIONS ● Decide to insert a peripherally inserted catheter before multiple peripheral attempts. ● Use a transilluminator to assist in vein location. ● Avoid terminology such as a "bee sting" or "stick." ● Attach extension tubing to decrease movement of the catheter. ● Use play therapy. ● Apply eutectic mixture of lidocaine and prilocaine (EM LA) to the site for 60 min prior to attempts. ● Keep equipment out of sight until procedure begins. ● Perform the procedure in a treatment room. ● Use nonpharmacologic therapies. ● Allow parents to stay if they prefer. ● Use therapeutic holding. ● Avoid using the dominant or sucking hand. ● Cover site with a colorful wrap. ● Swaddle infants. ● Offer nonnutritive sucking to infants before, during, and after the procedure

Methadone withdrawal

Neonatal abstinence syndrome: Increased incidence of seizures, sleep pattern disturbances, higher birth weights, and higher risk of sudden infant death syndrome (SIDS)

Heroin withdrawal

Neonatal abstinence syndrome: Low birth weight and small for gestational age (SGA), decreased Moro reflexes (rather than increased), jittery, hyperactive, and hypothermia or hyperthermia. The infant has a shrill persistent cry.

LA BORATO RY TESTS

Newborn metabolic screen: Blood spot analysis performed after the newborn has ingested a source of protein and usually within 2 days of birth. ●● Expected reference range of phenylalanine in newborns is 0.5 to 1 mg/dL. ●● Some states require a repeat newborn metabolic screen when the newborn is 1 to 2 weeks of age. Guthrie test: Confirms diagnosis when blood spot analysis is positive.

Newborn seizures

Newborn seizures are usually a manifestation of a serious underlying disease. The most common cause for newborn seizures is hypoxic‑ischemic encephalopathy (HIE), or cellular damage due to a hypoxic perinatal episode. ●● Newborn seizures are divided into four subtypes: clonic, tonic, myoclonic, and subtle. ●● Newborn seizures can be difficult to identify due to subtle manifestations. Seizures must be differentiated from normal newborn jitteriness and tremors. Newborns typically exhibit oral movements, oculomotor deviations and apnea during seizure activity.

RESPIRATIONS

Newborn to 1 year: 30 to 35/min 1 to 2 years: 25 to 30/min 2 to 6 years: 21 to 25/min 6 to 12 years: 19 to 21/min 12 years and older: 16 to 19/min

PULSE RATE

Newborn: 80 to 180/min (depending on activity) 1 week to 3 months: 80 to 220/min (depending on activity) 3 months to 2 years: 70 to 150/min (depending on activity) 2 to 10 years: 60 to 110/min (depending on activity) 10 years and older: 50 to 90/min (depending on activity)

NURSIN G CARE

Nursing care focuses on dietary intake. ●● Initiate dietary restrictions as soon as PKU is diagnosed, or within 7 to 10 days of birth. ●● Place newborn on a formula low in phenylalanine. ◯◯ Intake should be 20 to 30 mg phenylalanine per kilogram of body weight per day. ◯◯ Monitor phenylalanine level. ◯◯ Goal is a phenylalanine level between 2 and 8 mg/dL.

Single-parent family:

One parent and one or more children

SOCIAL CHARACTER OF PLAY

Onlooker: the child observing others Solitary: the child playing alone Parallel: children playing independently but among other children, which is characteristic of toddlers Associative: children playing together without organization, which is characteristic of preschoolers Cooperative play: organized playing in groups, which is characteristic of school-age children

A nurse is providing anticipatory guidance to the parents of a preschool-age child. PHYSICAL DEVELOPMENT: Identify general expectations for height and weight during the preschool years. COGNITIVE DEVELOPMENT: List two concepts related to language development in preschool-age children. AGE-APPROPRIATE ACTIVITIES: List five activities appropriate for preschool-age children. INJURY PREVENTION: Identify two p

PHYSICAL DEVELOPMENT ● Weight: Preschoolers should gain about 2 to 3 kg (4.5 to 6.5 lb) per year. ● Height: Preschoolers should grow about 6.5 to 9 cm (2.5 to 3.5 in) per year. COGNITIVE DEVELOPMENT ● Vocabulary increases to more than 2,100 words by the end of the fifth year. ● Speak in sentences of three to four words at the ages of 3 and 4 years. ● Speak in sentences of four to five words at the age of 4 to 5 years. ● Enjoy talking, and language becomes primary method of communication. AGE-APPROPRIATE ACTIVITIES ● Putting puzzles together ● Playing ball ● Playing pretend and dress-up activities ● Painting ● Role playing ● Riding tricyles ● Simple sewing ● Reading books ● Sandboxes ● Wading pools ● Skating ● Computer programs ● Musical toys ● Electronic games INJURY PREVENTION ● Stand back from curb while waiting to cross the street. ● Before crossing the street, look left, then right, then left again. ● Walk on the left, facing traffic, when there are no sidewalks. ● At night, wear light-colored clothing with fluorescent materials attached.

Palpation

Palpate the skin for temperature, texture, moistness, and resilience. Use your fingertips to assess the texture and moisture of the skin and the back of your hand to feel temperature. A normal finding is for the skin to be smooth, warm, and dry with no tenting of the skin when you test turgor, or resilience.

AGE-APPRO PRIATE ACTIVITIES

Parallel play shifts to associative play during the preschool years. Play is not highly organized, but cooperation does exist between children. Appropriate activities include: ● Playing ball ● Putting puzzles together ● Riding tricycles ● Playing pretend and dress-up activities ● Role playing ● Hand puppets ● Painting ● Simple sewing ● Reading books ● Wading pools ● Sand boxes ● Skating ● Computer programs ● Musical toys ● Electronic games

Passive

Parents are uninvolved, indifferent, and emotionally removed. The child may watch television whenever he wants

Democratic or authoritative

Parents direct the child's behavior by setting rules and explaining the reason for each rule setting. The child can watch television for 1 hr on school nights after completing all of his homework and chores. Parents negatively reinforce deviations from the rules. The privilege is taken away but later reinstated based on new guidelines.

Permissive

Parents exert little or no control over the child's behaviors, and consult the child when making decisions. The child assists with deciding whether he will watch television.

Dictatorial or authoritarian

Parents try to control the child's behaviors and attitudes through unquestioned rules and expectations. The child is never allowed to watch television on school nights.

Binuclear family:

Parents who have terminated spousal roles but continue their parenting roles

COGNITIVE DEVELOPMENT

Piaget: Sensorimotor stage transitions to the preoperational stage around age 19 to 24 months. ● The concept of object permanence becomes fully developed. ● Toddlers have and demonstrate memories of events that relate to them. ● Domestic mimicry (playing house) is evident. ● Preoperational thought does not allow for toddlers to understand other viewpoints, but it does allow them to symbolize objects and people to imitate previously seen activities.

COGNITI VE DE VELO PMENT

Piaget: formal operations ● Able to think through more than two categories of variables concurrently ● Capable of evaluating the quality of their own thinking ● Able to maintain attention for longer periods of time ● Highly imaginative and idealistic ● Increasingly capable of using formal logic to make decisions ● Think beyond current circumstances ● Able to understand how the actions of an individual influence others

COGNITI VE DEVELO PMENT

Piaget: preoperational phase The preconceptual thought transitions to the phase of intuitive thought around the age of 4 years. The phase of intuitive thought lasts until the age of 7 years. ● The preschooler moves from totally egocentric thoughts to social awareness and the ability to consider the viewpoints of others. ● Preschoolers make judgments based on visual appearances. Variations in thinking during this age include: ◯ Magical thinking: Thoughts are all powerful and can cause events to occur. ◯ Animism: Ascribing lifelike qualities to inanimate objects. ◯ Centration: Focus on one aspect instead of considering all possible alternatives. ◯ Time: Preschoolers begin to understand the sequence of daily events. Time is best explained to them in relation to an event. By the end of the preschool years, children have a better comprehension of time-oriented words.

Head circumference Infants

Place the tape measure around the widest part of the infant's head, which is slightly above the eyebrows and the pinna of the ears and around the occipital prominence at the back of the skull. Head circumference is noted to increase by 1.5 cm/month in first 6 months and then drops to 1.25 cm/month. Be sure to measure to tenths of a centimeter, because the percentile charts have grids with 0.5 cm.

Tobacco exposure

Prematurity, low birth weight, increased risk for SIDS, increased risk for bronchitis, pneumonia, and developmental delays

A nurse is planning care for a newborn who has a myelomeningocele. What actions should the nurse include in the plan of care? Use the ATI Active Learning Template: System Disorder to complete this item. NURSING CARE: Include nursing actions before and after surgery for a newborn who has a myelomeningocele.

Preoperative ●● Protect the sac. ●● Place the infant in a radiant warmer, without clothing. ●● Apply sterile, moist nonadhering dressing saturated with 0.9% sodium chloride. Re‑wet as needed. ●● Assess cysts for findings of fluid leak or infection. ●● Administer prescribed antibiotics. ●● Avoid measuring temperature rectally. ●● Prepare the parents for the newborn's surgery. Postoperative ●● Monitor vital signs. ●● Monitor I&O. ●● Assess the surgical site for redness, edema, and drainage. ●● Provide pain management. ●● Assess for leakage of CSF . ●● Maintain prone position until other positions are prescribed.

Self-concept developme nt

Preschoolers feel good about themselves with regard to mastering skills that allow independence (dressing, feeding). During stress, insecurity, or illness, preschoolers can regress to previous immature behaviors or develop habits (nose picking, bed-wetting, thumb sucking).

Infant: Capillary refill

Pressing on a central site such as the forehead can also assess capillary refill. Normal capillary refill time is less than 2 seconds. Delayed capillary refill indicates poor blood flow. infants, assess capillary blood flow by raising the child's extremity at or above the level of the heart, pressing gently over a finger's nailbed (or the heel of the foot) to cause blanching of the skin and occlusion of blood flow, releasing the pressure, and counting the time it takes for a full return of blood to the blanched tissue. Normal capillary refill time is less than 2 seconds.

Respiratory distress syndrome

RDS occurs as a result of surfactant deficiency in the lungs and is characterized by poor gas exchange and ventilatory failure. ●● Surfactant is a phospholipid that assists in alveoli expansion. Surfactant keeps alveoli from collapsing and allows gas exchange to occur. ●● Atelectasis (collapsing of a portion of lung) increases the work of breathing. As a result, respiratory acidosis and hypoxemia can develop. ●● Complications from RDS are related to oxygen therapy and mechanical ventilation. ◯◯ Pneumothorax ◯◯ Pneumomediastinum ◯◯ Retinopathy of prematurity ◯◯ Bronchopulmonary dysplasia ◯◯ Infection ◯◯ Intraventricular hemorrhage

A nurse working in a pediatric unit is planning play activities for a group of children of different ages. What activities should the nurse include in the plan of care? RELATED CONTENT: Identify appropriate toys and activities for children in three age groups

RELATED CONTENT Infants ● Birth to 3 months: colorful moving mobiles, music/sound boxes ● 3 to 6 months: noise‑making objects, soft toys ● 6 to 9 months: teething toys, social interaction ● 9 to 12 months: large blocks, toys that pop apart, push‑and‑pull toys Toddlers ● Cloth books ● Large crayons and paper ● Push‑and‑pull toys ● Tricycles ● Balls ● Puzzles with large pieces ● Educational television ● Videos for children Preschoolers ● Imitative and imaginative play ● Drawing, painting, riding a tricycle, swimming, jumping, running ● Educational television and videos School‑age children ● Games that can be played alone or with another person ● Team sports ● Musical instruments ● Arts and crafts ● Collections Adolescents ● Team sports ● School activities ● Reading, listening to music ● Peer interactions

A nurse is providing anticipatory guidance to the mother of a toddler. The nurse learns that the household includes the mother, toddler, an older brother, and a grandmother. RELATED CONTENT: Describe the composition of this family. UNDERLYING PRINCIPLES ● Describe two methods the parent can use to positively influence the child. ● Describe two ways the parent can promote acceptable behavior in the child. NURSING INTERVENTIONS: Include two additional family assessments the nurse should perform.

RELATED CONTENT: This is an extended family, which includes at least one parent, one or more children, and other individuals who are either related or not related. UNDERLYING PRINCIPLES ● Positive parental influences ◯ Have good mental health. ◯ Maintain structure and routine in the household. ◯ Engage in activities with the child. ◯ Validate the child's feelings when communicating. ◯ Monitor for safety concerns with special consideration for the child's developmental needs. ● Promoting acceptable behavior ◯ Validate the child's feelings, and offer sympathetic explanations. ◯ Provide role modeling and reinforcement for acceptable behavior. ◯ Set clear and realistic limits and expectations based on the child's developmental level. ◯ Focus on the behavior when implementing discipline. NURSING INTERVENTIONS: Family assessments ● Medical history on parents, siblings, and grandparents ● Family structure for roles/position within the family, as well as occupation and education of family members ● Developmental tasks a family works on as the child grows ● Family characteristics, such as cultural, religious, and economic influences on behavior, attitudes, and actions ● Family stressors, such as expected (birth of a child) and unexpected (illness of a child, divorce, disability or death of a family member) events that cause stress ● Availability of and family interactions with community resources ● Family support systems, such as availability of extended family; work and peer relationships; and social systems and community resources to assist the family in meeting needs or adapting to a stressor

Scoliosis:

School-age children should be screened for scoliosis by examining for a lateral curvature of the spine before and during growth spurts. Screening can take place at schools or at health care facilities.

Methamphetamine withdrawal

Small head circumference, SGA, agitation, vomiting, rapid respiratory rate, bradycardia or tachycardia, jitteriness, sleep pattern disturbances, emotional disturbances, and delayed growth and development

CONTENT OF PLAY

Social affective: taking pleasure in relationships Sense-pleasure: objects in the environment catching the child's attention Skill: demonstrating new abilities Unoccupied behavior: focusing attention on something of interest Dramatic: pretending and fantasizing Games: imitative, formal, or competitive

Joints

Stable and symmetric with full range of motion and no crepitus or redness

IMM UNIZATIONS

The Centers for Disease Control and Prevention immunization recommendations for healthy toddlers 12 months to 3 years of age (www.cdc.gov) include: ● 12 to 15 months: inactivated poliovirus (third dose between 6 to 18 months); Haemophilus influenzae type B; pneumococcal conjugate vaccine; measles, mumps, and rubella; and varicella ● 12 to 23 months: hepatitis A (Hep A), given in two doses at least 6 months apart ● 15 to 18 months: diphtheria, tetanus, and acellular pertussis ● 12 to 36 months: yearly seasonal trivalent inactivated influenza vaccine; live, attenuated influenza vaccine by nasal spray (must be 2 years or older)

IMMUNIZATIONS

The Centers for Disease Control and Prevention (CDC) immunization recommendations for healthy infants less than 12 months of age (http://www.cdc.gov) include: ● Birth: hepatitis B (Hep B) ● 2 months: diphtheria and tetanus toxoids and pertussis (DTaP), rotavirus vaccine (RV), inactivated poliovirus (IPV), Haemophilus influenzae type B (Hib), pneumococcal vaccine (PCV), and Hep B ● 4 months: DTaP, RV, IPV, Hib, PCV ● 6 months: DTaP, IPV (6 to 18 months), PCV, and Hep B (6 to 18 months); RV; Hib ● 6 to 12 months: seasonal influenza vaccination yearly (the trivalent inactivated influenza vaccine is available as an intramuscular injection)

IMM UNIZAT IONS

The Centers for Disease Control and Prevention (CDC) immunization recommendations for healthy preschoolers 3 to 6 years of age (www.cdc.gov) include: 4 TO 6 YEARS: Diphtheria and tetanus toxoids and pertussis (DTaP); measles, mumps, and rubella (MMR); varicella; and inactivated poliovirus (IPV) 3 TO 6 YEARS: Yearly seasonal influenza vaccine; trivalent inactivated influenza vaccine; or live, attenuated influenza vaccine by nasal spray

IMM UNIZATION S

The Centers for Disease Control and Prevention (CDC) immunization recommendations for healthy school-age children 6 to 12 years of age (www.cdc.gov) include: ● If not given between 4 and 5 years of age, children should receive the following vaccines by 6 years of age: diphtheria and tetanus toxoids and pertussis (DTaP); inactivated poliovirus; measles, mumps, and rubella (MMR); and varicella ● Yearly seasonal influenza vaccine: trivalent inactivated influenza vaccine (TIV) or live, attenuated influenza vaccine (LAIV) by nasal spray ● 11 to 12 years: tetanus and diphtheria toxoids and pertussis vaccine (Tdap); human papillomavirus vaccine - HPV2 or HPV4 in three doses for females, HPV4 for males; and meningococcal (MCV4).

Vision screening tools

The Tumbling E is used for children under 5 and the Snellen E is used for children over age 6.

Blood pressure

The cuff's bladder width should be about 40% of the child's arm circumference, measured at a point halfway between the olecranon and the acromion. The cuff's bladder length should cover 80% to 100% of the arm's circumference. A cuff that is too small can yield falsely high blood-pressure readings; a cuff that is too large can yield falsely low blood-pressure readings. When measuring blood pressure, position the limb at heart level, rapidly inflate the cuff to about 20 mm Hg above the point at which the radial pulse disappears, and release the cuff at the rate of about 2 to 3 mm Hg per second while using a pediatric stethoscope to listen to the Korotkoff sounds

Latex allergy

The infant can have a high risk of allergy to latex. Allergy responses range from urticaria to wheezing, which can progress to anaphylaxis. NURSING ACTIONS ●● Assist with testing for allergy. ●● Reduce exposure to latex. CLIENT EDUCATION ●● Educate parents to avoid exposing the infant to latex. ●● Provide the family with a list of household items that can contain latex (disposable diapers, cleaning gloves, water toys). ●● Educate the family about how to identify findings of an allergic reaction and to report them to the provider. ●● Provide instruction about the use of epinephrine.

lympnodes

There are many chains of lymph nodes in the head and neck. Lymph nodes in young children are more prominent until adolescence. Assess them in the same way for each age group in the following sequence: around the ears (preauricular, posterior auricular), under the jaw (tonssilar, submandibular, sub-mental), in the occipital area (occipital), and in the cervical chain of the neck (anterior, posterior, deep cervical). If you detect any masses in the neck, refer the child for further evaluation

Gait

Toddlers and young children: A bowlegged or knock-knee appearance is a common finding. Feet should face forward while walking. Older children and adolescents: A steady gait should be noted with even wear on the soles of shoes.

Self-concept development

Toddlers progressively see themselves as separate from their parents and increase their explorations away from them

Gay/lesbian family:

Two members of the same sex who have children and a legal or common-law tie

Nuclear family:

Two parents and their children (biologic, adoptive, step, foster)

A nurse is preparing to examine a preschool‑age child. UNDERLYING PRINCIPLES: Describe two behaviors that indicate the child is ready to cooperate. NURSING INTERVENTIONS ● Describe two actions to take if child is uncooperative. ● Include three actions to promote the child's comfort during the examination.

UNDERLYING PRINCIPLES ● Child is ready to cooperate. ● Interacting with nurse. ● Making eye contact. ● Permitting physical touch. ● Willingly sitting on examination table. ● Accepting and handling equipment. NURSING INTERVENTIONS ● Actions to take if child is uncooperative ◯ Engage both the child and parent. ◯ Be firm and direct about expected behavior. ◯ Complete the assessment as quickly as possible. ◯ Use a calm voice. ◯ Reduce environmental stimuli. ◯ Limit the people in the room. ● Actions to enhance child's comfort ◯ Perform examination in nonthreatening environment. ◯ Take time to play and develop rapport prior to beginning the examination. ◯ Keep the room warm and well lit. ◯ Keep medical equipment out of sight until needed. ◯ Provide privacy. ◯ Explain each step of the examination to the child. ◯ Examine the child in a secure, comfortable position. ◯ Examine the child in an organized sequence when possible. ◯ Encourage the child and family to ask questions during the examination.

Infant: Visual acuity

Visual acuity in infants is tested through checking for light perception and response to the light. Note the infant's ability to fix and follow an object. The infant should follow a light to midline at birth and by age 3 months will follow 180 degrees to the periphery. If an infant is unable to fix and follow by 4 months further evaluation is needed. Test the infant's blink reflex by moving your hand quickly toward the infant's eyes. A quick blink is the normal response. Or, shine a bright light in the infant's eyes. Again, the infant should blink.

Pre-Schoolers (3-6 years old) PHYSICAL DEVELO PMENT

WEIGHT: Preschoolers should gain about 2 to 3 kg (4.5 to 6.5 lb) per year. HEIGHT: Preschoolers should grow about 6.5 to 9 cm (2.5 to 3.5 in) per year

School-aged children (6-12 years old) PHYSICAL DEVELO PMENT

Weight: School-age children will gain about 2 to 3 kg (4.4 to 6.6 lb) per year. Height: School-age children will grow about 5 cm (2 inches) per year. Prepubescence ● Preadolescence is typically when prepubescence occurs. ● Onset of physiologic changes begins around the age of 9 years, particularly in girls. ● Rapid growth in height and weight occurs. ● Differences in the rate of growth and maturation between boys and girls becomes apparent. ● Visible sexual maturation is minimal in boys during preadolescence. ● Permanent teeth erupt. ● Bladder capacity differs, but remains greater in girls than boys. ● Immune system improves. ● Bones continue to ossify.

School-age children

When you use a tympanic thermometer, remember the principles for inserting eye drops or an otoscope into a child's ear: Straighten the ear canal by pulling the pinna up and back for children 3 years of age and older (as in this age group) and down and back for children younger than 3 years of age. Place the covered tip at the external opening of the ear canal and wait 2 to 5 seconds after you press the scan button for the temperature display

tonic neck reflex.

With the infant in a supine position, turn her head to one side with her chin over her shoulder. A normal response is for the arm and leg on the side her head is turned to extend and the opposite arm and leg to flex. If her head is turned to the other side, the position of her arms and legs should reverse. This reflex is present shortly after birth disappears by about 4 months of age.

Communicating with adolescents.

address fears verbally and directly. Expect the adolescent to use monosyllabic responses plus a wide range of nonverbal expressions, such as anger, reticence, or other behavior that is considered inappropriate in other settings. Whenever appropriate, do at least part of the examination and history taking without the parent in the room. This gives the adolescent an opportunity to convey any sensitive issues

Families often include individuals with a

biological, marital, or adoptive relationship, but in the absence of these characteristics, families also consist of individuals who have a strong emotional bond and commitment to one another. Due to the expanding concepts of family, the term household is sometimes used.

rooting reflex

by gently stroking the infant's cheek near her mouth. A normal response is for the infant to turn her head toward that side and open her mouth. This reflex is present at birth and usually disappears around 3 to 4 months of age.

Babinski, or plantar reflex, on the plantar aspect or sole of the foot

by tracing an upside-down J with the handle of the reflex hammer, starting at the child's heel and moving up the lateral aspect and then across the ball of the foot. The normal response to Babinski testing in an infant is a fanning of the toes. A positive Babinski response is an expected finding in an infant and is present until approximately age 2. A positive Babinski after the age of 2 is commonly associated with upper motor neuron disease.

● Toilet training

can begin when toddlers have the sensation of needing to urinate or defecate. Parents should demonstrate patience and consistency in toilet training. Nighttime control might develop last. ● Discipline should be consistent with well-defined boundaries that are established to develop appropriate social behavior.

Fetal alcohol spectrum disorder (FASD), formerly referred to as fetal alcohol syndrome (FAS), results from

exposure of the fetus to the chronic or periodic intake of alcohol during pregnancy. FASD is an umbrella term used to describe the range of clinical effects. FAS refers specifically to children who exhibit a triad of characteristic facial features, growth restriction, and neurodevelopmental deficits and a confirmed history of maternal alcohol consumption.

Temper tantrums result when toddlers are

frustrated with restrictions on independence. Providing consistent, age-appropriate expectations helps toddlers to work through frustration.

Stridor is a

high-pitched sound typically generated when a larger airway is blocked by a foreign body or severe inflammation, such as croup.

The tone generated by lung percussion in infants, toddlers, and preschoolers is usually

hyperresonance because of the thin chest wall.

The key to prevention of PKU in newborns

is identification of women in their reproductive years who have the disorder. These women must adhere to strict dietary guidelines from 3 months before conception throughout pregnancy. Failure to follow strict dietary guidelines during pregnancy can result in fetal microcephaly, cognitive impairment, and heart defects. Women who have PKU will have their phenylalanine levels monitored one to two times per week throughout pregnancy.

Palliative care

is a interprofessional approach that focuses on the process of dying rather than prolonging life when cures are not possible. Focus is on control of managing the client's manifestations and offering supportive care.

abdominal examination

is inspection, then auscultation, followed by palpation. Is the abdomen scaphoid, flat, rounded, or protuberant?

Moro

is the next reflex to test. Gently jar the crib, or support the infant's head and back in a semi-sitting position and then quickly lower the infant to about 30 degrees. A normal response is for the infant to abduct and extend her arms and legs symmetrically, fan her fingers, and curl her index finger and thumb into a "C" position. Then the arms and legs usually come back in close to the body. This reflex is present at birth and disappears between 1 and 4 months of age.

Myelomeningocele

is the protrusion of a sac‑like cyst that contains meninges, spinal fluid, and a portion of the spinal cord and nerves.

Meningocele

is the protrusion of a sac‑like cyst that contains meninges and spinal fluid.

Hoarseness is usually heard when the

larynx is inflamed and the child coughs to clear the airway. It is commonly heard when the child has a respiratory infection

Having an extra finger is called

polydactyly.

Pinna

pulling the pinna up and back in children 3 years of age and older and down and back in children younger than 3 years of age.

In older children, the tone generated should be

resonance, which is a low-pitched, hollow sound

School-age children are

sensitive to embarrassment and may fear injury. Explain every step of the examination, especially if the child has not had any prior experience in this type of setting. Talking in the third person to younger children in this group can be very effective in reducing their anxiety and gaining their cooperation.

A normal tympanic membrane is

shiny and pearly gray, with a cone of reflected light on the nasal aspect. In other words, the cone of light should be visible at "7 o'clock" in the left ear and "5 o'clock" in the right ear.

Hospice care

specializes in the care of a client who is dying. Family members are often the primary caregivers. Nursing focus is on pain control, comfort, and allowing the client to die with dignity. Family and client needs are equal. Provide support for the family's grieving process, which can continue after the client's death.

If webbing is noted between adjacent fingers, this is called

syndactyly.

Substance withdrawal in the newborn occurs when

the mother uses drugs that have addictive properties during pregnancy. This includes illicit substances, heroin, opiates, alcohol, tobacco, methadone, and prescription medications.

Remember, the right lung has

three lobes, while the left has two.

grasp reflex

which includes the palmar and plantar reflex, place your index finger in the infant's hand, the infant should grasp your finger tightly with all fingers. This reflex is present at birth, and disappears at 3 to 4 months of age. The plantar grasp disappears by 8 to 10 months of age.

adolescent's thorax is similar in shape to an adult's

with a 1:2 anteroposterior-to-transverse diameter. A barrel-shaped chest is an abnormal finding in this age group and reflects a respiratory problem. At this age, the diaphragm is no longer the primary muscle used for breathing, so you should see the abdomen and chest rise symmetrically with the respiratory cycle A normal respiratory rate for an adolescent is between 16 to 19 breaths per minute.

when inspecting the external structures of the infant's eye,

you might note an epicanthal fold, an extra skinfold that extends over the inner corner of the eye. This finding is especially common in Asian children. In other children, the epicanthal fold disappears by about 10 years of age.

FAMILY SYSTEMS The family is viewed as a whole system, instead of the individual members.

● A change to one member affects the entire system. ● The system can both initiate and react to change. ● Too much and too little change can lead to dysfunction

Erikson: industry vs. inferiority

● A sense of industry is achieved through the development of skills and knowledge that allows the child to provide meaningful contributions to society. ● A sense of accomplishment is gained through the ability to cooperate and compete with others. ● Children should be challenged with tasks that need to be accomplished, and be allowed to work through individual differences in order to complete the tasks. ● Creating systems that reward successful mastery of skills and tasks can create a sense of inferiority in children unable to complete the tasks or acquire the skills. ● Children should be taught that not everyone will master every skill.

LATER SCHOOL-AGE YEARS

● Able to judge the intentions of an act rather than just its consequences. ● Understand different points of view instead of just whether or not an act is right or wrong. ● Conceptualizes treating others as they like to be treated.

Intradermal

● Administer on the inside surface of the forearm. ● Use a TB syringe with 26- to 30-gauge needle with an intradermal bevel. ● Insert needle at 15° angle. ● Do not aspirate.

Erikson: identity vs. role confusion

● Adolescents develop a sense of personal identity, and come to view themselves as unique individuals. ● Group identity: Adolescents become part of a peer group that greatly influences behavior.

Family-centered nursing care includes the following.

● Agreed-upon partnerships between families of children, nurses, and providers, in which the families and children benefit. ● Respecting cultural diversity, and incorporating cultural views in the plan of care. ● Understanding growth and developmental needs of children and their families. ● Treating children and their families as clients. ● Working with all types of families. ● Collaborating with families regarding hospitalization, home, and community resources. ● Allowing families to serve as experts regarding their children's health conditions, usual behaviors in different situations, and routine needs.

Toddlers (1-3 years old) PHYSI CAL DEVELO PMENT

● Anterior fontanels close by 18 months of age. ● Weight: At 30 months of age, toddlers should weigh four times their birth weights. ● Height: Toddlers grow about 7.5 cm (3 in) per year. ● Head circumference and chest circumference are usually equal by 1 to 2 years of age.

Burns

● Avoid warming formula in a microwave; check temperature of liquid before feeding. ● The temperature of bath water should be checked. ● Hot water thermostats should be set at or below 49° C (120° F). ● Working smoke detectors should be kept in the home. ● Handles of pots and pans should be kept turned to the back of stoves. ● Sunscreen should be used when infants are exposed to the sun. ● Electrical outlets should be covered

School-age child LEVEL OF UNDERSTANDING

● Beginning awareness of body functioning ● Ability to describe pain ● Increasing ability to understand cause and effect IMPACT OF HOSPITALIZATION ● Fears loss of control ● Seeks information as a way to maintain a sense of control ● Can sense when not being told the truth ● Can experience stress related to separation from peers and regular routine

Sexual identity

● Begins with close, same-sex friendships during early adolescence, which sometimes involve sexual experimentation driven by curiosity. ● Self-exploration occurs through masturbation. ● Transition from friendships to intimate relationships during adolescence. ● In late adolescence, sexual identity typically is formed through the integration of sexual experiences, feelings, and knowledge.

PLAY ACTIVITIES RELATED TO AGE Infants

● Birth to 3 months: colorful moving mobiles, music/ sound boxes ● 3 to 6 months: noise-making objects, soft toys ● 6 to 9 months: teething toys, social interaction ● 9 to 12 months: large blocks, toys that pop apart, push-and-pull toys

ADOLESCENTS (12 TO 20 YEARS)

● Can have an adult-like concept of death. ● Can have difficulty accepting death because they are discovering who they are, establishing an identity, and dealing with issues of puberty. ● Rely more on peers than the influence of parents, which can result in the reality of a serious illness causing adolescents to feel isolated. ● Can be unable to relate to peers and communicate with parents. ● Can become increasingly stressed by changes in physical appearance due to medications or illness than the prospect of death. ● Can experience guilt and shame. Factors that can increase the family's potential for dysfunctional grieving following the death of a child ● Lack of a support system ● Presence of inadequate coping skills ● Association of violence or suicide with the death of a child ● Sudden and unexpected death of a child ● Lack of hope or presence of pre-existing mental health issues

DENTAL HEALT H

● Children should have an established dental home by the age of 1 year. ● Flossing and brushing should be performed by the adult caregiver and are the best methods of removing plaque. ● Brushing should occur after meals and at bedtime. Nothing to eat or drink, except water, is given to the child after the bedtime cleaning. ● Fluoride is supplemented for children living in areas without adequate levels in drinking water. ● Early childhood caries is a form a tooth decay that develops in toddlers and is more common in children who are put to bed with a bottle of juice or milk. ● Consumption of cariogenic foods should be eliminated if possible. If not, the frequency of consumption should be limited.

Motor-vehicle inju ries

● Children should use an approved car restraint system until they achieve a height of 145 cm (4 feet, 9 inches). ● Teach children appropriate seat belt use when no longer using a car restraint system or booster seat. ● Safest area for children is the backseat of the car. ● Never let children ride in the bed of a pickup truck. ● Reinforce safe pedestrian behaviors.

PLAY ACTIVITIES RELATED TO AGE Toddlers

● Cloth books, puzzles with large pieces ● Large crayons and paper ● Push-and-pull toys, balls ● Tricycles ● Educational television ● Videos for children

Falls

● Crib mattresses should be kept in the lowest position possible with the rails all the way up. ● Restraints should be used in infant seats. ● Infant seats should be placed on the ground or floor if used outside of the car, and they should not be left unattended or on elevated surfaces. ● Place safety gates at the top and bottom of stairs.

Language development

● Crying is the first form of verbal communication. ● Infants cry for 1 to 1½ hr each day up to 3 weeks of age and build up to 2 to 4 hr by 6 weeks. ● Crying decreases by 12 weeks of age. ● Vocalizes with cooing noises by 3 to 4 months. ● Shows considerable interest in the environment by 3 months. ● Turns head to the sound of a rattle by 3 months. ● Laughs and squeals by 4 months. ● Makes single vowel sounds by 2 months. ● By 3 to 4 months the consonants are added. ● Begins speaking two-word phrases and progresses to speaking three-word phrases. ● Says three to five words by the age of 1 year. ● Comprehends the word "no" by 9 to 10 months and obeys single commands accompanied by gestures.

EARLY SCHOOL-AGE YEARS

● Do not understand the reasoning behind rules and expectations for behavior. ● Believe what they think is wrong, and what others tell them is right. ● Judgment is guided by rewards and punishment. ● Sometimes interpret accidents as punishment.

Fall s

● Doors and windows should be kept locked. ● Crib mattresses should be kept in the lowest position with the rails all the way up. ● Safety gates should be used across the top and bottom of stairs.

Kohlberg: moral development

● Early preschoolers continue in the good-bad orientation of the toddler years, and actions are taken based on whether or not it will result in a reward or punishment. ● Older preschoolers primarily take actions based on satisfying personal needs, yet are beginning to understand the concepts of justice and fairness.

PRESCHOOL CHILDREN (3 TO 6 YEARS)

● Egocentric thinking. ● Magical thinking allows for the belief that thoughts can cause an event such as death (as a result, child can feel guilt and shame). ● Interpret separation from parents as punishment for bad behavior. ● View dying as temporary because of the lack of a concept of time and because the dead person can still have attributes of the living (sleeping, eating, breathing).

DEVELOPMENTAL Views families as small groups that interact with the larger social system.

● Emphasizes similarities and consistencies in how families develop and change. ● Uses Duvall's family life cycle stages to describe the changes a family goes through over time. ● How the family functions in one stage has a direct effect on how the family will function in the next stage.

DENTAL H EALT H

● Eruption of deciduous (primary) teeth is finalized by the beginning of the preschool years. ● Parents need to assist and supervise brushing and flossing to ensure it is performed correctly to prevent dental caries. ● Trauma to teeth is common in preschool-age children and should be immediately assessed by a dentist.

Poisonin g

● Exposure to lead paint should be avoided. ● Safety locks should be placed on cabinets that contain cleaners and other chemicals. ● The phone number for a poison control center should be kept near the phone. ● Medications should be kept in childproof containers, away from the reach of toddlers. ● A working carbon monoxide detector should be placed in the home.

Poisoning

● Exposure to lead paint should be avoided. ● Toxins and plants should be kept out of reach. ● Safety locks should be kept on cabinets that contain cleaners and other household chemicals. ● The phone number for a poison control center should be kept near the phone. ● Medications should be kept in childproof containers, away from the reach of infants. ● A working carbon monoxide detector should be kept in the home.

Bod ily ha rm

● Firearms should be kept in locked cabinets or containers. ● Preschoolers should be taught stranger safety. ● Preschoolers should be taught to wear protective equipment (helmet, pads).

PLAY ACTIVITIES RELATED TO AGE School-age children

● Games that can be played alone or with another person ● Team sports ● Musical instruments ● Arts and crafts ● Collections

Hair and scalp

● Hair should be evenly distributed, smooth, and strong. ◯ Manifestations of nutritional deficiencies include hair that is stringy, dull, brittle, and dry. ◯ Hair loss or balding spots on infants can indicate the child is spending too much time in the same position. ● Scalp should be clean and absent from any scaliness, infestations, and trauma. ● Assess children approaching adolescence for the presence of secondary hair growth.

INFANTS/TODDLERS (BIRTH TO 3 YEARS)

● Have little to no concept of death. ● Egocentric thinking prevents their understanding death (toddlers). ● Mirror parental emotions (sadness, anger, depression, anxiety). ● React in response to the changes brought about by being in the hospital (change of routine, painful procedures, immobilization, less independence, separation from family). ● Can regress to an earlier stage of behavior.

Aspiration of foreign objects

● Hold the infant for feedings; do not prop bottles. ● Small objects that can become lodged in the throat (grapes, coins, candy) should be avoided. ● Age-appropriate toys should be provided. ● Clothing should be checked for safety hazards (loose buttons).

Bu rns

● Hot water thermostats should be set at or below 49°C (120°F). ● Working smoke detectors should be kept in the home. ● Preschoolers should have sunscreen applied when outside.

PLAY ACTIVITIES RELATED TO AGE Preschoolers

● Imitative and imaginative play ● Drawing, painting, riding a tricycle, swimming, jumping, running ● Educational television and videos

Infant LEVEL OF UNDERSTANDING

● Inability to describe illness and follow directions ● Lack of understanding of the need of therapeutic procedures IMPACT OF HOSPITALIZATION ● Experiences stranger anxiety between 6 to 18 months of age ● Displays physical behaviors as expressions of discomfort due to inability to verbalize ● Can experience sleep deprivation due to strange noises, monitoring devices, and procedures ● Can experience anxiety due to the unfamiliar environment and fear of the unknown

Adolescent LEVEL OF UNDERSTANDING

● Increasing ability to understand cause and effect ● Perceptions of illness severity are based on the degree of body image changes IMPACT OF HOSPITALIZATION ● Develops body image disturbance ● Attempts to maintain composure but is embarrassed about losing control ● Experiences feelings of isolation from peers ● Worries about outcome and impact on school/activities ● Might not adhere to treatments/medication regimen due to peer influence

Motor-vehicle injuries

● Infant-only and convertible infant-toddler car seats are available. ● Infants and toddlers remain in a rear-facing car seat until the age of 2 years or the height recommended by the manufacturer. ● The safest area for infants and children is the backseat of the car. ● Do not place rear-facing car seats in the front seat of vehicles with passenger airbags. ● Infants should not be left in parked cars.

Motor-vehicle injurie s

● Infants and toddlers remain in a rear-facing car seat until the age of 2 years or the height recommended by the manufacturer. ● Toddlers over the age of 2 years, or who exceed the height recommendations for rear-facing car seats, are moved to a forward-facing car seat. ● Safest area for infants and children is the backseat of the car. ● Do not place rear-facing car seats in the front seat of vehicles with deployable passenger airbags.

Piaget: sensorimotor stage (birth to 24 months)

● Infants progress from reflexive to simple repetitive to imitative activities. ● Separation, object permanence, and mental representation are the three important tasks accomplished in this stage. ◯ Separation: Infants learn to separate themselves from other objects in the environment. ◯ Object permanence: The process by which infants learn that an object still exists when it is out of view. This occurs at approximately 9 to 10 months of age. ◯ Mental representation: The ability to recognize and use symbols.

Drowning

● Infants should not be left unattended in bathtubs or around water sources such as toilets, cleaning buckets, or drainage areas. ● Secure fencing around swimming pools. ● Close bathroom doors.

FEMALE: Hair distribution over the mons pubis should be documented in terms of amount and location during puberty. Hair should appear in an inverted triangle. No pubic hair should be noted in infants or small children.

● Labia: Symmetric, without lesions, moist on the inner aspects ● Clitoris: Small, without bruising or edema ● Urethral meatus: Slit-like in appearance with no discharge ● Vaginal orifice: The hymen can be absent, or it can completely or partially cover the vaginal opening prior to sexual intercourse.

Language d evelopment

● Language increases to about 300 words by the age of 2 years. ● 1 year: using one-word sentences, or holophrases ● 2 years: using multiword sentences by combining two to three words ● 3 years: combining several words to create simple sentences using grammatical rules

Toddler LEVEL OF UNDERSTANDING

● Limited ability to describe illness ● Poorly developed sense of body image and boundaries ● Limited understanding of the need for therapeutic procedures ● Limited ability to follow directions IMPACT OF HOSPITALIZATION ● Experiences separation anxiety ● Can exhibit an intense reaction to any type of procedure due to the intrusion of boundaries ● Behavior can regress

Preschooler LEVEL OF UNDERSTANDING

● Limited understanding of the cause of illness but knows what illness feels like ● Limited ability to describe manifestations ● Fears related to magical thinking ● Ability to understand cause and effect inhibited by concrete thinking IMPACT OF HOSPITALIZATION ● Can experience separation anxiety ● Can harbor fears of bodily harm ● Might believe illness and hospitalization are a punishment

Young infant

● Loud cry ● Rigid body or thrashing ● Local reflex withdrawal from pain stimulus ● Expressions of pain (eyes tightly closed, mouth open in a squarish shape, eyebrows lowered and drawn together) ● Lack of association between stimulus and pain Older infant ● Loud cry ● Deliberate withdrawal from pain ● Facial expression of pain

Toddler

● Loud cry or screaming ● Verbal expressions of pain ● Thrashing of extremities ● Attempt to push away or avoid stimulus ● Noncooperation ● Clinging to a significant person ● Behaviors occur in anticipation of painful stimulus ● Requests physical comfort

CHILDREN FROM 9 TO 12 YEARS OF AGE

● Make crafts. ● Build models. ● Collect things/engage in hobbies. ● Solve jigsaw puzzles. ● Play board and card games. ● Join organized competitive sports

Characteristics of healthy families

● Members communicate well and listen to each other. ● There is affirmation and support for all members. ● There is a clear set of family rules, beliefs, and values. ● Members teach respect for others. ● There is a sense of trust. ● Members play and share humor together. ● Members interact with one another. ● There is a shared sense of responsibility. ● There are traditions and rituals. ● There is adaptability and flexibility in roles. ● Members seek help for their problems.

Moral development

● Moral development is closely associated with cognitive development. ● Egocentric: Toddlers are unable to see things from the perspectives of others; they can only view things from their personal points of view. ● Punishment and obedience orientation begin with a sense that good behavior is rewarded and bad behavior is punished.

CARE OF THE NEWBORN AFTER DISCHARGE

● Newborn infants should be placed in an federally approved car seat at a 45 degree angle to prevent slumping and airway obstruction. The car seat is placed rear facing in the rear seat of the vehicle and secured using the safety belt. The shoulder harnesses are placed in the slots at or below the level of the infant's shoulders. The harness should be snug and the retainer clip placed at the level of the infant's armpits. ● Instruct parents that their newborn will require a checkup by a provider within 72 hr of discharge. This is especially important for breastfed newborns to evaluate weight and hydration status.

SLEEP AND REST

● Nocturnal sleep pattern is established by 3 to 4 months of age. ● Infants sleep 14 to 15 hr daily and 9 to 11 hr at night around the age of 4 months. ● Infants sleep through the night and take one to two naps during the day by the age of 12 months.

Social development

● Peer groups play an important part in social development. Peer pressure begins to take effect. ● Clubs and best friends are popular. ● Bullying actions are intended to cause harm or to control someone, and are sometimes attributed to poor relationships with peers and difficulty identifying with a group. ● Children prefer the company of same-gender companions, but begin developing an interest in the opposite sex toward the end of the school-age years. ● Most relationships come from school associations. ● Conformity becomes evident.

MALE: Hair distribution is diamond shaped after puberty in adolescent males. No pubic hair is noted in infants and small children.

● Penis ◯ Penis should appear straight. ◯ Urethral meatus should be at the tip of the penis. ◯ Foreskin might not be retractable in infants and small children. ◯ Enlargement of the penis occurs during adolescence. ◯ The penis can look abnormally small in males who are obese because of skin folds partially covering the base. ● Scrotum ◯ The scrotum hangs separately from the penis. ◯ The skin on the scrotum has a rugose appearance and is loose. ◯ The left testicle hangs slighter lower than the right. ◯ The inguinal canal should be absent of swelling. ◯ During puberty, the testes and scrotum enlarge with darker scrotal skin.

Otic

● Place the child in a prone or supine position with the affected ear upward. ● Children younger than 3 years: pull the pinna downward and straight back. ● Children older than 3 years: pull the pinna upward and back.

Suffocation

● Plastic bags should be avoided. ● Balloons should be kept away from infants. ● Crib mattresses should fit snugly. ● Crib slats should be no farther apart than 6 cm (2.375 in). ● Crib mobiles and/or crib gyms should be removed by 4 to 5 months of age. ● Pillows should be kept out of the crib. ● Infants should be placed on their backs for sleep. ● Toys with small parts should be kept out of reach. ● Drawstrings should be removed from jackets and other clothing.

Suffo cation

● Plastic bags should be avoided. ● Crib mattresses should fit tightly. ● Crib slats should be no farther apart than 6 cm (2.375 in). ● Pillows should be kept out of cribs. ● Drawstrings should be removed from jackets and other clothing.

CHILDREN FROM 6 TO 9 YEARS OF AGE .

● Play simple board and number games. ● Play hopscotch. ● Jump rope. ● Collect rocks, stamps, cards, coins, or stuffed animals. ● Ride bicycles. ● Build simple models. ● Join organized sports (for skill building)

Deltoid

● Position the child sitting or standing. ● Inject up to 1 mL. ● Provide atraumatic care ◯ Apply eutectic mixture of lidocaine and prilocaine (EMLA) to the site for 60 min prior to injection. ◯ Change needle after puncturing a rubber stopper. ◯ Use the smallest gauge of needle possible. ◯ Use therapeutic hugging ◯ Secure the child firmly to decrease movement of the needle while injecting. ◯ Use distraction. ◯ Encourage parents to hold the child after. ◯ Offer praise ◯ Use play therapy. ◯ Offer sucrose pacifiers to infants.

Ventrogluteal

● Position the child supine, side-lying, or prone. ● Inject 0.5 to 1 mL, depending on muscle size of infant. ● Inject up to 2 mL in children.

Fontanel

● Posterior fontanel closes by 6 to 8 weeks of age. ● Anterior fontanel closes by 12 to 18 months of age.

Erikson: initiative vs. guilt

● Preschoolers become energetic learners, despite not having all of the physical abilities necessary to be successful at everything. ● Guilt can occur when preschoolers believe they have misbehaved or when they are unable to accomplish a task. ● Guiding preschoolers to attempt activities within their capabilities while setting limits is appropriate.

Body-im age changes

● Preschoolers begin to recognize differences in appearances, and identify what is considered acceptable and unacceptable. ● By the age of 5 years, preschoolers begin comparing themselves with peers. ● Poor understanding of anatomy makes intrusive experiences, such as injections or cuts, frightening to preschoolers. Therefore, preschoolers believe it is important to use bandages after an injury.

Dro wning

● Preschoolers should not be left unattended in bathtubs. ● Preschoolers should be closely supervised when near the pool or any other body of water. ● Preschoolers should be taught to swim.

Motor-vehicle injuri es

● Preschoolers should use a federally approved car restraint according to the manufacturer recommendations. ● When the forward-facing car seat is outgrown, the preschooler transitions to a booster seat. ● It is recommended that children use an approved car restraint system until they achieve a height of 145 cm (4 feet, 9 in) or 8 to 12 years old. ● Safest area for children is the backseat of the car. ● Supervise preschool-age children when playing outside, and do not allow them to play near a curb or parked cars. ● Teach pedestrian safety rules to preschool-age children. ◯ Stand back from curb while waiting to cross the street. ◯ Before crossing the street, look left, then right, then left again. ◯ Walk on the left, facing traffic, when there are no sidewalks. ◯ At night, wear light-colored clothing with fluorescent materials attached.

SLEE P AND REST

● Required sleep is highly variable in the school-age years, and is dependent on the following: ◯ Age ◯ Level of activity ◯ Health status ● Approximately 9 hr of sleep is needed each night at the age of 11 years. ● Resistance to bedtime is sometimes experienced around the age of 8 and 9 years, and again around the age of 11 years, but is typically resolved by the age of 12 years.

Oral NURSING CONSIDERATIONS

● Route is preferred due to convenience, cost, and ability to maintain steady blood levels. ● Take 1 to 2 hr to reach peak analgesic effects. Oral medications are not suited for children experiencing pain that requires rapid relief or pain that is fluctuating in nature.

Pain internsity

● Self-report is used for children 4 years or older. Children under 4 are unable to accurately report their pain.

PHYSICAL MANIFESTATIONS OF DEATH

● Sensation of heat when the body feels cool ● Decreased sensation and movement in lower extremities ● Loss of senses (hearing is the last to be lost) ● Confusion or loss of consciousness ● Decreased appetite and thirst ● Swallowing difficulties ● Loss of bowel and bladder control ● Bradycardia, hypotension ● Cheyne-Stokes respirations

GUIDELINES FOR PROMOTING ACCEPTABLE BEHAVIOR IN CHILDREN

● Set clear and realistic limits and expectations based on the developmental level of the child. ● Validate the child's feelings, and offer sympathetic explanations. ● Provide role modeling and reinforcement for appropriate behavior. ● Focus on the child's behavior when disciplining the child.

Bodily harm

● Sharp objects should be kept out of reach. ● Anchor heavy objects and furniture so they cannot be overturned on top of the infant. ● Infants should not be left unattended with any animals present.

Bo dily harm

● Sharp objects should be kept out of reach. ● Firearms should be kept in locked boxes or cabinets. ● Toddlers should not be left unattended with any animals present. ● Toddlers should be taught stranger safety.

Neck

● Short in infants ● No palpable masses ● Midline trachea ● Full range of motion present whether assessed actively or passively

Central venous access devices

● Short term: nontunneled catheter or peripherally inserted central catheters (PICC) ● Long term: tunneled catheter or implanted infusion ports ● Provide atraumatic care ◯ Insert a PICC before multiple peripheral attempts. ◯ Use a transilluminator to assist in vein location. ◯ Avoid terminology such as a "bee sting" or "stick." ◯ Attach an extension tubing to decrease movement of the catheter. ◯ Use play therapy. ◯ Apply EMLA to the site for 60 min prior to attempt. ◯ Keep equipment out of site until procedure begins. ◯ Perform procedure in a treatment room. ◯ Use nonpharmacologic therapies. ◯ Allow parents to stay if they prefer. ◯ Use therapeutic holding. ◯ Avoid using the dominant or sucking hand. ◯ Cover site with a colorful wrap. ◯ Swaddle infants. ◯ Offer nonnutritive sucking

Dentition

● Six to eight teeth should erupt in infants' mouths by the end of the first year of age. The first teeth typically erupt between the ages of 6 and 10 months (average age 8 months). ● Some children show minimal indications of teething, such as sucking or biting on their fingers or hard objects and drooling. Others are irritable, have difficulty sleeping, have a mild fever, rub their ears, and have decreased appetite for solid foods. Teething pain can be eased using frozen teething rings or an ice cube wrapped in a wash cloth and over-the-counter teething gels. With topical anesthetic ointments, absorption rates vary in infants; therefore, parents should be advised to apply them correctly. Acetaminophen (Tylenol) and/or ibuprofen (Advil) are appropriate if irritability interferes with sleeping and feeding, but should not be used for more than 3 days. Ibuprofen should be used only in infants over the age of 6 months. ● Clean infants' teeth using cool, wet washcloths. ● Bottles should not be given to infants when they are falling asleep because prolonged exposure to milk or juice can cause early childhood dental caries.

SLEEP AND REST

● Sleep habits change with puberty due to increased metabolism and rapid growth. ● Adolescents tend to stay up late, sleep in later in the morning, and sleep more than during the school-age years. Sleep habits change with puberty due to increased metabolism and rapid growth during the adolescent years. ● During periods of active growth, the need for sleep increases.

Aspiration of foreign object s

● Small objects (grapes, coins, candy) that can become lodged in the throat should be avoided. ● Toys that have small parts should be kept out of reach. ● Age-appropriate toys should be provided. ● Clothing should be checked for safety hazards (loose buttons). ● Balloons should be kept away from toddlers. ● Parents should know emergency procedures for choking.

AGE-APPRO PRIATE ACTI VITIES

● Solitary play evolves into parallel play, in which toddlers observe other children and then might engage in activities nearby. ● Appropriate activities ◯ Filling and emptying containers ◯ Playing with blocks ◯ Looking at books ◯ Push-pull toys ◯ Tossing balls ◯ Finger paints ◯ Large-piece puzzles ◯ Thick crayons

School-age child

● Stalling behavior ● Muscular rigidity ● Any behaviors of the toddler, but less intense in the anticipatory phase and more intense with painful stimulus Adolescent ● More verbal expressions of pain with less protest ● Muscle tension with body control

SCHOOL‑AGE CHILDREN (6 TO 12 YEARS)

● Start to respond to logical or factual explanations. ● Begin to have an adult concept of death (inevitable, irreversible, universal), which generally applies to older school-age children (9 to 12 years). ● Experience fear of the disease process, death process, the unknown, and loss of control. ● Fear often displayed through uncooperative behavior. ● Can be curious about funeral services and what happens to the body after death.

FAMILY STRESS Describes stress as inevitable.

● Stressors can be expected or unexpected. ● Explains the reaction of a family to stressful events. ● Offers guidance for adapting to stress.

Face

● Symmetric appearance and movement ● Proportional features

PLAY ACTIVITIES RELATED TO AGE Adolescents

● Team sports ● School activities ● Reading, listening to music ● Peer interactions

PHARMACOLOGICAL MEA SURES

● The World Health Organization (2012) recommends a two-step approach for pharmacological management of pain in children. ◯ For children above 3 months of age with mild pain, the first step is to administer a nonopioid. Nonsteroidal anti‑inflammatory drugs (NSAIDs) are frequently used for mild pain. ◯ The second step for children who have moderate or severe pain is to administer a strong opioid. Morphine is the drug of choice. Give medications routinely, vs. PRN (as needed), to manage pain that is expected to last for an extended period of time. ● Combine adjuvant medications (steroids, antidepressants, sedatives, antianxiety medications, muscle relaxants, anticonvulsants) with other analgesics. ● Use nonopioid and opioid medications. ◯ Acetaminophen and NSAIDs are acceptable for mild to moderate pain. ◯ Opioids are acceptable for moderate to severe pain. Medications used include morphine sulfate, oxycodone, and fentanyl. ◯ Combining a nonopioid and an opioid medication treats pain peripherally and centrally. This offers greater analgesia with fewer adverse effects (respiratory depression, constipation, nausea). ● IM injections are not recommended for pain control in children. ● Intranasal medications are not recommended for children younger than 18 years. ● Rectal medications have variable absorption rates, and children dislike them. ● Intradermal medications are used for skin anesthesia prior to procedures.

Adolescents (12-20 years old) PHYSICAL DEVELO PMENT

● The final 20% to 25% of height is achieved during puberty. ● Acne can appear during adolescence. ● Girls stop growing at about 2 to 2.5 years after the onset of menarche. They grow 5 to 20 cm (2 to 8 in) and gain 7 to 25 kg (15.5 to 55 lb). ● Boys stop growing at around 18 to 20 years of age. They grow 10 to 30 cm (4 to 12 in) and gain 7 to 30 kg (15.5 to 66 lb). ● In girls, sexual maturation occurs in the following order. ◯ Breast development ◯ Pubic hair growth (some girls experience hair growth before breast development) ◯ Axillary hair growth ◯ Menstruation ● In boys, sexual maturation occurs in the following order. ◯ Testicular enlargement ◯ Pubic hair growth ◯ Penile enlargement ◯ Growth of axillary hair ◯ Facial hair growth ◯ Vocal changes

DEN TAL HEALT H

● The first permanent teeth erupt around 6 years of age. ● Children should brush after meals and snacks, and at bedtime. ● Children should floss daily. ● Children should have regular checkups. ● If necessary, children should have regular fluoride treatments.

NOSE

● The position should be midline. ● Patency should be present for each nostril without excessive flaring. ● Smell can be assessed in older children. Internal structures ● The septum is midline and intact. ● The mucosa is deep pink and moist with no discharge.

Head

● The shape of the head should be symmetric. ● Fontanels should be flat. The posterior fontanel usually closes by 6 and 8 weeks of age, and the anterior fontanel usually closes between 12 and 18 months of age.

Burn s

● The temperature of bath water should be checked. ● Thermostats on hot water heaters should be turned down to less than 49° C (120° F). ● Working smoke detectors should be kept in the home. ● Pot handles should be turned toward the back of the stove. ● Electrical outlets should be covered. ● Toddlers should wear sunscreen when outside.

Lang uage development

● The vocabulary of preschoolers increases to more than 2,100 words by the end of the fifth year. ● Preschoolers speak in sentences of three to four words at the ages of 3 and 4 years, and four to five words at the age of 4 to 5 years. ● This age group enjoys talking, and language becomes their primary method of communication.

Body-image changes

● Toddlers appreciate the usefulness of various body parts. ● Toddlers develop gender identity by 3 years of age.

Drownin g

● Toddlers should not be left unattended in bathtubs. ● Toilet lids should be kept closed. ● Toddlers should be closely supervised when near pools or any other body of water. ● Toddlers should be taught to swim.

SLEEP AND R EST

● Toddlers typically average 11 to 12 hr of sleep per day, including one nap. ● Naps often are eliminated in older toddlerhood. ● Resistance to bedtime and expression of fears are common in this age group. ● Maintaining a regular bedtime and bedtime routines are helpful to promote sleep.

Piaget: concrete operations

● Transitions from perceptual to conceptual thinking ● Masters the concept of conservation: ◯ Conservation of mass is understood first, followed by weight, and then volume ● Learns to tell time ● Classifies more complex information ● Able to see the perspective of others ● Able to solve problems

Intramuscular

● Use a 22- to 25-gauge, ½- to 1-inch needle. ● Vastus lateralis is the recommended site in infants and small children. ● Position the child supine, side-lying, or sitting. ● Inject up to 0.5 mL for infants. ● Inject up to 2 mL for children.

Peripheral venous access devices

● Use a 24- to 20-gauge catheter. ● Use for continuous and intermittent IV medication administration. ● Short-term IV therapy can be completed at home with the assistance of a home health nurse.

ATRAUMATI C MEA SURES

● Use a treatment room for painful procedures. ● Avoid procedures in "safe places," such as the play room or the child's bed. ● Use developmentally appropriate terminology when explaining procedures. ● Offer choices to the child. ● Allow parents to stay with the child during painful procedures. ● Use play therapy to explain procedures, allowing the child to perform the procedure on a doll or toy.

Skin

● Variations in skin color are expected based on race and ethnicity. ● Temperature should be warm or slightly cool to the touch. ● Skin texture should be smooth and slightly dry, not oily. ● Skin turgor exhibits brisk elasticity with adequate hydration. ● Lesions are not expected findings. ● Skin folds should be symmetric.

Infant size is tracked using weight, height, and head circumference measurements.

● Weight: Infants gain approximately 680 g (1.5 lb) per month during the first 5 months of life. The average weight of a 6 month old infant is 7.26 kg (16 lb). Birth weight is at least doubled by the age of 5 months, and tripled by the age of 12 months to an average of 9.75 kg (21.5 lb). ● Height: Infants grow approximately 2.5 cm (1 in) per month the first 6 months of life. Growth occurs in spurts after the age of 6 months, and the birth length increases by 50% by the age of 12 months. ● Head circumference: The circumference of infants' heads increases approximately 2 cm (0.75 in) per month during the first 3 months, 1 cm (0.4 in) per month from 4 to 6 months, and then approximately 0.5 cm (0.2 in) per month during the second 6 months.

Abdomen

● Without tenderness, no guarding. Peristaltic waves can be visible in thinner children. ● Shape: Symmetric and without protrusions around the umbilicus ◯ Infants and toddlers have rounded abdomens. ◯ Children and adolescents should have flat abdomens. ● Bowel sounds should be heard every 5 to 30 seconds.

ASSESSMENT FINDINGS OF COMPLICATIONS

●● Cognitive impairment (can be severe) ●● Hyperactivity with erratic behavior ●● Bizarre behavior such as fright reactions ●● Head banging ●● Arm biting ●● Disorientation ●● Spasticity or catatonic‑like positions ●● Seizures

Fetal alcohol syndrome

●● Craniofacial features include microcephaly, small eyes with epicanthal folds, and short palpebral fissures, thin upper lip, flat midface and indistinct philtrum. ●● Lack of stranger anxiety and appropriate judgment skills ●● Many vital organ anomalies, such as limb defect and heart defects, including ventricular septal defects ●● Prenatal and postnatal growth restriction ●● Developmental delays and neurologic abnormalities ●● IQ deficit ●● Diminished fine motor skills ●● Attention deficit disorder

NEWBORN PHYSICAL ASSESSMENT FINDINGS

●● Growth failure ●● Frequent vomiting ●● Irritability ●● Musty odor to urine ●● Microcephaly ●● Heart defects ●● Blue eyes, very fair skin, light blonde hair

Cocaine exposure

●● Infant can appear normal or exhibit neurologic problems at birth. Newborn can exhibit neurobehavioral depression or excitability. ●● High‑pitched cry, abnormal sleep patterns, excessive sucking, hypertonicity, tremors, irritability, inability to console, and poor tolerance to changes in routine.

POSTOPERATIVE NURSING ACTIONS

●● Monitor vital signs. ●● Monitor I&O. ●● Monitor weight. ●● Assess for manifestations of infection. ●● Provide pain management as prescribed. ●● Assess for leakage of CSF. ●● Maintain prone position until other positions are prescribed. ●● Resume oral feedings. ●● Provide range of motion (ROM) to extremities. ●● Assess fontanels for bulging. ●● Measure head circumference.

Phenylketonuria

●● PKU is an inherited metabolic disorder in which the newborn lacks the enzyme phenylalanine hydroxylase. This enzyme converts phenylalanine, an essential amino acid, into tyrosine. The lack of this enzyme leads to the accumulation of phenylalanine in the newborn's bloodstream and tissues, which causes cognitive impairment.

PREOPERATIVE NURSING ACTIONS

●● Prepare the family for the newborn's surgery (within 24 to 72 hr after birth). ●● Protect the sac from injury. ●● Place the infant in a radiant warmer, without clothing. ●● Apply a sterile, moist nonadhering dressing with 0.9% sodium chloride on the cyst, re‑wetting as needed to prevent drying. ●● Inspect the cyst closely for leakage of fluid or manifestations of irritation. ●● Assess for manifestations of infection (fever, irritability, and lethargy). ●● Administer IV antibiotics as prescribed. ●● Avoid measuring temperatures rectally. ●● Avoid putting pressure on the sac.

PHYSICAL ASSESSMENT FINDINGS

●● Protrusion of a sac‑like cyst midline of the spine: Cysts are most commonly found in the lumbar or lumbosacral area. ●● Sensory and/or neuromotor dysfunction ◯◯ Type and severity of dysfunction dependent on location of defect ◯◯ Observe lower extremities for movement and response to stimuli ●● Possible constant dribbling of urine and loss of feces ●● Possible limb deformities

N URSIN G CARE

●● Suction the newborn's mouth, trachea, and nose as needed. ●● Maintain thermoregulation. ●● Provide mouth and skin care. ●● Correct respiratory acidosis with ventilatory support. ●● Correct metabolic acidosis by administering sodium bicarbonate. ●● Maintain adequate oxygenation, prevent lactic acidosis, and avoid the toxic effects of oxygen.

P HYSICAL ASSESSMENT FINDINGS

●● Tachypnea (respiratory rate greater than 60/min) ●● Nasal flaring ●● Expiratory grunting ●● Retractions ●● Labored breathing with prolonged expiration ●● Fine crackles on auscultation ●● Cyanosis ●● Unresponsiveness, flaccidity, and apnea with decreased breath sounds (manifestations of worsened RDS)

Feeding alternatives

◯ Breastfeeding provides a complete diet for infants during the first 6 months. ◯ Iron-fortified formula is an acceptable alternative to breast milk. Cow's milk is not recommended. ◯ It is recommended to begin vitamin D supplements within the first few days of life to prevent rickets and vitamin D deficiency. ◯ Iron supplements are recommended for infants who are being exclusively breastfed after the age of 4 months. ◯ Alternative sources of fluids, such as juice or water, are not needed during the first 4 months of life. Excessive intake of water could result in hyponatremia and water intoxication. ◯ After the age of 6 months, 100% fruit juice should be limited to 4 to 6 oz per day.

Solids are introduced around 4 to 6 months of age.

◯ Indicators for readiness include interest in solid foods, voluntary control of the head and trunk, and disappearance of the extrusion reflex. ◯ Iron-fortified cereal is typically introduced first due to its high iron content. ◯ New foods should be introduced one at a time, over a 5- to 7-day period, to observe for signs of allergy or intolerance, which might include fussiness, rash, vomiting, diarrhea, and constipation. ◯ Vegetables or fruits are started first between 6 and 8 months of age. After both have been introduced, meats may be added. ◯ Citrus fruits, meat, and eggs are not started until after 6 months of age. ◯ Breast milk/formula should be decreased as intake of solid foods increases, but should remain the primary source of nutrition through the first year. ◯ Table foods that are well-cooked, chopped, and unseasoned are appropriate by 1 year of age. ◯ Appropriate finger foods include ripe bananas, toast strips, graham crackers, cheese cubes, noodles, firmly-cooked vegetables, and raw pieces of fruit (except grapes)

Provide atraumatic care.

◯ Mix the medication in a small amount of nonessential food (such as applesauce or sherbet). ◯ Offer juice, a soft drink, or snack after administration. ◯ Add flavoring to medications as available. ◯ Use a nipple to allow the infant to suck the medication.

Separation anxiety during hospitalization manifests in three behavioral responses.

◯ Protest: screaming, clinging to parents, verbal and physical aggression toward strangers ◯ Despair: withdrawal from others, depression, decreased communication, developmental regression ◯ Detachment: interacting with strangers, forming new relationships, happy appearance ● Each child's understanding of illnesses and hospitalization is dependent on the child's stage of development and cognitive ability.

Poisoning/substance abuse

● Cleaners and chemicals should be kept in locked cabinets or out of reach of younger children. ● Children should be taught to say "no" to substance abuse.

Nails

● Pink over the nail bed and white at the tips ● Smooth and firm (but slightly flexible in infants)