Peds Exam #4

20. The nurse is assessing a child's functional self-care level for feeding, bathing and hygiene, dressing, and grooming and toileting. The child requires assistance or supervision from another person and equipment or device. What code does the nurse assign for this child? a. I b. II c. III d. IV

ANS: C A code of III indicates the child requires assistance from another person and equipment or device. A code of I indicates use of equipment or device. A code of II indicates assistance or supervision from another person. A code of IV indicates the child is totally dependent.

7. A student athlete was injured during a basketball game. The nurse observes significant swelling. The player states he thought he "heard a pop," that the pain is "pretty bad," and that the ankle feels "as if it is coming apart." Based on this description, the nurse suspects what injury? Sprain Fracture Dislocation Stress fracture

ANS: A Sprains account for approximately 75% of all ankle injuries in children. A sprain results when the trauma is so severe that a ligament is either stretched or partially or completely torn by the force created as a joint is twisted or wrenched. Joint laxity is the most valid indicator of the severity of a sprain. A fracture involves the cross-section of the bone. Dislocations occur when the force of stress on the ligaments disrupts the normal positioning of the bone ends. Stress fractures result from repeated muscular contraction and are seen most often in sports involving repetitive weight bearing such as running, gymnastics, and basketball.

3. The nurse is teaching parents the proper use of a hip-knee-ankle-foot orthosis (HKAFO) for their 4-year-old child. The parents demonstrate basic essential knowledge by making what statement? "Alcohol will be used twice a day to clean the skin around the brace." "Weekly visits to the orthotist are scheduled to check screws for tightness." "Initially, a burning sensation is expected and the brace should remain in place." "Condition of the skin in contact with the brace should be checked every 4 hr."

ANS: D This type of brace has several contact points with the child's skin. To minimize the risk of skin breakdown and facilitate use of the brace, vigilant skin monitoring is necessary. Alcohol should not be used on the skin. It is drying. Parents are capable of checking and tightening the screws when necessary. If a burning sensation occurs, the brace should be removed. If several complaints of burning occur, the orthotist should be contacted.

11. Parents are considering treatment options for their 5-year-old child with Legg-Calvé-Perthes disease. Both surgical and conservative therapies are appropriate. They are able to verbalize the differences between the therapies when they make what statement? "All therapies require extended periods of bed rest." "Conservative therapy will be required until puberty." "Our child cannot attend school during the treatment phase." "If conservative measures are unsuccessful, surgical reconstruction may be necessary."

ANS: D Surgical correction involves additional risks of anesthesia, infection, and possibly blood transfusion. The recovery period is only 3 to 4 months rather than the 2 to 4 years of conservative therapies. The use of non-weight-bearing appliances and surgical intervention does not require prolonged bed rest. Conservative therapy is indicated for 2 to 4 years. The child is encouraged to attend school and engage in activities that can be adapted to therapeutic appliances.

2. The nurse is caring for an immobilized preschool child. What intervention is helpful during this period of immobilization? Encourage wearing pajamas. Let the child have few behavioral limitations. Keep the child away from other immobilized children if possible. Take the child for a "walk" by wagon outside the room.

ANS: D Transporting the child outside of the room by stretcher, wheelchair, or wagon increases environmental stimuli and provides social contact. Street clothes are preferred for hospitalized children. This decreases the sense of illness and disability. The child needs appropriate limits for both adherence to the medical regimen and developmental concerns. It is not necessary to keep the child away from other immobilized children.

A 3-day-old infant presents with abdominal distention, is vomiting, and has not passed any meconium stools. What disease should the nurse suspect? Pyloric stenosis Intussusception Hirschsprung disease Celiac disease

ANS: C The clinical manifestations of Hirschsprung disease in a 3-day-old infant include abdominal distention, vomiting, and failure to pass meconium stools. Pyloric stenosis would present with vomiting but not distention or failure to pass meconium stools. Intussusception presents with abdominal cramping and celiac disease presents with malabsorption.

5. A 12-year-old child with Guillain-Barré syndrome (GBS) is admitted to the pediatric intensive care unit. She tells you that yesterday her legs were weak and that this morning she was unable to walk. After the nurse determines the current level of paralysis, which should the next priority assessment be? Swallowing ability Parental involvement Level of consciousness Antecedent viral infections

ANS: A Assessment of swallowing is essential. Both pharyngeal involvement and respiratory function are usually involved at the same time. The child may require ventilatory support. The inability to swallow also contributes to aspiration pneumonia. Parental involvement is important after the physiologic assessment is complete. The child is answering questions and describing the onset of the illness, which demonstrates she is alert and oriented. Information regarding antecedent viral infections can be obtained after the child is assessed and stabilized.

13. The nurse is assisting with a growth hormone stimulation test for a child with short stature. What should the nurse monitor closely on this child during the test? Hypotension Tachycardia Hypoglycemia Nausea and vomiting

ANS: A Patients receiving clonidine (Catapres) for a growth hormone stimulation test require close blood pressure monitoring for hypotension. Tachycardia, hypoglycemia, and nausea and vomiting do not occur with Catapres administered for a growth hormone stimulation test.

A spinal tap must be done on a 9-year-old boy. While he is waiting in the treatment room, the nurse observes that he seems composed. When the nurse asks him if he wants his mother to stay with him, he says, "I am fine." How should the nurse interpret this situation? This child is unusually brave. He has learned that support does not help. Nine-year-old boys do not usually want a parent present during the procedure. Children in this age-group often do not request support even though they need and want it.

ANS: D The school-age child's visible composure, calmness, and acceptance often mask an inner longing for support. Children of this age have a more passive approach to pain and an indirect request for support. It is especially important to be aware of nonverbal cues such as facial expression, silence, and lack of activity. Usually when someone identifies the unspoken messages, the child will readily accept support.

12. During the summer many children are more physically active. What changes in the management of the child with diabetes should be expected as a result of more exercise? Increase food intake Decrease food intake Increase risk of hyperglycemia Decrease of insulin reaction

ANS: A Exercise is encouraged and never restricted unless indicated by other health conditions. Exercise lowers blood glucose levels, depending on the intensity and duration of the activity. Consequently, exercise should be included as part of diabetes management, and the type and amount of exercise should be planned around the child's interests and capabilities. However, in most instances, children's activities are unplanned, and the resulting decrease in blood glucose can be compensated for by providing extra snacks before (and, if the exercise is prolonged, during) the activity. In addition to a feeling of well-being, regular exercise aids in utilization of food and often results in a reduction of insulin requirements.

The nurse is providing support to parents adapting to the hospitalization of their child to the pediatric intensive care unit. The nurse notices that the parents keep asking the same questions. What should the nurse do? Patiently continue to answer questions, trying different approaches. Kindly refer them to someone else for answering their questions. Recognize that some parents cannot understand explanations. Suggest that they ask their questions when they are not upset.

ANS: A In addition to a general pediatric unit, children may be admitted to special facilities such as an ambulatory or outpatient setting, an isolation room, or intensive care. Wherever the location, the core principles of patient and family-centered care provide a foundation for all communication and interventions with the patient, family, and health care team. The nurse should do the therapeutic action and patiently continue to answer questions, trying different approaches.

20. What intervention is contraindicated in a suspected case of appendicitis? Enemas Palpating the abdomen Administration of antibiotics Administration of antipyretics for fever

ANS: A In any instance in which severe abdominal pain is observed and appendicitis is suspected, the nurse must be aware of the danger of administering laxatives or enemas. Such measures stimulate bowel motility and increase the risk of perforation. The abdomen is palpated after other assessments are made. Antibiotics should be administered, and antipyretics are not contraindicated.

17. A child is being admitted to the hospital with acute gastroenteritis. The health care provider prescribes an antiemetic. What antiemetic does the nurse anticipate being prescribed? Ondansetron (Zofran) Promethazine (Phenergan) Metoclopramide (Reglan) Dimenhydrinate (Dramamine)

ANS: A Ondansetron reduces the duration of vomiting in children with acute gastroenteritis. This would be the expected prescribed antiemetic. Adverse effects with earlier generation antiemetics (e.g., promethazine and metoclopramide) include somnolence, nervousness, irritability, and dystonic reactions and should not be routinely administered to children. For children who are prone to motion sickness, it is often helpful to administer an appropriate dose of dimenhydrinate (Dramamine) before a trip, but it would not be ordered as an antiemetic.

The clinic nurse is assessing infant reflexes. What assessment indicates a persistence of primitive reflexes? Tonic neck reflex at 8 months of age Palmar grasp at 4 months of age Plantar grasp at 9 months of age Rooting reflex at 3 months of age

ANS: A Persistence of primitive reflexes is one of the earliest clues to CP (e.g., obligatory tonic neck reflex at any age or nonobligatory persistence beyond 6 months of age and the persistence or even hyperactivity of the Moro, plantar, and palmar grasp reflexes). The palmar grasp disappears by 6 months, the plantar grasp disappears by 12 months, and the rooting reflex disappears at 4 months, so these are normal findings.

20. The nurse is teaching the family of an infant with cerebral palsy how to administer a diazepam (Valium) pill by gastrostomy tube. What should the nurse include in the teaching session? The pill should be crushed and mixed with a small amount of water. The pill should be crushed and mixed with the infant's formula. After administering the medication, flush the tube with air. Before administering the medication, check the placement of the tube.

ANS: A Pills may be crushed and mixed with small amounts of water but not other liquids, such as formula or elixir medications, because these may act together to form a sludge that can interfere with gastrostomy tube function. When crushed pills or tablets are administered, flush the feeding tube with more water after instilling the dissolved pill in water. The tube should not be flushed with air, and placement does not need to be checked because it is directly into the stomach.

6. An adolescent whose leg was crushed when she fell off a horse is admitted to the emergency department. She has completed the tetanus immunization series, receiving the last tetanus toxoid booster 8 years ago. What care is necessary for therapeutic management of this adolescent to prevent tetanus? Tetanus toxoid booster is needed because of the type of injury. Human tetanus immunoglobulin is indicated for immediate prophylaxis. Concurrent administration of both tetanus immunoglobulin and tetanus antitoxin is needed. No additional tetanus prophylaxis is indicated. The tetanus toxoid booster is protective for 10 years.

ANS: A Protective levels of antibody are maintained for at least 10 years. Children with serious "tetanus-prone" wounds, including contaminated, crush, puncture, or burn wounds, should receive a tetanus toxoid booster prophylactically as soon as possible. This adolescent has circulating antibodies. The immunoglobulin is not indicated.

16. Parents of a hospitalized child often question the skill of staff. The nurse interprets this behavior by the parents as what? Normal Paranoid Indifferent W anting attention

ANS: A Recent research has identified common themes among parents whose children were hospitalized, including feeling an overall sense of helplessness, questioning the skills of staff, accepting the reality of hospitalization, needing to have information explained in simple language, dealing with fear, coping with uncertainty, and seeking reassurance from the health care team. The behavior does not indicate the parents are paranoid, indifferent, or wanting attention.

5. An 8-year-old girl is being admitted to the hospital from the emergency department with an injury from falling off her bicycle. What intervention will help her most in her adjustment to the hospital? Explain hospital schedules to her, such as mealtimes. Use terms such as "honey" and "dear" to show a caring attitude. Explain when parents can visit and why siblings cannot come to see her. Orient her parents, because she is too young, to her room and hospital facility.

ANS: A School-age children need to have control of their environment. The nurse should offer explanations or prepare the child for what to expect. The nurse should refer to the child by the preferred name. Explaining when parents can visit and why siblings cannot come focuses on the limitations rather than helping her adjust to the hospital. At the age of 8 years, the child should be oriented to the environment along with the parents.

The mother of a 7-month-old infant newly diagnosed with cystic fibrosis is rooming in with her infant. She is breastfeeding and provides all the care except for the medication administration. What should the nurse include in the plan of care? Ensuring that the mother has time away from the infant Making sure the mother is providing all of the infant's care Determining whether other family members can provide the necessary care so the mother can rest Contacting the social worker because of the mother's interference with the nursing care

ANS: A The mother needs sufficient rest and nutrition, so she can be effective as a caregiver. While the infant is hospitalized, the care is the responsibility of the nursing staff. The mother should be made comfortable with the care the staff provides in her absence. The mother has a right to provide care for the infant. The nursing staff and the mother should agree on the care division.

15. The nurse is caring for a neonate born with a myelomeningocele. Surgery to repair the defect is scheduled the next day. What is the most appropriate way to position and feed this neonate? Prone with the head turned to the side On the side Supine in an infant carrier Supine, with defect supported with rolled blankets

ANS: A The prone position with the head turned to the side for feeding is the optimum position for the infant. It protects the spinal sac and allows the infant to be fed without trauma. The side-lying position is avoided preoperatively. It can place tension on the sac and affect hip dysplasia if present. The infant should not be placed in a supine position.

17. When a preschool-age child is hospitalized, particularly when isolation is required without adequate preparation, the nurse should recognize that the child may likely see hospitalization as what? Punishment Loss of parental love Threat to the child's self-image Loss of companionship with friends

ANS: A The rationale for preparing children for the hospital experience and related procedures is based on the principle that a fear of the unknown (fantasy) exceeds fear of the known. Preschool-age children see hospitalization as a punishment. Loss of parental love would be a toddler's reaction. Threat to the child's self-image would be a school-age child's reaction. Loss of companionship with friends would be an adolescent's reaction.

Chapter 31 1. A child with hypopituitarism is being started on growth hormone (GH) therapy. Nursing considerations should be based on which knowledge? Therapy is most successful if it is started during adolescence. Replacement therapy requires daily subcutaneous injections. Hormonal supplementation will be required throughout child's lifetime. Treatment is considered successful if children attain full stature by adolescence.

ANS: B Additional support is required for children who require hormone replacement therapy, such as preparation for daily subcutaneous injections and education for self-management during the school-age years. Young children, obese children, and those who are severely GH deficient have the best response to therapy. Replacement therapy is not needed after attaining final height. The children are no longer GH deficient. When therapy is successful, children can attain their actual or near-final adult height at a slower rate than their peers.

11. The nurse is notified that a 9-year-old boy with nephrotic syndrome is being admitted. Only semiprivate rooms are available. What roommate should be best to select? A 10-year-old girl with pneumonia An 8-year-old boy with a fractured femur A 10-year-old boy with a ruptured appendix A 9-year-old girl with congenital heart disease

ANS: B An 8-year-old boy with a fractured femur would be the best choice for a roommate. The boys are similar in age. The child with nephrotic syndrome most likely will be on immunosuppressive agents and susceptible to infection. The child with a fractured femur is not infectious. A girl should not be a good roommate for a school-age boy. In addition, the 10-year-old girl with pneumonia and the 10-year-old boy with a ruptured appendix have infections and could pose a risk for the child with nephrotic syndrome.

16. An infant is born with one lower limb deficiency. When is the optimum time for the child to be fitted with a functional prosthetic device? As soon as possible after birth. When the infant is developmentally ready to stand up. At about ages 12 to 15 months, when most children are walking. At about 4 years, when the healthy limb is not growing so rapidly.

ANS: B An infant should be fitted with a functional prosthetic leg when the infant is developmentally ready to pull to a standing position. When the infant begins limb exploration, a soft prosthesis can be used. The child should begin using the prosthesis as part of his or her normal development. This will match the infant's motor readiness.

Chapter 25 1. A toddler's mother calls the nurse because she thinks her son has swallowed a button type of battery. He has no signs of respiratory distress. The nurse's response should be based on which premise? An emergency laparotomy is very likely. The location needs to be confirmed by radiographic examination. Surgery will be necessary if the battery has not passed in the stool in 48 hr. Careful observation is essential because an ingested battery cannot be accurately detected.

ANS: B Button batteries can cause severe damage if lodged in the esophagus. If both poles of the battery come in contact with the wall of the esophagus, acid burns, necrosis, and perforation can occur. If the battery is in the stomach, it will most likely be passed without incident. Surgery is not indicated. The battery is metallic and is readily seen on radiologic examination.

11. The nurse is preparing a staff education in-service session for a group of new graduate nurses who will be working in a long-term care facility for children; many of the children have cerebral palsy (CP). What statement should the nurse include in the training? Children with dyskinetic CP have a wide-based gait and repetitive movements. Children with spastic pyramidal CP have a positive Babinski sign and ankle clonus. Children with hemiplegia CP have mouth muscles and one lower limb affected. Children with ataxic CP have involvement of pharyngeal and oral muscles with dysarthria.

ANS: B CP has a variety of clinical classifications. Spastic pyramidal CP includes manifestations such as a positive Babinski sign and ankle clonus; ataxic CP has a wide-based gait and repetitive movements; hemiplegia CP is characterized by motor dysfunction on one side of the body with upper extremity more affected than lower limbs; and dyskinetic CP involves the pharyngeal and oral muscles, causing drooling and dysarthria.

6. A 13-year-old child with cystic fibrosis (CF) is a frequent patient on the pediatric unit. This admission, she is sleeping during the daytime and unable to sleep at night. What should be a beneficial strategy for this child? Administer prescribed sedative at night to aid in sleep. Negotiate a daily schedule that incorporates hospital routine, therapy, and free time. Have the practitioner speak with the child about the need for rest when receiving therapy for CF.d. Arrange a consult with the social worker to determine whether issues at home are interfering with her care.

ANS: B Children's response to the disruption of routine during hospitalization is demonstrated in eating, sleeping, and other activities of daily living. The lack of structure is allowing the child to sleep during the day, rather than at night. Most likely the lack of schedule is the problem. The nurse and child can plan a schedule that incorporates all necessary activities, including medications, mealtimes, homework, and patient care procedures. The schedule can then be posted, so the child has a ready reference. Sedatives are not usually used with children. The child has a chronic illness and most likely knows the importance of rest. The parents and child can be questioned about changes at home since the last hospitalization.

The nurse should suspect a child has cerebral palsy (CP) if the parent says what? "My 6-month-old baby is rolling from back to prone now." "My 4-month-old doesn't lift his head when on his tummy." "My 8-month-old can sit without support." "My 10-month-old is not walking."

ANS: B Delayed gross motor development is a universal manifestation of CP. The child shows a delay in all motor accomplishments, and the discrepancy between motor ability and expected achievement tends to increase with successive developmental milestones as growth advances. The infant who does not lift his head when on the tummy is showing a gross motor delay, as that is seen at 0 to 3 months. The other statements are within normal growth and development expectations.

A child has just returned from surgery for repair of a fractured femur. The child has a long-leg cast on. The toes on the leg with the cast are edematous, but they have color, sensitivity, and movement. What action should the nurse take? Call the health care provider to report the edema. Elevate the foot and leg on pillows. Apply a warm moist pack to the foot. Encourage movement of toes.

ANS: B During the first few hours after a cast is applied, the chief concern is that the extremity may continue to swell to the extent that the cast becomes a tourniquet, shutting off circulation and producing neurovascular complications (compartment syndrome). One measure to reduce the likelihood of this problem is to elevate the body part and thereby increase venous return. The health care provider does not need to be notified because edema is expected and warm moist packs will not decrease the edema. The child should move the toes, but that will not help reduce the edema.

10. What should preoperative care of a newborn with an anorectal malformation include? Frequent suctioning Gastrointestinal decompression Feedings with sterile water only Supine position with head elevated

ANS: B Gastrointestinal decompression is an essential part of nursing care for a newborn with an anorectal malformation. This helps alleviate intra-abdominal pressure until surgical intervention. Suctioning is not necessary for an infant with this type of anomaly. Feedings are not indicated until it is determined that the gastrointestinal tract is intact. Supine position with head elevated is indicated for infants with a tracheoesophageal fistula, not anorectal malformations.

A 6-month-old infant with Hirschsprung disease is scheduled for a temporary colostomy. What should postoperative teaching to the parents include? Dilating the stoma Assessing bowel function Limitation of physical activities Measures to prevent prolapse of the rectum

ANS: B In the postoperative period, the nurse involves the parents in the care of the child with a temporary colostomy, allowing them to help with feedings and observe for signs of wound infection or irregular passage of stool (constipation or true incontinence). Some children will require daily anal dilatations in the postoperative period to avoid anastomotic strictures but not stoma dilatations. Physical activities should be encouraged. There is not a risk of prolapse of the rectum in Hirschsprung disease, just strictures.

5. Congenital adrenal hyperplasia (CAH) is suspected in a newborn because of ambiguous genitalia. The parents are appropriately upset and concerned about their child's gender. In teaching the parents about CAH, what should the nurse explain? Reconstructive surgery as a female is preferred. Sexual assignment should wait until genetic sex is determined. Prenatal masculinization will strongly influence the child's development. The child should be raised as a boy because of the presence of a penis and scrotum.

ANS: B It is preferable to raise the child according to genetic sex. With hormone replacement and surgical intervention if needed, genetically female children achieve satisfactory results in reversing virilism and achieving normal puberty and ability to conceive. Reconstructive surgery as a female is only preferred for infants who are genetically female. Infants who are genetically male should be given hormonal supplementation. Sex assignment and rearing depend on psychosocial influences, not on genetic sex hormone influences during fetal life. It is not advised to raise the child as a boy because of the presence of a penis and scrotum unless the child is genetically male. If a genetic female, the child will be sterile and may never be able to function satisfactorily in a heterosexual relationship.

A child, age 3 years, has cerebral palsy (CP) and is hospitalized for orthopedic surgery. His mother says he has difficulty swallowing and cannot hold a utensil to feed himself. He is slightly underweight for his height. What is the most appropriate nursing action related to feeding this child? Bottle or tube feed him a specialized formula until he gains sufficient weight. Stabilize his jaw with caregiver's hand (either from a front or side position) to facilitate swallowing. Place him in a well-supported, semi-reclining position. Place him in a sitting position with his neck hyperextended to make use of gravity flow.

ANS: B Jaw control is compromised in many children with CP. More normal control is achieved if the feeder stabilizes the oral mechanisms from the front or side of the face. Bottle or tube feeding will not improve feeding without jaw support. The semi-reclining position and hyperextended neck position increase the chances of aspiration.

6. An infant with short bowel syndrome is receiving total parenteral nutrition (TPN). The practitioner has added continuous enteral feedings through a gastrostomy tube. The nurse recognizes this as important for which reason? Wean the infant from TPN the next day. Stimulate adaptation of the small intestine. Give additional nutrients that cannot be included in the TPN. Provide parents with hope that the child is close to discharge.

ANS: B Long-term survival without TPN depends on the small intestine's ability to increase its absorptive capacity. Continuous enteral feedings facilitate the adaptation. TPN is indicated until the child is able to receive all nutrition via the enteral route. Before this is accomplished, the small intestine must adapt and increase in cell number and cell mass per villus column. TPN is formulated to meet the infant's nutritional needs. Continuous enteral feedings through a gastrostomy tube is a positive sign, but the infant's ability to tolerate increasing amounts of enteral nutrition is only one factor that determines readiness for discharge.

14. The nurse is caring for a 10-year-old child during a long hospitalization. What intervention should the nurse include in the care plan to minimize loss of control and autonomy during the hospitalization? Allow the child to skip morning self-care activities to watch a favorite television program. Create a calendar with special events such as a visit from a friend to maintain a routine.c. Allow the child to sleep later in the morning and go to bed later at night to promote control.d. Create a restrictive environment so the child feels in control of sensory stimulation.

ANS: B School-age children may feel an overwhelming loss of control and autonomy during a longer hospitalization. One intervention to minimize this loss of control is to create a calendar with planned special events such as a visit from a friend. Maintaining the child's daily routine is another intervention to minimize the sense of loss of control; allowing the child to skip morning self-care activities, sleep later, or stay up later would work against this goal. Environments should be as nonrestrictive as possible to allow the child freedom to move about, thus allowing a sense of autonomy.

An adolescent comes to the school nurse after experiencing shin splints during a track meet. What reassurance should the nurse offer? Shin splints are expected in runners. Ice, rest, and nonsteroidal anti-inflammatory drugs (NSAIDs) usually relieve pain. It is generally best to run around and "work the pain out." Moist heat and acetaminophen are indicated for this type of injury.

ANS: B Shin splints result when the ligaments tear away from the tibial shaft and cause pain. Actions that have an anti-inflammatory effect are indicated for shin splints. Ice, rest, and NSAIDs are the usual treatment. Shin splints are rarely serious, but they are not expected, and preventive measures are taken. Rest is important to heal the shin splints. Continuing to place stress on the tibia can lead to further damage.

14. The nurse is teaching the parent of a 4-year-old child with a cast on the arm about care at home. What statement by the parent indicates a correct understanding of the teaching? "I should have the affected limb hang in a dependent position." "I will use an ice pack to relieve the itching." "I should avoid keeping the injured arm elevated." "I will expect the fingers to be swollen for the next 3 days."

ANS: B Teaching the parent to use an ice pack to relieve the itching is an important aspect when planning discharge for a child with a cast. The affected limb should not be allowed to hang in a dependent position for more than 30 minutes. The affected arm should be kept elevated as much as possible. If there is swelling or redness of the fingers, the parent should notify the health care provider.

17. The nurse knows that parents need further teaching with regard to the treatment of congenital clubfoot when they state what? "We'll keep the cast dry." "We're happy this is the only cast our baby will need." "We'll watch for any swelling of the foot while the cast is on." d. "We're getting a special car seat to accommodate the cast."

ANS: B The common approach to clubfoot management and treatment is the Ponseti method. Serial casting is begun shortly after birth. Weekly gentle manipulation and stretching of the foot along with placement of serial long-leg casts allow for gradual repositioning of the foot. The extremity or extremities are casted until maximum correction is achieved, usually within 6 to 10 weeks. If parents state that this is the only cast the infant will need, they need further teaching.

14. The most important nursing intervention when caring for an infant with myelomeningocele in the preoperative stage is which? Take vital signs every hour. Place the infant in the prone position to minimize tension on the sac. Watch for signs that might indicate developing hydrocephalus. Apply a heat lamp to facilitate drying and toughening of the sac.

ANS: B The spinal sac is protected from damage until surgery is performed. Early surgical closure is recommended to prevent local trauma and infection. Monitoring vital signs and watching for signs that might indicate developing hydrocephalus are important interventions, but preventing trauma to the sac is a priority. The sac is kept moist until surgical intervention is done.

11. The parents of a newborn with an umbilical hernia ask about treatment options. The nurse's response should be based on which knowledge? Surgery is recommended as soon as possible. The defect usually resolves spontaneously by 3 to 5 years of age. Aggressive treatment is necessary to reduce its high mortality. Taping the abdomen to flatten the protrusion is sometimes helpful.

ANS: B The umbilical hernia usually resolves by ages 3 to 5 years of age without intervention. Umbilical hernias rarely become problematic. Incarceration, where the hernia is constricted and cannot be reduced manually, is rare. Umbilical hernias are not associated with a high mortality rate. Taping the abdomen flat does not help heal the hernia; it can cause skin irritation.

4. A 10-year-old girl needs to have another intravenous (IV) line started. She keeps telling the nurse, "Wait a minute," and, "I'm not ready." How should the nurse interpret this behavior? IV insertions are viewed as punishment. This is expected behavior for a school-age child. Protesting like this is usually not seen past the preschool years. The child has successfully manipulated the nurse in the past.

ANS: B This school-age child is attempting to maintain some control over the hospital experience. The nurse should provide the girl with structured choices about when the IV line will be inserted. Preschoolers can view procedures as punishment; this is not typical behavior of a preschool-age child.

5. What is an appropriate nursing intervention when caring for a child in traction? Removing adhesive traction straps daily to prevent skin breakdown Assessing for tightness, weakness, or contractures in uninvolved joints and muscles Providing active range of motion exercises to affected extremity three times a day Keeping child prone to maintain good alignment

ANS: B Traction places stress on the affected bone, joint, and muscles. The nurse must assess for tightness, weakness, or contractures developing in the uninvolved joints and muscles. The adhesive straps should be released or replaced only when absolutely necessary. Active, passive, or active with resistance exercises should be carried out for the unaffected extremity only. Movement is expected with children. Each time the child moves, the nurse should check to ensure that proper alignment is maintained.

9. To help an adolescent deal with diabetes, the nurse needs to consider which characteristic of adolescence? Desire to be unique Preoccupation with the future Need to be perfect and similar to peers Awareness of peers that diabetes is a severe disease

ANS: C Adolescence is a time when the individual has a need to be perfect and similar to peers. Having diabetes makes adolescents different from their peers. Adolescents do not wish to be unique; they desire to fit in with the peer group. An adolescent is usually not future oriented. Awareness of peers that diabetes is a severe disease would further alienate the adolescent with diabetes. The peer group would focus on the differences.

10. The nurse is teaching the girls' varsity sports teams about the "female athlete triad." What is essential information to include? They should take low to moderate calcium to avoid hypercalcemia. They have strong bones because of the athletic training. Low estrogen levels may lead to a deficit in bone mineral density. A diet high in carbohydrates accommodates increased training.

ANS: C Adolescent athletes with amenorrhea have a lower bone mineral density. Increased calcium (1500 mg) is recommended for amenorrheic athletes. The decreased estrogen in girls with the female athlete triad, coupled with potentially inadequate diet, leads to osteoporosis. Diets high in protein and calories are necessary to avoid potentially long-term consequences of intensive, prolonged exercise programs in pubertal girls.

3. A child is receiving propylthiouracil for the treatment of hyperthyroidism (Graves disease). The parents and child should be taught to recognize and report which sign or symptom immediately? Fatigue Weight loss Fever, sore throat Upper respiratory tract infection

ANS: C Children being treated with propylthiouracil must be carefully monitored for the side effects of the drug. Parents must be alerted that sore throat and fever accompany the grave complication of leukopenia. These symptoms should be immediately reported. Fatigue and weight loss are manifestations of hyperthyroidism. Their presence may indicate that the drug is not effective but does not require immediate evaluation. Upper respiratory tract infections are most likely viral in origin and not a sign of leukopenia.

7. Two hospitalized adolescents are playing pool in the activity room. Neither of them seems enthusiastic about the game. How should the nurse interpret this situation? Playing pool requires too much concentration for this age-group. Pool is an activity better suited for younger children. The adolescents may be enjoying themselves but have lower energy levels than healthy children. The adolescents' lack of enthusiasm is one of the signs of depression.

ANS: C Children who are ill and hospitalized typically have lower energy levels than healthy children. Therefore, children may not appear enthusiastic about an activity even when they are enjoying it. Pool is an appropriate activity for adolescents. They have the cognitive and psychomotor skills that are necessary. If the adolescents were significantly depressed, they would be unable to engage in the game.

Chapter 34 1. The parents of an infant with cerebral palsy (CP) ask the nurse if their child will have cognitive impairment. The nurse's response should be based on which knowledge? Affected children have some degree of cognitive impairment. Around 20% of affected children have normal intelligence. About 30% to 50% of affected children have significant cognitive impairments. Cognitive impairment is expected if motor and sensory deficits are severe.

ANS: C Children with CP have a wide range of intelligence, and 30% to 50% have significant cognitive impairments. A large percentage of children with CP do not have mental impairment. Many individuals who have severely limiting physical impairment have the least amount of intellectual compromise.

What nursing intervention is most appropriate when caring for the child with osteomyelitis? Encourage frequent ambulation. Administer antibiotics with meals. Move and turn the child carefully and gently to minimize pain. Provide active range of motion exercises for the affected extremity.

ANS: C During the acute phase, any movement of the affected limb causes discomfort to the child. Careful positioning with the affected limb supported is necessary. Weight bearing is not permitted until healing is well under way to avoid pathologic fractures. Intravenous antibiotics are used initially. Food is not necessary with parenteral therapy. Active range of motion would be painful for the child.

The nurse is caring for a hospitalized adolescent whose femur was fractured 18 hr ago. The adolescent suddenly develops chest pain and dyspnea. The nurse should suspect what complication? Sepsis Osteomyelitis Pulmonary embolism Acute respiratory tract infection

ANS: C Fat emboli are of greatest concern in individuals with fractures of the long bones. Fat droplets from the marrow are transferred to the general circulation, where they are transported to the lung or brain. This type of embolism usually occurs within the second 12 hr after the injury. Sepsis would manifest with fever and lethargy. Osteomyelitis usually is seen with pain at the site of infection and fever. A child with an acute respiratory tract infection would have nasal congestion, not chest pain.

19. A feeding technique the nurse can teach to parents of a child with cerebral palsy to improve use of the lips and the tongue to facilitate speech is which? Feeding pureed foods Placing food on the tongue Placing food at the side of the tongue Placing food directly into the mouth with a spoon

ANS: C Feeding techniques such as forcing the child to use the lips and tongue in eating facilitate speech. An example of this technique is placing food at the side of the tongue, first one side and then the other, and making the child use the lips to take food from a spoon rather than placing it directly on the tongue. Feeding pureed foods would not encourage use of the lips and tongue.

2. The mother of a child with cognitive impairment calls the nurse because her son has been gagging and drooling all morning. The nurse suspects foreign body ingestion. What physiologic occurrence is most likely responsible for the presenting signs? Gastrointestinal perforation may have occurred. The object may have been aspirated. The object may be lodged in the esophagus. The object may be embedded in stomach wall.

ANS: C Gagging and drooling may be signs of esophageal obstruction. The child is unable to swallow saliva, which contributes to the drooling. Signs of gastrointestinal (GI) perforation include chest or abdominal pain and evidence of bleeding in the GI tract. If the object was aspirated, the child would most likely have coughing, choking, inability to speak, or difficulty breathing. If the object was embedded in the stomach wall, it would not result in symptoms of gagging and drooling.

9. The nurse at a summer camp recognizes the signs of heatstroke in an adolescent girl. Her temperature is 40° C (104° F). She is slightly confused but able to drink water. Nursing care while waiting for transport to the hospital should include what intervention? Administer antipyretics. Administer salt tablets. Apply towels wet with cool water. Sponge with solution of rubbing alcohol and water.

ANS: C Heatstroke is a failure of normal thermoregulatory mechanisms. The onset is rapid with initial symptoms of headache, weakness, and disorientation. Immediate care is relocation to a cool environment, removal of clothing, and applying of cool water (wet towels or immersion). Antipyretics are not used because they are metabolized by the liver, which is already not functioning. Salt tablets are not indicated and may be harmful by increasing dehydration. Rubbing alcohol is not used.

19. An infant had a gastrostomy tube placed for feedings after a Nissen fundoplication and bolus feedings are initiated. Between feedings while the tube is clamped, the infant becomes irritable, and there is evidence of cramping. What action should the nurse implement? Burp the infant. Withhold the next feeding. Vent the gastrostomy tube. Notify the health care provider.

ANS: C If bolus feedings are initiated through a gastrostomy after a Nissen fundoplication, the tube may need to remain vented for several days or longer to avoid gastric distention from swallowed air. Edema surrounding the surgical site and a tight gastric wrap may prohibit the infant from expelling air through the esophagus, so burping does not relieve the distention. Some infants benefit from clamping of the tube for increasingly longer intervals until they are able to tolerate continuous clamping between feedings. During this time, if the infant displays increasing irritability and evidence of cramping, some relief may be provided by venting the tube. The next feeding should not be withheld, and calling the health care provider is not necessary.

The nurse is caring for an infant who had surgical repair of a tracheoesophageal fistula 24 hr ago. Gastrostomy feedings have not been started. What do nursing actions related to the gastrostomy tube include? Keep the tube clamped. Suction the tube as needed. Leave the tube open to gravity drainage. Lower the tube to a point below the level of the stomach.

ANS: C In the immediate postoperative period, the gastrostomy tube is open to gravity drainage. This usually is continued until the infant is able to tolerate feedings. The tube is unclamped in the postoperative period to allow for the drainage of secretions and air. Gastrostomy tubes are not suctioned on an as-needed basis. They may be connected to low suction to facilitate drainage of secretions. Lowering the tube to a point below the level of the stomach would create too much pressure.

20. The nurse is teaching infant care to parents with an infant who has been diagnosed with osteogenesis imperfecta (OI). What should the nurse include in the teaching session? "Bisphosphonate therapy is not beneficial for OI." "Physical therapy should be avoided as it may cause damage to bones." "Lift the infant by the buttocks, not the ankles, when changing diapers." "The infant should meet expected gross motor development without assistive devices."

ANS: C Infants and children with this disorder require careful handling to prevent fractures. They must be supported when they are being turned, positioned, moved, and held. Even changing a diaper may cause a fracture in severely affected infants. These children should never be held by the ankles when being diapered but should be gently lifted by the buttocks or supported with pillows. Bisphosphonate and physical therapy are beneficial for OI. Lightweight braces will be used when the child starts to ambulate.

7. During a well-child visit, the mother tells the nurse that her 4-month-old infant is constipated, is less active than usual, and has a weak-sounding cry. The nurse suspects botulism and questions the mother about the child's diet. What factor should support this diagnosis? Breastfeeding Commercial formula Infant cereal with honey Improperly sterilized bottles

ANS: C Ingestion of honey is a risk factor for infant botulism in the United States. Honey should not be given to children younger than the age of 1 year. Botulism is not found with the use of commercial infant cereals. Although there is a slight increase in botulism in breastfed infants when compared with formula-fed infants, there is not sufficient evidence to support formula feeding as prevention. Thoroughly cleaning bottles used for formula feeding is sufficient for botulism prevention. Inadequate sterilization of home-canned foods can contribute to botulism.

A child with juvenile idiopathic arthritis (JIA) is started on a nonsteroidal anti-inflammatory drug (NSAID). What nursing consideration should be included? Monitor heart rate. Administer NSAIDs between meals. Check for abdominal pain and bloody stools. Expect inflammation to be gone in 3 or 4 days.

ANS: C NSAIDs are the first-line drugs used in JIA. Potential side effects include gastrointestinal (GI), renal, and hepatic side effects. The child is at risk for GI bleeding and elevated blood pressure. The heart rate is not affected by this drug class. NSAIDs should be given with meals to minimize gastrointestinal problems. The anti-inflammatory response usually takes 3 weeks before effectiveness can be evaluated.

9. The parents of a 3 year old admitted for recurrent diarrhea are upset that the practitioner has not told them what is going on with their child. What is the priority intervention for this family? Answer all of the parents' questions about the child's illness. Immediately page the practitioner to come to the unit to speak with the family. Help the family develop a written list of specific questions to ask the practitioner. Inform the family of the time that hospital rounds are made so that they can be present.

ANS: C Often families ask general questions of health care providers and do not receive the information they need. The nurse should determine what information the family does want and then help develop a list of questions. When the questions are written, the family can remember which questions to ask or can hand the sheet to the practitioner for answers. The nurse may have the information the parents want, but they are asking for specific information from the practitioner. Unless it is an emergency, the nurse should not place a stat page for the practitioner. Being present is not necessarily the issue but rather the ability to get answers to specific questions.

4. The nurse uses the five Ps to assess ischemia in a child with a fracture. What finding is considered a late and ominous sign? a. Petaling b. Posturing c. Pulselessness d. Positioning

ANS: C Puslselessness is an ominous sign that requires immediate notification of the practitioner. Permanent muscle and tissue damage can occur within 6 hr. The other signs of ischemia that need to be reported are pain, pallor, pulselessness, and paralysis. Petaling is a method of placing protective or smooth edges on a cast. Posturing is not a sign of peripheral ischemia. Finding a position of comfort can be difficult with a fracture. It would not be an ominous sign unless pain was increasing or uncontrollable.

4. When caring for a child with probable appendicitis, the nurse should be alert to recognize which sign or symptom as a manifestation of perforation? Anorexia Bradycardia Sudden relief from pain Decreased abdominal distention

ANS: C Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation. Anorexia is already a clinical manifestation of appendicitis. Tachycardia, not bradycardia, is a manifestation of peritonitis. Abdominal distention usually increases in addition to an increase in pain (usually diffuse and accompanied by rigid guarding of the abdomen).

9. A 14-year-old girl is in the intensive care unit after a spinal cord injury 2 days ago. What nursing intervention is a priority for this child? Minimizing environmental stimuli Administering immunoglobulin Monitoring and maintaining systemic blood pressure Discussing long-term care issues with the family

ANS: C Spinal cord injury patients are physiologically labile, and close monitoring is required. They may be unstable for the first few weeks after the injury. Increased blood pressure may be an indication of autonomic dysreflexia. It is not necessary to minimize environmental stimuli for this type of injury. Spinal cord injury is not an infectious process. Immunoglobulin is not indicated. Discussing long-term care issues with the family is inappropriate. The family is focusing on the recovery of their child. It will not be known until the rehabilitation period how much function the child may recover.

A 6 year old is being discharged home, which is 90 miles from the hospital, after an outpatient hernia repair. In addition to explicit discharge instructions, what should the nurse provide? An ambulance for transport home Verbal information about follow-up care Prescribed pain medication before discharge Driving instructions for a route with less traffic

ANS: C The nurse should anticipate that the child will begin experiencing pain on the trip home. By providing a dose of oral analgesia, the nurse can ensure the child remains comfortable during the trip. Transport by ambulance is not indicated for a hernia repair. Discharge instructions should be written. The parents will be focusing on their child and returning home, which limits their ability to retain information. The parents should know the most expedient route home.

16. The nurse is assisting a child with celiac disease to select foods from a menu. What foods should the nurse suggest? Hamburger on a bun Spaghetti with meat sauce Corn on the cob with butter Peanut butter and crackers

ANS: C Treatment of celiac disease consists primarily of dietary management. Although a gluten-free diet is prescribed, it is difficult to remove every source of this protein. Some patients are able to tolerate restricted amounts of gluten. Because gluten occurs mainly in the grains of wheat and rye but also in smaller quantities in barley and oats, these foods are eliminated. Corn, rice, and millet are substitute grain foods. Corn on the cob with butter would be gluten free.

12. What should the nurse consider when providing support to a family whose infant has just been diagnosed with biliary atresia? The prognosis for full recovery is excellent. Death usually occurs by 6 months of age. One third requires a liver transplant. Children with surgical correction live normal lives.

ANS: C Untreated biliary atresia results in progressive cirrhosis and death usually by 2 years of age. Surgical intervention at 8 weeks of age is associated with somewhat better outcomes. Liver transplantation is also improving outcomes for 10-year survival. Even with surgical intervention, most children require supportive therapy. With early intervention, 10-year survival rates range from 27% to 75%.

14. The nurse is taking care of a child who had a thyroidectomy. The nurse recognizes what as a positive Chvostek sign? Paresthesia occurring in feet and toes Frequent sharp flexion of wrist and ankle joints Carpal spasm elicited by pressure applied to the nerves of the upper arm Facial muscle spasm elicited by tapping the facial nerve in the region of the parotid gland

ANS: D A positive Chvostek sign is a facial muscle spasm that is elicited by tapping the facial nerve in the region of the parotid gland. Paresthesia occurring in the feet and toes and frequent sharp flexion of the wrist and ankle joints can be signs of hypoparathyroidism but are not part of a positive Chvostek sign. Carpal spasm elicited by pressure applied to nerves of the upper arm is called a positive Trousseau sign.

3. An 8-year-old girl with moderate cerebral palsy (CP) recently began joining a regular classroom for part of the day. Her mother asks the school nurse about joining the after-school Girl Scout troop. The nurse's response should be based on which knowledge? Most activities such as Girl Scouts cannot be adapted for children with CP. After-school activities usually result in extreme fatigue for children with CP. Trying to participate in activities such as Girl Scouts leads to lowered self-esteem in children with CP. Recreational activities often provide children with CP with opportunities for socialization and recreation.

ANS: D After-school and recreational activities serve to stimulate children's interest and curiosity. They help the children adjust to their disability, improve their functional ability, and build self-esteem. Increasing numbers of programs are adapted for children with physical limitations. Almost all activities can be adapted. The child should participate to her level of energy. Self-esteem increases as a result of the positive feedback the child receives from participation.

19. What should the nurse plan for an immobilized child in cervical traction to prevent deep vein thrombosis (DVT)? Elevate the child's legs. Place a foot cradle on the bed. Place a pillow under the child's knees. Assist the child to dorsiflex the feet and rotate the ankles.

ANS: D For a child who is immobilized, circulatory stasis and DVT development are prevented by instructing patients to change positions frequently, dorsiflex their feet and rotate the ankles, sit in a bedside chair periodically, or ambulate several times daily. Elevating the legs or placing a foot cradle on the bed will not prevent DVTs. A pillow under the knee would impair circulation, not improve it.

The nurse needs to assess a 15-month-old child who is sitting quietly on his father's lap. What initial action by the nurse would be most appropriate? Ask the father to place the child on the exam table. Undress the child while he is still sitting on his father's lap. Talk softly to the child while taking him from his father. Begin the assessment while the child is in his father's lap.

ANS: D For young children, particularly infants and toddlers, preserving parent-child contact is a good way of decreasing stress or the need for physical restraint during an assessment. For example, much of a patient's physical examination can be done with the patient in a parent's lap with the parent providing reassuring and comforting contact. The initial action would be to begin the assessment while the child is in his father's lap.

18. A parent needs to leave a hospitalized toddler for a short period of time. What action should the nurse suggest to the parent to ease the separation for the toddler? Bring a new toy when returning. Leave when the child is distracted. Tell the child when they will return. Leave a favorite article from home with the child.

ANS: D If the parents cannot stay with the child, they should leave favorite articles from home with the child, such as a blanket, toy, bottle, feeding utensil, or article of clothing. Because young children associate such inanimate objects with significant people, they gain comfort and reassurance from these possessions. They make the association that if the parents left this, the parents will surely return. Bringing a new toy would not help with the separation. The parent should not leave when the child is distracted, and toddlers would not understand when the parent should return because time is not a concept they understand.

10. What functional ability should the nurse expect in a child with a spinal cord lesion at C7? Complete respiratory paralysis No voluntary function of upper extremities Inability to roll over or attain sitting position Almost complete independence within limitations of wheelchair

ANS: D Individuals who sustain injuries at the C7 level are able to achieve a significant level of independence. Some assistance is needed with transfers and lower extremity dressing. Patients are able to roll over in bed and to sit and eat independently. Patients with injuries at C3 or higher have complete respiratory paralysis. Those with injuries at C4 or higher do not have voluntary function of higher extremities. Injuries at C5 or higher prevent rolling over or sitting.

15. An infant is born with a gastroschisis. Care preoperatively should include which priority intervention? Prone position Sterile water feedings Monitoring serum laboratory electrolytes Covering the defect with a sterile bowel bag

ANS: D Initial management of a gastroschisis involves covering the exposed bowel with a transparent plastic bowel bag or loose, moist dressings. The infant cannot be placed prone, and feedings will be withheld until surgery is performed. Electrolyte laboratory values will be monitored but not before covering the defect with a sterile bowel bag.

18. The nurse should instruct parents to administer a daily proton pump inhibitor to their child with gastroesophageal reflux at which time?a. Bedtime With a meal Midmorning 30 minutes before breakfast

ANS: D Proton pump inhibitors are most effective when administered 30 minutes before breakfast so that the peak plasma concentrations occur with mealtime. If they are given twice a day, the second best time for administration is 30 minutes before the evening meal.

4. An 8-year-old child is hospitalized with infectious polyneuritis (Guillain-Barré syndrome [GBS]). When explaining this disease process to the parents, what should the nurse consider? Paralysis is progressive with little hope for recovery. Disease is inherited as an autosomal, sex-linked, recessive gene. Disease results from an apparently toxic reaction to certain medications. Muscle strength slowly returns, and most children recover.

ANS: D Recovery usually begins within 2 to 3 weeks, and most patients regain full muscle strength. The paralysis is progressive with proximal muscle weakness occurring before distal weakness. The recovery of muscle strength occurs in the reverse order of onset of paralysis. Most individuals regain full muscle strength. Better outcomes are associated with younger ages. GBS is an immune-mediated disease often associated with a number of viral or bacterial infections or the administration of vaccines.

Chapter 21 Because of their striving for independence and productivity, which age-group of children is particularly vulnerable to events that may lessen their feeling of control and power? Infants Toddlers Preschoolers School-age children

ANS: D When a child is hospitalized, the altered family role, physical disability, loss of peer acceptance, lack of productivity, and inability to cope with stress usurp individual power and identity. This is especially detrimental to school-age children, who are striving for independence and productivity and are now experiencing events that decrease their control and power. Infants, toddlers, and preschoolers, although affected by loss of power, are not as significantly affected as school-age children.

10. The nurse is admitting a 7-year-old child to the pediatric unit for abdominal pain. To determine what the child understands about the reason for hospitalization, what should the nurse do? Find out what the parents have told the child. Review the note from the admitting practitioner. Ask the child why he came to the hospital today. Question the parents about why they brought the child to the hospital.

ANS: C School-age children are able to answer questions. The only way for the nurse to know about the child's understanding of the reason for hospitalization is to ask the child directly. Finding out what the parents told the child and why they brought the child to the hospital or reading the admitting practitioner's description of the reason for admission will not provide information about what the child has heard and retained.

11. What statement applies to the current focus of the dietary management of children with diabetes? Measurement of all servings of food is vital for control. Daily calculate specific amounts of carbohydrates, fats, and proteins. The number of calories for carbohydrates remains constant on a daily basis; protein and fat calories are liberal. The intake ensures day-to-day consistency in total calories, protein, carbohydrates, and moderate fat while allowing for a wide variety of foods.

ANS: D Essentially the nutritional needs of children with diabetes are no different from those of healthy children. Children with diabetes need no special foods or supplements. They need sufficient calories to balance daily expenditure for energy and to satisfy the requirement for growth and development.

3. What procedure is most appropriate for assessment of an abdominal circumference related to a bowel obstruction? Measuring the abdomen after feedings Marking the point of measurement with a pen Measuring the circumference at the symphysis pubis Using a new tape measure with each assessment to ensure accuracy

ANS: B Pen marks on either side of the tape measure allow the nurse to measure the same spot on the child's abdomen at each assessment. The child most likely will be kept NPO (nothing by mouth) if a bowel obstruction is present. If the child is being fed, the assessment should be done before feedings. The symphysis pubis is too low. Usually the largest part of the abdomen is at the umbilicus. Leaving the tape measure in place reduces the trauma to the child.

15. The nurse is teaching the parents of a 1-month-old infant with developmental dysplasia of the hip about preventing skin breakdown under the Pavlik harness. What statement by the parent would indicate a correct understanding of the teaching? "I should gently massage the skin under the straps once a day to stimulate circulation." "I will apply a lotion for sensitive skin under the straps after my baby has been given a bath to prevent skin irritation." "I should remove the harness several times a day to prevent contractures." "I will place the diaper over the harness, preferably using a superabsorbent disposable diaper that is relatively thin."

ANS: A To prevent skin breakdown with an infant who has developmental dysplasia of the hip and is in a Pavlik harness, the parent should gently massage the skin under the straps once a day to stimulate circulation. The parent should not apply lotions or powder because this could irritate the skin. The parent should not remove the harness, except during a bath, and should place the diaper under the straps.

The nurse is caring for a neonate with a suspected tracheoesophageal fistula. What should nursing care include? Feed glucose water only. Elevate the patient's head for feedings. Raise the patient's head and give nothing by mouth. Avoid suctioning unless the infant is cyanotic.

ANS: CWhen a newborn is suspected of having a tracheoesophageal fistula, the most desirable position is supine with the head elevated on an inclined plane of at least 30 degrees. It is imperative that any source of aspiration be removed at once; oral feedings are withheld. The oral pharynx should be kept clear of secretions by oral suctioning. This is to prevent the cyanosis that is usually the result of laryngospasm caused by overflow of saliva into the larynx.

16. A goal for children with spina bifida is to reduce the chance of allergy development. What is a priority nursing intervention? Recommend allergy testing. Provide a latex-free environment. Use only powder-free latex gloves. Limit use of latex products as much as possible.

ANS: B A latex-free environment is the goal. This includes eliminating the use of latex gloves and other medical devices containing latex. Allergy testing would provide information about whether the allergy has developed. It will not reduce the chances of developing the allergy. Although powder-free latex gloves are less allergenic, latex should not be used. Limiting the use of latex products is one component of providing a latex-free environment, but latex products should not be used.

Chapter 33 The nurse stops to assist an adolescent who has experienced severe trauma when hit by a motorcycle. The emergency medical system (EMS) has been activated. The first person who provided assistance applied a tourniquet to the child's leg because of arterial bleeding. What should the nurse do related to the tourniquet? Loosen the tourniquet. Leave the tourniquet in place. Remove the tourniquet and apply direct pressure if bleeding is still present. Remove the tourniquet every 5 minutes, leaving it off for 30 seconds each time.

ANS: B A tourniquet is applied only as a last resort, and then it is left in place and not loosened until definitive treatment is available. After the tourniquet is applied, skin and tissue necrosis occur below the site. Loosening or removing the tourniquet allows toxins from the tissue necrosis to be released into the circulation. This can induce systemic, deadly tourniquet shock.

7. The nurse is discussing home care with a mother whose 6-year-old child has hepatitis A. What information should the nurse include? Advise bed rest until 1 week after the icteric phase. Teach infection control measures to family members. Inform the mother that the child cannot return to school until 3 weeks after onset of jaundice. Reassure the mother that hepatitis A cannot be transmitted to other family members.

ANS: BHand washing is the single most effective measure in preventing and controlling hepatitis. Hepatitis A can be transmitted through the fecal-oral route. Family members must be taught preventive measures. Rest and quiet activities are essential and adjusted to the child's condition, but bed rest is not necessary. The child is not infectious 1 week after the onset of jaundice and may return to school as activity level allows.

8. An adolescent has just been brought to the emergency department with a spinal cord injury and paralysis from a diving accident. The parents keep asking the nurse, "How bad is it?" The nurse's response should be based on which knowledge? Families adjust better to life-threatening injuries when information is given over time. Immediate loss of function is indicative of the long-term consequences of the injury. Extent and severity of damage cannot be determined for several weeks or even months. Numerous diagnostic tests will be done immediately to determine extent and severity of damage.

ANS: C The extent and severity of damage cannot be determined initially. The immediate loss of function is caused by anatomic and impaired physiologic function, and improvement may not be evident for weeks or months. It is essential to provide information about the adolescent's status to the parents. Immediate treatment information should be provided. Long-term rehabilitation and prognosis can be addressed after the child is stabilized. During the immediate postinjury period, physiologic responses to the injury make an accurate assessment of damage difficult.

7. A 20-kg (44-pounds) child in ketoacidosis is admitted to the pediatric intensive care unit. What order should the nurse not implement until clarified with the physician? Weigh on admission and daily. Replace fluid volume deficit over 48 hr. Begin intravenous line with D5 0.45% normal saline with 20 mEq of potassium chloride. Give intravenous regular insulin 2 units/kg/hr after initial rehydration bolus.

ANS: C The initial hydrating solution is 0.9% normal saline. Potassium is not given until the child is voiding 25 mL/hr, demonstrating adequate renal function. After initial rehydration and insulin administration, then potassium is given. Dextrose is not given until blood glucose levels are between 250 and 300 mg/dL. An accurate, current weight is essential for determination of the amount of fluid loss and as a basis for medication dosage. Replacing fluid volume deficit over 48 hr is the current recommendation in diabetic ketoacidosis in children. Cerebral edema is a risk of more rapid administration. Intravenous regular insulin 2 units/kg/hr after initial rehydration bolus is the recommended insulin administration for a child of this weight. Only regular insulin can be given intravenously, and it is given after initial fluid volume expansion.

2. A child with growth hormone (GH) deficiency is receiving GH therapy. When is the best time for the GH to be administered? At bedtime After meals Before meals After arising in morning

ANS: A Injections are best given at bedtime to more closely approximate the physiologic release of GH. After meals, before meals, and after arising in the morning do not parallel the physiologic release of the hormone.

10. A school-age child with diabetes gets 30 units of NPH insulin at 0800. According to when this insulin peaks, the child should be at greatest risk for a hypoglycemic episode between when? Lunch and dinner Breakfast and lunch 0830 to his midmorning snack Bedtime and breakfast the next morning

ANS: A Intermediate-acting (NPH and Lente) insulin reaches the blood 2 to 6 hr after injection. The insulin peaks 4 to 14 hr later and stays in the blood for about 14 to 20 hr.

15. The nurse is caring for a child after a parathyroidectomy. What medication should the nurse have available if hypocalcemia occurs? Insulin Calcium gluconate Propylthiouracil (PTU) Cortisone (hydrocortisone)

ANS: B Because hypocalcemia is a potential complication after a parathyroidectomy, observing for signs of tetany, instituting seizure precautions, and having calcium gluconate available for emergency use are part of the nursing care.

A child with pyloric stenosis is having excessive vomiting. The nurse should assess for what potential complication? Hyperkalemia Hyperchloremia Metabolic acidosis Metabolic alkalosis

ANS: D Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen ions. Potassium and chloride ions are lost with vomiting. Metabolic alkalosis, not acidosis, is likely.

A child eats some sugar cubes after experiencing symptoms of hypoglycemia. This rapid-releasing sugar should be followed by which dietary intervention? Sports drink and fruit Glucose tabs and protein Glass of water and crackers Milk and peanut butter on bread

ANS: D Symptoms of hypoglycemia are treated with a rapid-releasing sugar source followed by a complex carbohydrate and protein. Milk supplies lactose and a more prolonged action from the protein. The bread is a complex carbohydrate, which with the peanut butter provides a sustained action. The sports drink contains primarily simple carbohydrates. The fruit contains additional carbohydrates. A protein source is needed for sustained action. The glucose tabs are simple carbohydrates. Complex carbohydrates are needed with the protein. Crackers are a complex carbohydrate, but protein is needed to stabilize the blood sugar.

8. The nurse is discussing with a child and family the various sites used for insulin injections. What site usually has the fastest rate of absorption? a. Arm b. Leg c. Buttock d. Abdomen

ANS: D The abdomen has the fastest rate of absorption but the shortest duration. The arm has a fast rate of absorption but a short duration. The leg has a slow rate of absorption but a long duration. The buttock has the slowest rate of absorption and the longest duration.

12. The nurse is doing a pre-hospitalization orientation for a girl, age 7 years, who is scheduled for cardiac surgery. As part of the preparation, the nurse explains that after the surgery, the child will be in the intensive care unit. How might the explanation by the nurse be viewed? Unnecessary The surgeon's responsibility Too stressful for a young child An appropriate part of the child's preparation

ANS: D The explanation is a necessary part of preoperative preparation and will help reduce the anxiety associated with surgery. If the child wakes in the intensive care unit and is not prepared for the environment, she will be even more anxious. This is a joint responsibility of nursing, medical staff, and child life personnel.

17. When a child develops latex allergy, which food may also cause an allergic reaction? a. Yeast b. Wheat c. Peanuts d. Bananas

ANS: D There are cross-reactions between allergies to latex and to a number of foods such as bananas, avocados, kiwi, and chestnuts. Although yeast, wheat, and peanuts are potential allergens, currently they are not known to cross-react with latex allergy.

13. A woman who is 6 weeks pregnant tells the nurse that she is worried that, even though she is taking folic acid supplements, the baby might have spina bifida because of a family history. The nurse's response should be based on what? Prenatal detection is not possible yet. There is no genetic basis for the defect. Chromosome studies done on amniotic fluid can diagnose the defect prenatally. Open neural tube defects (NTDs) result in elevated concentrations of alpha-fetoprotein in amniotic fluid.

ANS: D Ultrasound scanning and measurement of alpha-fetoprotein may indicate the presence of anencephaly or myelomeningocele. The optimum time for performing this analyzing is between 16 and 18 weeks. Prenatal diagnosis is possible through amniocentesis. A multifactorial origin is suspected, including drugs, radiation, maternal malnutrition, chemicals, and possibly a genetic mutation. Chromosome abnormalities are not present in NTDs.

4. A child with hypoparathyroidism is receiving vitamin D therapy. The parents should be advised to watch for which signs or symptoms of vitamin D toxicity? Headache and seizures Weakness and lassitude Anorexia and insomnia Physical restlessness, voracious appetite without weight gain

NS: B Vitamin D toxicity can be a serious consequence of therapy. Parents are advised to watch for weakness, fatigue, lassitude, headache, nausea, vomiting, and diarrhea. Renal impairment is manifested through polyuria, polydipsia, and nocturia. Headaches may be a sign of vitamin D toxicity, but seizures are not. Anorexia and insomnia are not characteristic of vitamin D toxicity. Physical restlessness and a voracious appetite with weight loss are manifestations of hyperthyroidism.

8. A 6-year-old child is admitted to the pediatric unit and requires bed rest. Having art supplies available meets which purpose? Allows the child to create gifts for parents. Provides developmentally appropriate activities. Is essential for play therapy so the child can work on past problems. Lets the child express thoughts and feelings through pictures rather than words.

NS: D The art supplies allow the child to draw images that come into the mind. This can help the child develop symbols and then verbalize reactions to illness and hospitalization. The child can make gifts and drawings for parents, but the goal is to allow expression of feelings. Although art is developmentally and situationally appropriate, the child benefits by being able to express feelings nonverbally. The art supplies are not therapeutic play but a mechanism for expressive play. The child will not work on past problems.