peds final

The nurse is administering a transfusion to a child. What signs/symptoms are most indicative of a transfusion reaction?

2 degree elevation in temp, bp changes more than 10 up or down, fever and chills, tachypnea, tachycardia, hypotension.

Calculate the patient's total intake measured in ml's for the end of the shift report. Patient's I & O's (intake & output) for the end of the shift include: IV: D5 1/2NS 100ml, 1/2NS 25 ml, PO: 4 ounces milk, 2 ounces juice, 1 popsicle=80 ml, ½ of a 3 ounce hamburger patty, 2 ounces of a box of cheerios, 4 crackers and 2 tablespoons of peanut butter; Urine: 400cc, BM: times one

385ml

As the telephone triage nurse, what finding suggests a serious problem in a 2-year-old child who has fallen from a tree swing?

??

The nurse is conducting Denver Developmental Screening Test II on a toddler who as born 3 weeks prematurely. The test date is July 30, 2003. The date of birth of the infant is: January 21, 2002. What is the developmental age of this child?

???

The nurse is preparing to administer 0.7 mL of Zantac p.o. to a 7-month old. Which device would be the most appropriate choice to prepare and administer this medication?

Administer into the checks 0.25mL at a time allowing the child to swallow or suck on a pacifier after each 0.25mL. Hide med in food if possible, oral syringe.

A 14-month old has had a cleft palate since birth. The child can only speak syllables and is not understandable. What diagnostic test would the nurse anticipate?

Answer is not cranial nerve 12. May be 5,9 and 10 or 12. .

When palpating the abdomen of a 3-month old admitted with projectile vomiting, where should you find evidence of pyloric stenosis?

Click on the letter A*** Epigastic/ RUQ

The nurse is analyzing the lab report for a toddler who was admitted for dehydration and diarrhea. What findings would support these diagnoses?

Concentrated urine= high SG >1.030, BUN >18, Creatinine elevated 0.18-1.21dc, sodium and potassium can be either high or low, glucose low <60.

A 26-month old is admitted for reactive airway disease or asthma. What is the nurse's best approach method for this child? (Select all that apply).

Help find triggers, obtain background history and family history, perform a physical examination, assess status, medications, strict I&O, avoid ICE/cold drinks, high fowlers position, education

The nurse is administering a liquid iron preparation to a 4-year old with iron deficiency anemia. What action should the nurse take when administering this medication?

If iron causes vomiting or diarrhea administer with food, give with vitmen c, avoid giving tea within one hour, give through straw, brush teeth after.

A toddler with Phenylketonuria has been admitted. The child is hungry and his mom requests a snack from the pantry. What food would the nurse be therapeutic in giving to this child?

Nothing with protein. Vegetables, fruits.

The nurse is assessing a 2-year old. What finding would the nurse recognize as normal for this child's age?

Pot belly.

A 9-year old child is being assessed by the nurse. When assessing this child neurologically, what cognitive skills best represents those associated with concrete operational thought?

Start using thinking skills, understanding objects, conservstion. Ex; child rolls up dough does not change quantity cause it can be rolled back out.

A pediatric nurse has been assigned several patients. Of the assigned patients, what client would be the first to receive care at the start of the shift?

Use ABC or emergency/non-emergency

What cardiac defect has increased pulmonary blood flow?

VSD*****

A 4-month old is hospitalized with RSV (Respiratory Syncytial Virus). What level of precautions/isolation should be instituted?

contact

A child has an order for cefotaxime sodium (Claforan) 120 mg I.M. Cefotaxime sodium (Claforan) is supplied 500mg/1mL. How many mL should the nurse prepare for the I.M. injection?

0.24ml

The nurse is caring for a child who has a NG to low wall suction with orders to replace the drainage ml/ml by administering ½ NS IV over 8 hours. How many ml/hr will the nurse set the rate of the pump to infuse the IVF over an 8 hour period for 100ml of NG drainage?

12.5ml/hr

A nurse is caring for a 15-year old who weighs 110 pounds has been admitted to the pediatric unit with a diagnosis of gastroenteritis/acute dehydration. What would the nurse calculate as the minimum fluid requirements for this patient to maintain basic fluid needs for the 24 hour period?

2,100ml/hr

When assessing the neurological status of a 4-month old with Hydrocephalus using a Pediatric Glasgow Coma Scale, what finding under verbal response would the nurse need to take further action?

4. Irritable or criea( confused). 3. Inappropriate crying or words/ speech/ disoriented/ delirium.2. grunts, moans or incomprehensible words1. No response.

When assessing the four patients assigned to the nurse for this shift, what developmental finding is abnormal?

???

A 9-year old has been admitted to the unit with pneumonia O2 saturations 85-88% on room air; and decreased breath sounds in right lower lobe. The child also has Attention Deficit Hyperactivity Disorder (ADHD). What patient care issues should the nurse anticipate when caring for this child?

A?

toddler is hospitalized and has awakened crying, "The monster got me!" The child pulled off the pulse oximeter probe and pulled out the intravenous catheter. The nurse correctly reassures the parents that this episode is normal with what statement?

Animism***

A 14-year old female with aplastic anemia has come to the hospital with severe anemia. Where would the nurse place the stethoscope to auscultate for an innocent murmur?

Answer is B. (Pulmonic stenosis- middle or right side of chest).

During an outbreak of viral gastroenteritis, the local dial a nurse hotline is receiving many calls about the management of mild diarrhea. What is the nurse's best advice to these parents?

Bland diet (no fat or grease), fluid and electrolyte imbalances, oral rehydration (pedialyte and Infalyte, avoid carbonated drinks, push fluid, strict I and O.

The nurse is caring for a 5-year old with a history of tonic-clonic seizures. The child has seized for 5-minutes and the nurse has an order to give phenytoin (Dilantin) 100 mg IV for seizures of 3-minutes or more. What is the best action for the nurse to administer this drug?

Can only push for 25mg/ minute.

As the camp nurse for the Hemophilia Society, four children arrive injured at the same time. When prioritizing for immediate care, the nurse would select which child as highest priority?

Child with neuro changes maybe?

A father brings his 2 year old child to the pediatrician's office. The nurse receives the following health history: Temperature: 102-103°F for 3 days, cough, runny nose with some congestion, rash started today (which the nurse assesses) blanches and occurs mainly on the trunk. Considering these assessment findings, the nurse suspects Roseola. Based on this, what treatments would the nurse anticipate?

Contact precautions, treat fever, antipyretic.

When developing a recreational plan for a 3-year old child hospitalized with cystic fibrosis, the nurse should select which toy as most therapeutic for this child?

Cutting and pasting, not too much physical activity

A 15-month old who is currently receiving chemotherapy for acute lymphocytic leukemia has come to the clinic for routine immunizations. The schedule indicates they can have IPV, Dtap, MMR and Varicella based on their age. What is the proper intervention for this child?

Do not give MMR or Varicella

The nurse is assessing a 4-year old male that is suspected of having Autism. What finding/findings should the nurse recognize as a common clinical manifestation of autism? (Select all that apply)

Does not like to be touched or cuddled, no eye contact, blank response, no fear of separation, bizarre body movements, echolalia, plays alone, slow speak development, severe temper tantrums, self-destructive, repetitive behaviors, lack of expression to verbal stimulation

The nurse is caring for a school-aged child with viral meningitis. What nursing intervention is most appropriate?

Droplet precautions if meningitis is suspected, and maintain precautions for at least 24 hours following initiation of antibiotics. Keep patient NPO if they have a decreased LOC. Providea quiet, dark environment.

The nurse is caring for an unconcious child with closed head trauma who was hit by a car that has developed a nosocomial case of Rotovirus while in the ICU. What order would the nurse question?

Enemas, stool softners, increased fiber, nothing that will cause more diarrhea.

The nurse is caring for a child with a positive monospot. What other assessment finding would confirm this diagnosis? (Select all that apply).

Fever, fatigue, malaise, headache, abdominal pain, sore throat, anorexia, irritability, spleen enlargement, lymphadenopathy.

The nurse is assigned to a 3-year old who with gastroenteritis. Orders: clear liquids and advance diet as tolerated. The child has not vomited in 24 hours while on clear liquids but continues to have loose stools. How should the nurse begin advancing this diet?

Full liquids or soft bland foods

The nurse is giving medications to a 6-month old with an unrepaired ventricular septal defect and congestive heart failure has an 0800 dose of Digoxin (Lanoxin®) ordered. The 0800 vital signs were: T=98.9, apical HR=80, RR=34, B/P 100/60. What is the top priority nursing action at 0800 for this patient?

Hold the medication, notify the doctor.

A two-year old is suspected of drinking Tylenol infant drops. What signs would lead the nurse to suspect early acetaminophen toxicity?

Malaise, N/V, diaphoresis

The nurse is admitting a 14-month old to the hospital. The mother informs you that the child has ingested paint chips from the windowsill. What signs and symptoms would the nurse interpret as early lead toxicity?

N/V CNS-poor motor skills, blue lead line level.

A 15-year old female has just returned from surgery following a scoliosis repair with Harrington rods. The nurse assessed her breathing and vital signs (T 98.4, HR 80, RR-18, B/P=100/62). What is the priority nursing intervention needed at this time?

Proper alignment

A nurse is making a home visit on a newborn with Tetralogy of Fallot. She observes the mother bathing the newborn, who begins crying. The nurse notes that the child's lips have become deep blue. What is the nurse's priority intervention?

Put the childs knees to chest.

The nurse is preparing to administer a bolus gavage feeding to a 7-year old who has Cystic Fibrosis. The child received 240 mL at his last feeding 6 hours ago. Upon checking residual the nurse notes a return of 132 mL. The nurses best action would be?

Return aspirate and hold feeding if residual is >1/2 of feeding you hold.

The nurse has admitted a 2-year old child with sickle cell in vaso-occlusive crisis. As the nurse begins the assessment, the child begins to drool and can not speak or raise her right arm. The nurse correctly interprets these findings and intervenes appropriately with what response?

Stay with pt and notify doctor of any changes***

The nurse has received a 10-month old with acute myelocytic leukemia that presents with a temperature of 102 degrees F following antineoplastic therapy for 12-days ago. What nursing intervention should be initiated as a priority?

Strict handwashing, give antipyretic

What feeding method should the nurse promote for a 2-hour old baby that has a bilateral cleft lip and palate?

Upright, burp frequently

When developing the plan of care for a child with early Duchenne's muscular dystrophy, what would the nurse identify as the primary nursing goal for the child?

assess and manage airway, ROM exercises, skin integrity, deep breathing.

The ER nurse is admitting a child who has had fever and nuchal rigidity for 24 hours? What is the initial priority nursing action for a child admitted with questionable meningitis?

droplet

The pediatric nurse is evaluating a child with cerebral palsy and failure-to-thrive. What nursing intervention should be implemented as a priority?

???

The nurse is caring for a 10-year old boy during the acute phase of rheumatic fever. What is the most age appropriate diversional activity for the nurse to offer this child?

Bed rest, video games, hobbies.

In providing care to a child with glomerulonephritis, what nursing interventions would be most important?

Bedrest (self imposed), monitor and restor Fluid and electrolyte imbalance, prevent infection, skin care, nutritional support (low protein), worried about high bp, no sodium (edema/ high blood pressure)

The nurse is to provide chest physiotherapy to a 5-year-old with cystic fibrosis. What is the optimum time to perform vibropercussion and postural drainage?

Before meals or 1 ½ to 2 hours after meals to prevent vomiting

A child is hospitalized with Acetominophen toxicity one of the most common drug poisonings in children. What assessment findings would be expected? (Select all that apply).

Stage 1- (24 hours) Pallor, malaise, diaphoresis, N/V. Stage 2- (24-36 days to 5 days) symptom free, LFT increased. Stage 3(3-5 days)- jaundice liver enlargement, RUQ pain, signs of impending liver failure, increased bilirubin, increased liver enzymes, N/V, Ascited.

A nurse is monitoring a 10-year old child receiving a blood transfusion. The child begins crying with severe itching. Assessment reveals a RR of 40, coughing and an oxygen saturation of 88%. What should the nurse do? (Select all that apply).

Stop infusion, keep IV but flush with normal saline, notify doctor and blood bank, do urinalysis, Administer epinephrine, suction, elevate head of bed assess airway, apply oxygen, may need to administer fluids, quick body assessment, document on blood slip as well as nurses not. May need med for low bp.

Your patient has an order for: Biaxin (clarithromycin) administer dose appropriate for age and weight. The child weighs 132 lbs and the drug guide recommends administering 7.5mg/kg/every day in 2 evenly divided doses. What should the every 12 hour (BID) dosage be for this child in mg?

225mg

The nurse is caring for an 8-month old child who has sickle cell anemia and pneumonia. The child has respiratory rate (RR)=68, crackles and wheezing in the right lung fields, severe retractions, oxygen saturation is 86%, and intravenous fluids running at 50 ml/hr. What actions should the nurse do as a priority of care now? (Select all that apply).

??

A child is seen for a Denver developmental screening test. The child's birth date is April 12, 1999. The day of the test is May 4, 2002. The grandmother reports that the child was born exactly six weeks early. What is the developmental age of this child?

???

A girl (6½ years old) has been hospitalized with periorbital cellulitis. Her IV is infiltrated. When the nurse tries to apply a warm, moist washcloth to her swollen arm, she begins to whine and pull away. What comment would be most likely to gain the patient's cooperation?

???

What interventions should the nurse include in a plan of the care for a teenager with severe spastic cerebral palsy? (Select all that apply).

Aid in maximizing motor potential, assist in feeding/maintain nutritional needs, facilitate communication skills, engage in self-care activities, maximize educational potential, maintain safety and prevent injury, promote healthy self-image and growth and development, support family

The nurse is caring for child with hemophilia who was admitted for periorbital cellulitis. He jumped off the bed and is beginning to have a joint bleed. When the mother calls out for help to the desk telling them that she is administering RICE care, what is the nurse's priority action?

Assess LOC, use a factor replacement after RICE, don't use aspirin or advil.

The nurse has just admitted an 18-month-old with acute laryngotracheobronchitis (croup). During the initial assessment, what signs and symptoms would the nurse expect to find that support the diagnosis of laryngotracheobronchitis?

Bark seal like cough, progresses to stridor, emergency.

A 5-month old child is admitted with suspected shaken baby syndrome and increased intracranial pressure (ICP). What assessment findings would be most indicative of increased ICP? (Select all that apply).

Bulging fontanels and tense, cranial sutures separated, increased head circumference, irritability, poor feeding, high pitched cry, difficult to soothe, sun setting sign in eyes, scalp veins distended, Ha, Vomiting with or without nausea, seizures, blurred vision, diplopia.

A 12-year old child is admitted with the diagnosis of "rule out rheumatic fever." Based on this diagnosis which signs and symptoms would the nurse expect to find?

Carditis, polyarthritis, chorea, emotion instability, subcutaneous nodules, erythema, marginatum

A 5-year old child is seen in the clinic for impetigo. What nursing action is the highest priority?

Contact precautions

Your patient is a 5-year old boy and he is due for his kindergarten immunization series. According to his chart and history, he has no immunity to chickenpox and he has no previous allergies to immunizations. He needs all required vaccines for his age today. What vaccines will you give today?

DTAP, IPV, MMR, Influenza, Varicella.

A newborn has been delivered and the nurse is suspecting Down Syndrome. What characteristics would the nurse assess to indicate Down Syndrome? (Select all that apply)

Epicantrial folds, slanting of eyelids, short broad hands, mottled skin, transpaalmar crease, protruding tongue, decreased muscle tone, flat nasal bridge, small ears, mouth, jaw, hands, and feet.

Parents of a child recently diagnosed with Down Syndrome relate to the nurse that they feel guilty about "causing the condition"? What is the nurse's best response?

Exact cause is unknown. Don't blame the parent.

A 13-year old with celiac disease has learned the dietary restrictions necessary for compliance with the treatment regimen. What breakfast menu choices by the patient reflect correct compliance? (Select all that apply).

Gluten free diet (Cant have oatmeal, toast, cereal, barely, wheat, flour, beer, cake). Can have cheese, fruits, vegtables, meats and fish, potatoes, milk, yogurt, corn, eggs.

A 16-year old with cystic fibrosis who has a history of noncompliance with the treatment regimen has been admitted with a pulmonary exacerbation. What finding confirms that the adolescent is not following her plan of care?

Infection (Pseudomonas aeruginosa, Burkholderia cepacia, Staph aureus [methicillin resistant], Haemophilus influenza, Escherichia coli, Klebsiella pneumoniae)

A 5-year old child is seen in the clinic for chickenpox. What nursing action is the highest priority?

Initiate Air borne and contact isolation.

The nurse is caring for a child with muscle weakness. The child's mother asks about Duchenne Muscular dystrophy. What is the nurse's best response?

It is a x-linked- passed from mom to son, absence of protein that hold muscles together, absence of dystrophin, degeneration of skeletal muscles

A 9-year old has a history of asthma and uses rescue and preventer medications as needed based on her peak expiratory flow rates. Her personal best is 270 L/minute. The child's current peak flow reading is 128 L/minute. The nurse interprets this reading and recommends that the child take what actions?

It is less than 50 percent of personal best, use rescue medication (allbuteral), emergency, seek medical attention.

The next door neighbor of a nurse has called requesting advice on treating her 6-year old who has head lice (pediculosis capitis). What health promotion and maintenance instructions are best for this nurse to give the neighbor? Kwell shampoo (medicated. Repeat in 7 days). Identify all contacts (fam), Electronic head lice. Doctor comb and kill with electrical charge. Place items that cant be washed in plastic bag for 14 days. Vacuum/ wash stuffed animals, can se mayo (leave in hair with a shower cap on then wash) ½ strength vinegar to comb out nits with a fine tooth comb.

Kwell shampoo (medicated. Repeat in 7 days). Identify all contacts (fam), Electronic head lice. Doctor comb and kill with electrical charge. Place items that cant be washed in plastic bag for 14 days. Vacuum/ wash stuffed animals, can se mayo (leave in hair with a shower cap on then wash) ½ strength vinegar to comb out nits with a fine tooth comb.

A 7-month old boy is being seen for a well-child visit. What finding obtained during the nurse's screening reflects a hearing deficit? (Select all that apply)

Lack of startle/ blink reflex to noise, failure to be awakened by loud noise, failure to localize sound by 6 months, does not babble by 7 months, indifferent to sound, responds to loud noises but not voice.

The nurse is caring for a 6-year old child who has just returned to the day-surgery unit following a tonsillectomy and adenoidectomy. The patient begins to have bleeding from the right nares. What nursing intervention should be taken? (Select all that apply).

Lean the pt forward, apply pressure, stick gauze up nose, don't give aspirin or blood thinner crap.

The nurse has given report on a child who has been diagnosed with Reye's Syndrome. What assessment or lab findings would be important for the nurse to communicate in the transfer of care? (select all that apply)

Liver function test, fever, impaired loc, edema, liver enlargement, liver enzymes, PT, Ammonia, Elevated AST and ALT, n/v, seizures, hypoglycemia.

A 12-year old girl with asthma is on every 2 hour respiratory checks with albuterol nebulizer treatments. What assessment findings indicate worsening condition and impending respiratory arrest?

Low O2 <92%, wheezes, increases RR.

The nurse is treating a boy that was brought to the emergency department with 40% partial thickness second degree burns on his arms, hands and chest. What is the priority nursing interventions for this child?

Maintain airway, circulation, control fluid loss, maintain body temp.

A group of 14-year-old girls are attending a class on decision-making. When talking to the group, the nurse accurately incorporates understanding of this developmental level with what intervention?

Make decisions independently, think about future and career.

A 17-year old has come to the hospital for Harrington rod placement to repair scoliosis. What assessment finding immediately postoperatively would the nurse report to the physician as abnormal?

Monitor VS (observe for changes in temperature that coud be associated with complications of infection), and monitor for changes in neurovascular status (numbness; tingling; decreased mobility, sensation, or capillary refill)

The nurse has admitted a 2-month old with an unrepaired cleft lip and palate who is scheduled for cleft lip repair in the next 24 hours. What is priority nursing action for this child post-operatively?

Monitor vital signs and airway, position supine in the semi- fowlers postion, after feedings wash the wound with saline and apply sterile vasaline or antibiotic ointment, and pain control (swaddling). ELBOW RESTRAINTS, REMOVE ONE AT A TIME EVERY TWO HOURS, DON'T STICK ANYTHING IN THEIR MOUTH.

A nurse examines a 2-week old girl for her well-child visit. What finding suggests congenital dislocation of the hip?

Ortanli Click, Barlow test, allis sign, trendeelenburg sign, asymmetric gluteal fold, broadening perineum, limp or toe walking.

A baby is brought to the emergency room. What assessment findings would lead the nurse to suspect the onset of intussusception?

Pain (crying with knees drawed up), vomiting, stools change from brown to red/ bloody, mucoid (current jelly stool) , palapable ssausage shaped mask in the RUQ, constipation.

The nurse is caring for a 13-year old child in a vaso-occlusive crisis. What signs and symptoms would require immediate intervention?

Pain, abdomen sinks in, bp falls, hr increases

What side effects should the nurse instruct the parents to report after their child received a DTaP immunization? (Select all that apply).

Pain, redness, or swelling in the arm where the shot was given. Swollen glands, mild fever. Headache, fatique, n/v/d, muscle aches and pain.

The nurse is caring for an 8-year old with a draining wound on his leg on contact precautions. What activity would be best for the nurse to check-out of the activity room for this patient?

Puzzle, book, video game, nintendo

The nurse has just received a patient back from the cardiac catheterization lab following a pulmonary artery banding to minimize the effects of a ventricular septal defect. What is the goal of this procedure?

Raises pressure in ventricles so shunting of blood does not occur.

A school nurse examines a child with a complaint of throat pain and dysphagia. In order to prevent future complications, what should the nurse do?

Refer to throat culture.**

The charge nurse is reviewing new lab results for patients on the adolescent unit. What patients' results would include an elevated erythrocyte sedimentation rate (ESR)? (Select all that apply ).

Rheumatic fever, anemia, kidney disease, lymphoma, thyroid disease, arthritis, bone infection, heart infection, tuberculosis.

A 2-year old has received a chemotherapy treatment with etoposide (VP-16) 7-days ago. He has a platelet count of 4,000/mm3. What nursing interventions should be initiated?

Safety, may stroke, no im injection, no rectal temp, no rough play or sports, or anything that could cause bleeding.

A nursing student is observing a group of children, one of whom is a 6-year old boy. What statement by the student nurse correctly assesses and reports this child's normal development? School aged- psychosocial -Erikson Freud- Sports- jumps rope, skateboard, jobs or chores, hobbies muscical instruments etc, writes in ?, ? play, identifies objects with

School aged- reversibility of matter, loose teeth, psychosocial -Erikson industry vs Inferiority Freud- latency. Sports- jumps rope, skateboard, jobs or chores, hobbies muscical instruments etc, writes in print advances to cursive, cooperative play, math (adding and subtracting), identifies objects with common attributes.

The nurse is caring for a 14-month old that just had a short leg cast applied for a clubfoot repair. She is in the crib with her leg elevated. What toy is the best choice for this child?

Scribble on paper, anything with hands.

The nurse is admitting a 9-month old with a ventriculoperitoneal shunt for hydrocephalus to rule out a shunt malfunction. What developmental milestone would the nurse interpret as normal for this child's age level?

Sits up unsupported, pincer grasp, push toys.

The state health officer contacts school nurses about an outbreak of scarlatina. The school nurse would best educate the teachers to observe for what signs and symptoms?

Sore throat, rash on face and neck arms and legs, desquamation (peeling), fever, circumoral pallor, begins as red macules.

Each of the following 4 children have been admitted to the unit. What assessment finding from one of these children would the nurse report as suggestive of acute glomerulonephritis?

Strep infection 10-21 days earlier, edema, urine tea colored (report immediately), urinalysis positive for protein, RBC and white cell carts, frank or mid abdominal pain, irritability, malaise, fever. They have hypertension that could lead to encephalopathy. Check for color blindness.

In order to maintain droplet precautions, what interventions must occur? (Select all that apply).

Surgical mask needed if coming within 3 feet of patient, patient musk wear a mask while leaving the room. Door may remain open if wanted and patient is over 3 feet away.

A newborn is delivered 2-weeks prematurely with a loud systolic murmur, dyspnea, and bounding pulses. During feedings, the infant is very diaphoretic and fatigues easily taking only 5-10 ml. What condition would the nurse correctly recognize by these signs and symptoms?

TEF*** Tracheoesophageal fistula

What assessment finding would indicate that parents need to be encouraged to begin anticipatory sexual education?

Tanner Stage 2*

The nurse is taking a history on a 14-year old who has come in for a sports physical. The mother speaks up and states, " I am concerned that my teenager's behavior has changed recently. After school, my adolescent comes home and goes to the bedroom and is not social with the rest of the family any more." What would the nurse's best response be to the mother?

This is an appropriate finding. Don't be judgemental***

A school-aged group of boy scouts are learning about safety. What teaching points should the nurse include to cover the leading cause of accidents in this age group?

Traffic safety.

A 4-year old has been admitted for gastroenteritis and severe dehydration. The child's temperature is 103.8ºF when the nursing tech reports it to the nurse. As the nurse enters the room, the child begins to have a tonic-clonic seizure. What is the nurse's best first action?

Turn on their side, call for help, move harmful objects out of way.

The nurse is caring for a 6-hour old neonate with a suspected tracheoesophageal fistula (TEF). What nursing intervention is needed to maintain safety of this child?

Watch for first feeding of all newborns