PEDS Saunders Rationales

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? Select all that apply.

Place the infant in a private room and Ensure that nurses caring for the infant with RSV do not care for other high-risk children; RSV is a highly communicable disorder and is not transmitted via the airborne route. The virus usually is transferred by the hands. Use of contact and standard precautions during care (wearing gloves and a gown) reduces nosocomial transmission of RSV. A mask is unnecessary. In addition, it is important to ensure that nurses caring for a child with RSV do not care for other high-risk children to prevent the transmission of the infection. An infant with RSV should be isolated in a private room or in a room with another infant with RSV infection. The infant should be positioned with the head and chest at a 30- to 40-degree angle and the neck slightly extended to maintain an open airway and decrease pressure on the diaphragm. Cool humidified oxygen is delivered to relieve dyspnea, hypoxemia, and insensible water loss from tachypnea.

A child is brought to the emergency department after being accidentally struck in the lower back region with a baseball bat. When gathering assessment data, the nurse discovers that the child has hemophilia. The nurse should immediately assess for which data?

Presence of hematuria; Because the kidneys are located in the flank region of the body, trauma to the back area can cause hematuria, particularly in a child with hemophilia. The nurse would be most concerned about the child's airway and respiratory rate if the child had sustained an injury to the neck region. Slurred speech and headache are associated with head trauma.

The nurse is reviewing the laboratory results for a child scheduled for a tonsillectomy. The nurse determines that which laboratory value is most significant to review?

Prothrombin time; A tonsillectomy is the surgical removal of the tonsils. Because the tonsillar area is so vascular, postoperative bleeding is a concern. Prothrombin time, partial thromboplastin time, platelet count, hemoglobin and hematocrit, white blood cell count, and urinalysis are performed preoperatively. The prothrombin time results would identify a potential for bleeding.

The nurse is reviewing a health care provider's prescriptions for a child with sickle cell anemia who was admitted to the hospital for the treatment of vaso-occlusive crisis. Which prescriptions documented in the child's record should the nurse question? Select all that apply.

Restrict fluid intake and Give meperidine, 25 mg intravenously, every 4 hours for pain; Sickle cell anemia is one of a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell; insufficient oxygen causes the cells to assume a sickle shape, and the cells become rigid and clumped together, obstructing capillary blood flow. Oral and intravenous fluids are an important part of treatment. Meperidine is not recommended for a child with sickle cell disease because of the risk for normeperidine-induced seizures. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. The nurse would question the prescription for restricted fluids and meperidine for pain control. Positioning for comfort, avoiding strain on painful joints, oxygen, and a high-calorie and high-protein diet are also important parts of the treatment plan.

The nurse on the pediatric unit is caring for a child with hemophilia who has been in a motor vehicle crash. Which assessment finding, if noted in the child, indicates the need for follow-up?

The child is drowsy and difficult to arouse; previously the child was able to respond to questions effectively; When caring for a child with hemophilia who has sustained injuries, the nurse should monitor for signs of internal bleeding. One sign of internal bleeding is change in level of consciousness, which could indicate intracranial hemorrhage. Additional signs of bleeding include pain, tenderness, and bruising of the affected area and hematuria. Denial of pain of affected joints, clear and light yellow urine that is negative for red blood cells, and bruises that are beginning to turn yellow are not signs of internal or external bleeding.

The nurse is caring for a child with a diagnosis of neutropenia. Which nursing interventions are most appropriate for a child placed in protective isolation for neutropenia? Select all that apply.

-Place the child on a low-bacteria diet -Change dressings using sterile technique -Peel fruits and vegetables before allowing the child to eat them For the hospitalized neutropenic child, flowers or plants should not be kept in the room because standing water and damp soil harbor Aspergillus and Pseudomonas species, to which these children are very susceptible. Fruits and vegetables not peeled before being eaten harbor molds and should be avoided until the white blood cell count rises. The child is placed on a low-bacteria diet. Dressings are always changed using sterile technique. Individuals who are ill are not allowed to visit the client.

Vaso-occlusive crisis

Caused by stasis of blood with clumping of cells in the microcirculation, ischemia and infarction. Manifestations: fever, painful swelling of hands, feet, and joints; abdominal pain.

The nursing student is presenting a clinical conference and discusses the cause of β-thalassemia. The nursing student informs the group that a child at greatest risk of developing this disorder is which of these?

A child of mediterranean descent; β-Thalassemia is an autosomal recessive disorder characterized by the reduced production of 1 of the globin chains in the synthesis of hemoglobin (both parents must be carriers to produce a child with β-thalassemia major). This disorder is found primarily in individuals of Mediterranean descent.

Hyperhemolytic Crisis

An accelerated rate of RBC destruction. Manifestations: anemia, jaundice and reticulocytosis.

A nursing student is conducting a clinical conference about measures that assist in preventing sudden infant death syndrome. The student plans to write on a handout that it is best to place an infant in which position for sleep?

On the back or supine; Healthy infants should only be placed on their backs for sleep. This is also referred to as the supine position.

Splenic Sequestration

caused by pooling and clumping of blood in the spleen (hypersplenism); Manifestations: profound anemia, hypovolemia and shock.

The pediatric nurse educator is providing a teaching session to nursing staff about hemophilia. Which statement should the nurse educator include?

"Affected prepubescent girls should be counseled concerning menorrhagia, which may be life-threatening." The female offspring of an affected male and a carrier female is at risk for hemorrhage once puberty is attained and menstrual cycles begin, and depending on the severity of the hemophilia, a hysterectomy or ablation may be performed.

The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the health care provider did not prescribe antibiotics. Which response should the nurse make?

"Antibiotics are not indicated unless a bacterial infection is present." Laryngotracheobronchitis (croup) is the inflammation of the larynx, trachea, and bronchi and is the most common type of croup. It can be viral or bacterial. Antibiotics are not indicated in the treatment of croup unless a bacterial infection is present.

A child with rheumatic fever will be arriving to the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever?

"Did the child have a sore throat or fever within the last 2 months?" Rheumatic fever is an inflammatory autoimmune disease that affects the connective tissues of the heart, joints, skin (subcutaneous tissues), blood vessels, and central nervous system. Rheumatic fever characteristically manifests 2 to 6 weeks after an untreated or partially treated group A β-hemolytic streptococcal infection of the upper respiratory tract. Initially, the nurse determines whether the child had a sore throat or an unexplained fever within the past 2 months.

The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instruction?

"I can apply lotion or powder to the incision if it is itchy." The mother should be instructed that lotions and powders should not be applied to the incision site after cardiac surgery. Lotions and powders can irritate the surrounding skin, which could lead to skin breakdown and subsequent infection of the incision site.

The nurse employed in an emergency department is monitoring a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. How should the nurse interpret this finding?

An airway obstruction; Clinical manifestations suggestive of airway obstruction include tripod positioning (leaning forward supported by arms, chin thrust out, mouth open), nasal flaring, tachycardia, a high fever, and sore throat.

Oral iron is prescribed for a child with iron deficiency anemia. The nurse provides instructions to the mother regarding the administration of the iron. The nurse should instruct the mother to administer the medication in which way?

Between meals; The mother should be instructed to administer oral iron supplements between meals. The iron should be given with a citrus fruit or juice high in vitamin C because vitamin C increases the absorption of iron by the body.

A child is brought to the emergency department after falling from a high swing and landing on the back. The nurse notes that the client also has hemophilia. Based on the client's history and the nature of the injury, which should the nurse assess for first?

Blood in the urine; Because the kidneys are located in the flank region of the body, trauma to the back area can cause hematuria, particularly in the child with hemophilia. The nurse would be most concerned about the child's airway and respiratory rate if the child sustained an injury to the neck region.

The nurse is caring for a child with a diagnosis of a right-to-left cardiac shunt. On review of the child's record, the nurse should expect to note documentation of which most common assessment finding?

Bluish discoloration of the skin; The child with a right-to-left shunt will be considerably sicker than a child with a left-to-right shunt. Many of these children will present with symptoms in the first week of life. The most common assessment finding in these children is bluish discoloration of the skin, known as cyanosis. The child may also become dyspneic after feeding, crying, and other exertional activities. Severe bradycardia and asymptomatic after feedings are inaccurate findings. Many children with a left-to-right shunt may remain asymptomatic. High body weight is incorrect because these children usually have lower than normal body weight.

A child is seen in the health care clinic for complaints of fever. On data collection, the nurse notes that the child is pale, tachycardic, and has petechiae. Aplastic anemia is suspected. The nurse should prepare the child to obtain which specimen that will confirm the diagnosis?

Bone marrow biopsy; Although the diagnosis of aplastic anemia may be suspected from the child's history and from the results of a complete blood count, a bone marrow biopsy must be performed to confirm the diagnosis.

The nurse is caring for an infant with a diagnosis of congenital heart disease. Which finding, on physical assessment, does the nurse attribute to chronic hypoxia?

Clubbing of the fingers; The child with congenital heart disease may develop clubbing of the fingers. Clubbing of the fingers is thought to be caused by anoxia or poor oxygenation. Tachypnea and tachycardia are signs of acute hypoxia.

The nurse is caring for a hospitalized infant with a diagnosis of bronchiolitis. In which position should the nurse place the infant?

Head and chest at a 30-degree angle with the neck slightly extended; The nurse should position the infant with the head and the chest at a 30- to 40-degree angle with the neck slightly extended to maintain an open airway and to decrease pressure of the diaphragm.

An infant of a mother infected with human immunodeficiency virus (HIV) is seen in the clinic each month and is being monitored for symptoms indicative of HIV infection. With knowledge of the most common opportunistic infection of children infected with HIV, the nurse assesses the infant for which sign?

Cough; Acquired immunodeficiency syndrome (AIDS) is a disorder caused by HIV and characterized by generalized dysfunction of the immune system. The most common opportunistic infection of children infected with HIV is Pneumocystis jiroveci pneumonia, which occurs most frequently between the ages of 3 and 6 months, when HIV status may be indeterminate. Cough is a common sign of this opportunistic infection. Cytomegalovirus infection is also characteristic of HIV infection; however, it is not the most common opportunistic infection.

The nurse is creating a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse should include monitoring the child for signs of which condition?

Heart failure; Nursing care initially centers on observing for signs of heart failure. The nurse monitors for increased respiratory rate, increased heart rate, dyspnea, crackles, and abdominal distension.

The nurse is caring for an infant with congenital heart disease. Which, if noted in the infant, should alert the nurse to the early development of heart failure?

Diaphoresis during feeding; The early symptoms of heart failure (HF) include tachypnea, poor feeding, and diaphoresis during feeding. Tachycardia would occur during feeding.

The pediatric nurse educator provides a teaching session to the nursing staff regarding hemophilia. Which statement regarding this disorder should the nurse plan to include in the discussion?

Hemophilia A results from deficiency of factor VIII; Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Hemophilia A results from a deficiency of factor VIII. Males inherit hemophilia from their mothers, and females inherit the carrier status from their fathers. Hemophilia is inherited in a recessive manner via a genetic defect on the X chromosome. Hemophilia B (Christmas disease) is a deficiency of factor IX.

The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position?

Side lying; A tonsillectomy is the surgical removal of the tonsils. The child should be placed in a prone or side-lying position after the surgical procedure to facilitate drainage.

The nurse has provided instructions to the mother of a child with cystic fibrosis about appropriate dietary measures. Which statement by the mother indicates an understanding of these dietary measures?

The diet needs to be high in calories; Children with cystic fibrosis are managed with a high-calorie, high-protein diet. Pancreatic enzyme replacement therapy and water-soluble vitamin supplements (A, D, E, and K) are administered. If nutritional problems are severe, supplemental tube feedings or parenteral nutrition is administered. Fats are not restricted unless steatorrhea cannot be controlled by administration of increased pancreatic enzymes.

During clinical conference, a nursing student is discussing care for a child with a diagnosis of cystic fibrosis (CF). Which comment by a student indicates the need for further review of information about CF?

This disease causes dilation of the passageways of many organs; CF is a chronic multisystem disorder affecting the exocrine glands. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and pancreatic and bile ducts) is abnormally thick, causing obstruction (not dilation) of the small passageways of these organs. It is transmitted as an autosomal recessive trait.

The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output?

Weighing the infant's diapers; Heart failure is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. The most appropriate method for assessing urine output in an infant receiving diuretic therapy is to weigh the diapers.

The nurse is assessing a newborn with heart failure before administering the prescribed digoxin. In reviewing the laboratory data, the nurse notes that the newborn has a digoxin blood level of 1.6 ng/mL (2.05 mmol/L) and an apical heart rate of 90 beats/min. The mother also tells the nurse that the newborn just vomited her formula. Which intervention should the nurse take?

Withhold the medication and notify the health care provider; The apical pulse rate for a newborn is 120 to 160 beats/min. The therapeutic digoxin level ranges from 0.5 to 0.8 ng/dL (0.64 to 1.02 mmol/L). Because the apical rate is low and the digoxin blood level is elevated, indicating toxicity, the nurse would withhold the medication and notify the health care provider.

The nurse provides home care instructions to the parent of a child with acquired immunodeficiency syndrome (AIDS). Which statement by the parent indicates the need for further teaching?

"I can send my child to day care if he has a fever, as long as it is a low-grade fever." AIDS is a disorder caused by human immunodeficiency virus (HIV) and characterized by generalized dysfunction of the immune system. A child with AIDS who is sick or has a fever should be kept home and not brought to a day care center.

A 3-year-old child with human immunodeficiency virus infection is being discharged from the hospital. The nurse is providing discharge instructions to the mother regarding home care and infection control measures. Which statement by the mother indicates a need for further teaching?

"I should discard any unused food and formula immediately." Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy.The parents should be instructed to cover unused food and formula and refrigerate. They should also be informed to discard unused refrigerated food or formula after 24 hours.

The nurse is providing instructions to the mother of a child with croup regarding treatment measures if an acute spasmodic episode occurs. Which statement made by the mother indicates a need for further teaching?

"I should place a steam vaporizer in my child's room." Steam from running water in a closed bathroom will assist in keeping secretions thin so that they can be easily expectorated. Steam from a vaporizer however can present a danger of scald burns because of the more direct effect than that provided from steam from running water. A cool mist from a bedside humidifier may be effective in reducing mucosal edema. Cool-mist humidifiers are recommended over steam vaporizers. Taking the child out into the cool, humid night air may also relieve mucosal swelling.

The nurse is preparing to administer an MMR (measles, mumps, and rubella) vaccine to a 15-month-old child. Before administering the vaccine, which question should the nurse ask the mother of the child?

"Is the child allergic to any antibiotics?" Before the administration of MMR vaccine, a thorough health history needs to be obtained. MMR is used with caution in a child with a history of an allergy to gelatin, eggs, or neomycin because the live measles vaccine is produced by chick embryo cell culture and because MMR also contains a small amount of the antibiotic neomycin.

The nurse is caring for a child with acquired immunodeficiency syndrome (AIDS) and notes the presence of mouth sores. The nurse provides instructions to the mother regarding maintaining adequate nutritional intake in the child. Which statement by the mother indicates a need for further teaching?

"Salty foods are very important to maintain an appropriate sodium level in the child." Acquired immunodeficiency syndrome is a viral disease caused by the human immunodeficiency virus (HIV), which destroys T cells, thereby increasing susceptibility to infection and malignancy. Salty or spicy foods should be avoided because they irritate mouth sores. The child should be weighed each morning, and calorie intake should be reviewed every 24 hours. If mouth sores are present, the child should be offered an iced pop to lick or ice before meals to numb the mouth. The mother should be instructed to offer foods high in protein and calories and to give vitamin and mineral supplements if prescribed.

A CD4+ count has been prescribed for a child with human immunodeficiency virus (HIV) infection. The nurse has explained to the mother the purpose of the blood test. Which comment by the mother indicates the need for further explanation?

"This test identifies the specific diagnosis of HIV infection." Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. CD4+ counts are used to assess a young child's immune status, risk for disease progression, and need for P. jiroveci pneumonia prophylaxis after 1 year of age. These counts are measured at 1 and 3 months, every 3 months until the age of 2 years, and at least every 6 months thereafter. More frequent monitoring of CD4+ counts is indicated when P. jiroveci pneumonia prophylaxis and antiretroviral therapy are recommended. The CD4+ count is not diagnostic of HIV infection.

A child is being discharged from the hospital following heart surgery. Prior to discharge, the nurse reviews the discharge instructions with the mother. Which statement by the mother indicates a need for further teaching?

"Visitors are not allowed for 1 month." Visitors without signs of any infection are allowed to visit the child. The mother should be instructed, however, that the child needs to avoid large crowds of people for 1 week following discharge.

A child is admitted to the pediatric unit with a diagnosis of acute stage Kawasaki disease. Which assessment findings by the nurse are characteristic of this disorder? Select all that apply.

- Red throat - Conjunctival hyperemia - Enlargement of cervical lymph nodes Kawasaki disease is known as mucocutaneous lymph node syndrome and is an acute systemic inflammatory disease. Assessment findings in the acute stage include fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. Desquamation of the skin, cracking lips, joint pain, cardiac manifestations, and thrombocytosis are characteristics of the subacute stage.

The nurse reviews the laboratory results for a child with rheumatic fever and would expect to note which findings? Select all that apply.

-Elevated C-reactive protein -Elevated antistreptolysin O titer -Presence of group A beta-hemolytic strep

The nurse is monitoring an infant with heart failure. Which sign alerts the nurse to suspect fluid accumulation and the need to call the health care provider?

A weight gain of 1lb (.5 kg) in one day; Heart failure (HF) is the inability of the heart to pump a sufficient amount of oxygen to meet the metabolic needs of the body. A weight gain of 1 lb (0.5 kg ) in 1 day is caused by the accumulation of fluid. The nurse should assess urine output, assess for evidence of facial or peripheral edema, auscultate lung sounds, and report the weight gain to the health care provider. Tachypnea and increased blood pressure occur with fluid accumulation.

An 11-year-old child is admitted to the hospital in vaso-occlusive sickle cell crisis. The nurse plans for which priority treatments in the care of the child?

Adequate hydration and pain management; During vaso-occlusive sickle cell crisis, the care focuses on adequate hydration and pain management. Adequate hydration with intravenous normal saline and oral fluids maintains blood flow and decreases the severity of the vaso-occlusive crisis. Analgesics for pain management are necessary during a vaso-occlusive crisis. Splenectomy would not be done with a vaso-occlusive crisis.

A 1-year-old infant with a diagnosis of heart failure is prescribed digoxin. The nurse takes the apical pulse for 1 minute before administering the medication and obtains a result of 102 beats/minute. What is the nurse's best action?

Administer the medication; The apical pulse rate for a 1-year-old infant is 90 to 130 beats/min.

A child was seen in the health care clinic and received an immunization of DPT (diphtheria, pertussis, tetanus) vaccine. One hour later, the mother calls the clinic and tells the nurse that the injection site is painful and red. Which instruction should the nurse provide to the mother?

Apply cold compresses for 24 hours for 20 minutes at a time; For painful or red injection sites, the nurse should instruct the mother to apply cold compresses for the first 24 hours for 20 minutes at a time and then to use warm or cold compresses as long as needed.

A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant?

Back rather than on the stomach; SIDS is the unexpected death of an apparently healthy infant younger than 1 year for whom an investigation of the death and a thorough autopsy fail to show an adequate cause of death. Several theories are proposed regarding the cause, but the exact cause is unknown. Nurses should encourage parents to place the infant on the back (supine) for sleep. Infants in the prone position (on the stomach) may be unable to move their heads to the side, increasing the risk of suffocation.

On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease?

Conjunctival hyperemia; Kawasaki disease, also known as mucocutaneous lymph node syndrome, is an acute systemic inflammatory illness. In the acute stage, the child has a fever, conjunctival hyperemia, red throat, swollen hands, rash, and enlargement of the cervical lymph nodes. In the subacute stage, cracking lips and fissures, desquamation of the skin on the tips of the fingers and toes, joint pain, cardiac manifestations, and thrombocytosis occur. In the convalescent stage, the child appears normal, but signs of inflammation may be present.

The nurse is providing instructions to the mother of a child who has been exposed to human immunodeficiency virus infection. The nurse should include notifying the health care provider if which symptom occurs in the child?

Coughing; Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. The mother should be instructed to call the health care provider (HCP) if the child develops a fever higher than 101°F (38.3°C); has vomiting and diarrhea, a decreased appetite, difficulty in swallowing, or drooling; develops rashes or sores on the skin; or has coughing or chest congestion. The mother should also notify the HCP if ear pain, ear pulling, or drainage from the ears occurs; if wounds appear that do not heal; or if the child is exposed to chickenpox.

The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic, and the nurse recognizes that the infant is experiencing a hypercyanotic spell (blue or tet spell). The nurse immediately places the infant in what position?

Knee-chest position; Tetralogy of Fallot includes four defects-ventricular septal defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy. If pulmonary vascular resistance is higher than systemic resistance, the shunt is from right to left; if systemic resistance is higher than pulmonary resistance, the shunt is left to right. If a hypercyanotic spell occurs, the nurse immediately places the infant in a knee-chest position. This position improves systemic arterial oxygen saturation.

A 2-year-old boy with a diagnosis of hemophilia is admitted to the hospital with bleeding into the joint of the right knee. Which intervention should the nurse plan to implement with this child?

Measure the injured knee-joint every shift; Interventions for bleeding into the joint include measuring the injured joint to assess for progression of the bleeding. This provides objective rather than subjective data, which are needed to determine if the bleeding is increasing. Rectal temperatures can cause tissue trauma, causing further bleeding. The application of heat and the administration of acetylsalicylic acid will increase bleeding.

The clinic nurse reads the results of a tuberculin skin test (TST) on a 3-year-old child. The results indicate an area of induration measuring 10 mm. The nurse should interpret these results as which finding?

Positive; Induration measuring 10 mm or more is considered to be a positive result in children younger than 4 years of age and in children with chronic illness or at high risk for exposure to tuberculosis. A reaction of 5 mm or more is considered to be a positive result for the highest risk groups, such as a child with an immunosuppressive condition or a child with human immunodeficiency virus (HIV) infection. A reaction of 15 mm or more is positive in children 4 years or older without any risk factors.

The nurse is collecting data on a 12-month-old child with iron deficiency anemia. Which finding should the nurse expect to note in this child?

Tachycardia; Clinical manifestations of iron deficiency anemia will vary with the degree of anemia but usually include extreme pallor with a porcelain-like skin, tachycardia, lethargy, and irritability.

The nurse is reviewing the immunization schedule for a child with human immunodeficiency virus (HIV) infection with the mother. Which instruction should the nurse provide to the mother?

The child and the siblings will need to receive inactivated polio vaccine; Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. The mother should be instructed that the child with HIV infection should keep immunizations up to date. The child with HIV infection and the siblings will receive an inactivated polio vaccine because the child with HIV infection is immunocompromised. All household members will receive the influenza vaccine. The immunization schedule would not be altered in any other way, and it is important for the mother to understand clearly the immunization schedule.

The student nurse is presenting a clinical conference regarding human immunodeficiency virus (HIV) in children. Which information should the student include?

The mother is infected with the HIV virus; Human immunodeficiency virus (HIV) can cause acquired immunodeficiency syndrome, which is a viral disease that destroys T cells, thereby increasing susceptibility to infection and malignancy. A positive HIV antibody test result in a child younger than 18 months indicates only that the mother is infected because maternal IgG antibodies persist in infants for 6 to 9 months and, in some cases, as long as 18 months.

The nurse is preparing to administer digoxin to an infant with heart failure. Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 80 beats/minute. Based on this finding, which is the appropriate nursing action?

Withhold the medication; Digoxin is a cardiac glycoside that is used to treat heart failure. A primary concern is digoxin toxicity, and the nurse needs to monitor closely for signs of toxicity and monitor digoxin blood levels. The medication is effective within a narrow therapeutic digoxin range (0.5 to 0.8 ng/mL). Safety in administration is achieved by double-checking the dose and counting the apical heart rate for 1 full minute. The apical pulse rate for an infant is 90 to 130 beats/min If the heart rate is less than 90 beats/minute in an infant, the nurse would withhold the dose and contact the health care provider.

The nurse in the ambulatory care unit is caring for a child after a tonsillectomy. The child's mother tells the nurse that the child is complaining of a dry throat and would like something to relieve the dryness. Which item should the nurse provide for the mother to give to the child?

yellow non-citrus jello; After tonsillectomy, clear, cool liquids should be given. Citrus, carbonated, and extremely hot or cold liquids should be avoided because they may irritate the throat. Milk and milk products, including pudding, are avoided because they coat the throat, which causes the child to clear the throat, thereby increasing the risk of bleeding. Red liquids should be avoided because they give the appearance of blood if the child vomits.

The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further instruction?

"If my child vomits after medication administration, I will repeat the dose." Digoxin is a cardiac glycoside. The parents need to be instructed that if the child vomits after digoxin is administered, they are not to repeat the dose.

A child is scheduled for a tonsillectomy in a day surgical unit. On the day after surgery, the mother calls the surgical unit and expresses concern because the child has a bad mouth odor. Which response is most appropriate?

"Bad mouth odor is normal and may be relieved by drinking more liquids." A tonsillectomy is the surgical removal of the tonsils. Bad mouth odor is normal after tonsillectomy and may be relieved by drinking more liquids.

The mother of a child with cystic fibrosis (CF) asks the clinic nurse about the disease. What should the nurse tell the mother about CF?

A chronic multisystem disorder affecting the exocrine glands; CF is a chronic multisystem disorder that affects the exocrine glands. The mucus produced by these glands (particularly those of the bronchioles, small intestine, and pancreatic and bile ducts) is abnormally thick, causing obstruction of the small passageways of these organs. It is transmitted as an autosomal recessive trait.

A child with a diagnosis of tetralogy of Fallot exhibits an increased depth and rate of respirations. On further assessment, the nurse notes increased hypoxemia. The nurse interprets these findings as indicating which situation?

A hypercyanotic episode; Children with tetralogy of Fallot or similar physiology may experience hypercyanotic episodes, or tet spells. These episodes are characterized by increased respiratory rate and depth and increased hypoxia.

A health care provider prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV). The nurse anticipates that which laboratory study will be prescribed for the infant?

p24 antigen assay; Infants born to HIV-infected mothers need to be screened for the HIV antigen. The detection of HIV in infants is confirmed by a p24 antigen assay, virus culture of HIV, or polymerase chain reaction. A Western blot test confirms the presence of HIV antibodies.

A 12-year-old is admitted to the hospital with a low-grade fever and joint pain. Which diagnostic test finding will assist to determine a diagnosis of rheumatic fever?

Elevated erythrocyte sedimentation rate; Rheumatic fever develops after a group A beta- hemolytic streptococcal infection, particularly pharyngitis. Initial diagnosis is made by noting the presence of Aschoff's bodies, or hemorrhagic bullous lesions, in the heart, joints, skin, and central nervous system; an elevated antistreptolysin O titer; an elevated C-reactive protein level; and an elevated erythrocyte sedimentation rate.

Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The mother of the child is a registered nurse and asks the nurse why the child needs the medication. What is the most appropriate response to the mother about the action of the medication?

Maintains adequate cardiac output; A child with transposition of the great arteries may receive prostaglandin E1 temporarily to increase blood mixing if systemic and pulmonary mixing is inadequate to maintain adequate cardiac output.

A mother calls the health care provider's office requesting an appointment for her 8-year-old child. She states he has asthma and is telling her he had trouble breathing last night and does not want to go to school. In triaging this child, which is the most important question to initially ask the mother?

"Is your child telling you at this time he is having trouble breathing?" Airway is always the most important indicator to determine if the child can be seen in the health care provider's office or needs to be taken to the emergency department.

The mother of a child being discharged after heart surgery asks the nurse when the child will be able to return to school. Which is the most appropriate response to the mother?

"The child may return to school in 3 weeks but needs to go half-days for the first few days." After heart surgery, the child may be able to return to school in 3 weeks but needs to go half-days for the first few days. The mother also should be told that that the child cannot participate in physical education for 2 months.

The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent?

"The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination." Cystic fibrosis is a chronic multisystem disorder (autosomal recessive trait disorder) characterized by exocrine gland dysfunction. The mucus produced by the exocrine glands is abnormally thick, tenacious, and copious, causing obstruction of the small passageways of the affected organs, particularly in the respiratory, gastrointestinal, and reproductive systems. Adequately protecting children with cystic fibrosis from communicable diseases by immunization is essential. In addition to the basic series of immunizations, a yearly influenza immunization is recommended for children with cystic fibrosis.

The nurse is conducting staff in-service training on von Willebrand's disease. Which should the nurse include as characteristics of von Willebrand's disease? Select all that apply.

-Easy bruising occurs. -Gum bleeding occurs. -It is a hereditary bleeding disorder. -Treatment and care are similar to that for -hemophilia. -The disorder causes platelets to adhere to damaged endothelium. von Willebrand's disease is a hereditary bleeding disorder characterized by a deficiency of or a defect in a protein termed von Willebrand factor. The disorder causes platelets to adhere to damaged endothelium. It is characterized by an increased tendency to bleed from mucous membranes. Assessment findings include epistaxis, gum bleeding, easy bruising, and excessive menstrual bleeding.

The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis?

Anti-stretolysin O-titer; Rheumatic fever is an inflammatory autoimmune disease that affects the connective tissues of the heart, joints, skin (subcutaneous tissues), blood vessels, and central nervous system. A diagnosis of rheumatic fever is confirmed by the presence of 2 major manifestations or 1 major and 2 minor manifestations from the Jones criteria. In addition, evidence of a recent streptococcal infection is confirmed by a positive anti-streptolysin O titer, Streptozyme assay, or anti-DNase B assay.

The nurse is instructing the parents of a child with iron deficiency anemia regarding the administration of a liquid oral iron supplement. Which instruction should the nurse tell the parents?

Administer the iron through a straw; In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. An oral iron supplement should be administered through a straw or medicine dropper placed at the back of the mouth because the iron stains the teeth. The parents should be instructed to brush or wipe the child's teeth or have the child brush the teeth after administration. Iron is administered between meals because absorption is decreased if there is food in the stomach. Iron requires an acid environment to facilitate its absorption in the duodenum.

The nurse is caring for a child with a diagnosis of hemophilia, and hemarthrosis is suspected because the child is complaining of pain in the joints. Which measure should the nurse expect to be prescribed for the child?

Application of a bivalved cast for joint immobilization; In an acute period, immobilization of the joint would be prescribed. Range-of-motion exercise during the acute period can increase the bleeding and would be avoided at this time. Heat will increase blood flow to the area, so it would promote increased bleeding to the area. Nonsteroidal antiinflammatory drugs (NSAIDs) can prolong bleeding time and would not be prescribed for the child.

Aplastic crisis

Caused by diminished production and increased destruction of red blood cells, triggered by viral infection or depletion of folic acid. Manifestations: Profound anemia and pallor.

The nurse is reviewing the health care provider's prescriptions for a child with rheumatic fever who is suspected of having a viral infection. The nurse notes that aspirin is prescribed for the child. Which nursing action is most appropriate?

Consult with the health care provider to verify the prescription; Antiinflammatory agents, including aspirin, may be prescribed for the child with rheumatic fever. Aspirin should not be given to a child who has chickenpox or other viral infections because of the risk of Reye's syndrome. Therefore, the nurse should consult with the health care provider (HCP) to verify the prescription. The nurse would not administer acetaminophen without specific HCP prescriptions.

The nurse is caring for a child with hemophilia and is reviewing the results that were sent from the laboratory. Which result should the nurse expect in this child?

Prolonged PTT; PTT measures the activity of thromboplastin, which is dependent on intrinsic factors. In hemophilia, the intrinsic clotting factor VIII (antihemophilic factor) is deficient, resulting in a prolonged PTT.

A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition?

Decreased wheezing; Asthma is a chronic inflammatory disease of the airways. Decreased wheezing in a child with asthma may be interpreted incorrectly as a positive sign when it may actually signal an inability to move air. A "silent chest" is an ominous sign during an asthma episode. With treatment, increased wheezing actually may signal that the child's condition is improving. Warm, dry skin indicates an improvement in the child's condition because the child is normally diaphoretic during exacerbation.

A child has been tentatively diagnosed with rheumatic fever. The nurse interprets that this diagnosis is consistent with which laboratory result obtained for this child?

Elevated antistreptolysin O titer; In the presence of rheumatic fever, the child will exhibit an elevated antistreptolysin O titer, an elevated erythrocyte sedimentation rate, leukocytosis, and a positive result on C-reactive protein determination. A positive result on antinuclear antibody testing is used to diagnose a wide variety of connective-tissue, vascular, and immune complex disorders and also will be positive with rheumatic fever.

The mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother?

Encourage the child to lay on the right side; Pneumonia is an inflammation of the pulmonary parenchyma or alveoli, or both, caused by a virus, mycoplasmal agents, bacteria, or aspiration of foreign substances. Splinting of the affected side by lying on that side may decrease discomfort.

The clinic nurse reviews the record of a child just seen by a health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder?

Exercise intolerance; Aortic stenosis is a narrowing or stricture of the aortic valve, causing resistance to blood flow in the left ventricle, decreased cardiac output, left ventricular hypertrophy, and pulmonary vascular congestion. A child with aortic stenosis shows signs of exercise intolerance, chest pain, and dizziness when standing for long periods. Pallor may be noted, but is not specific to this type of disorder alone.

The clinic nurse instructs parents of a child with sickle cell anemia about the precipitating factors related to sickle cell crisis. Which, if identified by the parents as a precipitating factor, indicates the need for further instruction?

Fluid overload; Sickle cell crises are acute exacerbations of the disease, which vary considerably in severity and frequency; these include vaso-occlusive crisis, splenic sequestration, hyperhemolytic crisis, and aplastic crisis. Sickle cell crisis may be precipitated by infection, dehydration, hypoxia, trauma, or physical or emotional stress. The mother of a child with sickle cell disease should encourage fluid intake of 1½ to 2 times the daily requirement to prevent dehydration.

The nurse is caring for a child after a tonsillectomy. The nurse monitors the child, knowing that which finding indicates the child is bleeding?

Frequent swallowing; A tonsillectomy is the surgical removal of the tonsils. Frequent swallowing, restlessness, a fast and thready pulse, and vomiting bright red blood are signs of bleeding.

A 10-year-old child with hemophilia A has slipped on the ice and bumped his knee. The nurse should prepare to administer which prescription?

Intravenous infusion of factor VIII; Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. The primary treatment is replacement of the missing clotting factor; additional medications, such as agents to relieve pain, may be prescribed depending on the source of bleeding from the disorder. A child with hemophilia A is at risk for joint bleeding after a fall. Factor VIII would be prescribed intravenously to replace the missing clotting factor and minimize the bleeding.

A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent. Which is the most appropriate nursing action?

Let the mother hold the child and direct the cool mist over the child's face; Laryngotracheobronchitis (croup) is the inflammation of the larynx, trachea, and bronchi and is the most common type of croup. Cool mist therapy may be prescribed to liquefy secretions and to assist in breathing. If the use of a tent or hood is causing distress, treatment may be more effective if the child is held by the parent and a cool mist is directed toward the child's face (blow-by).

The student nurse is caring for an infant with a tracheostomy and is preparing to suction the infant. The nursing instructor should intervene if the nursing student stated she would take which action to perform this procedure?

Limit insertion and suctioning time to 15 seconds to prevent hypoxia; When suctioning a tracheostomy in an infant, it is necessary to limit insertion and suctioning time to 5 seconds to prevent hypoxia. Correct suctioning procedures for an infant include inserting the catheter the length of the tracheostomy tube with the suction off, applying intermittent suction and withdrawing the catheter with a twisting motion, and reoxygenating between suction catheter passage.

The nurse is reviewing the laboratory results of a child with aplastic anemia and notes that the white blood cell count is 2000 mm3 (2 × 109/L) and that the platelet count is 150,000 mm3 (150 × 109/L). Which intervention should the nurse incorporate into the plan of care?

Maintain strict neutropenic precautions; The normal white blood cell (WBC) count ranges from 5000 to 10,000 mm3 (5 to 10 × 109/L) and the normal platelet count ranges from 150,000 to 400,000 mm3 (150 to 400 × 109/L). Strict neutropenic procedures would be required if the WBC count were low to protect the child from infection. Precautionary measures to prevent bleeding should be taken when a child has a low platelet count. These include no injections, no rectal temperatures, use of a soft toothbrush, and abstinence from contact sports or activities that could cause an injury.

The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action?

Move the infant to a room with another child with RSV; RSV is a highly communicable disorder and is not transmitted via the airborne route. The virus usually is transferred by the hands. Use of contact and standard precautions during care is necessary. Using good hand-washing technique and wearing gloves and gowns are also necessary. Masks are not required. An infant with RSV is isolated in a single room or placed in a room with another child with RSV.

The nurse analyzes the laboratory results of a child with hemophilia. The nurse understands that which result will most likely be abnormal in this child?

Partial thromboplastin time; Hemophilia refers to a group of bleeding disorders resulting from a deficiency of specific coagulation proteins. Results of tests that measure platelet function are normal; results of tests that measure clotting factor function may be abnormal. Abnormal laboratory results in hemophilia indicate a prolonged partial thromboplastin time.

Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder?

Patent ductus arteriosus; A patent ductus arteriosus is failure of the fetal ductus arteriosus (artery connecting the aorta and the pulmonary artery) to close. A characteristic machinery-like murmur is present, and the infant may show signs of heart failure. Aortic stenosis is a narrowing or stricture of the aortic valve. Atrial septal defect is an abnormal opening between the atria. Ventricular septal defect is an abnormal opening between the right and left ventricles.

Breathing exercises and postural drainage are prescribed for a hospitalized child with cystic fibrosis. What instruction should the nurse include in the client's teaching plan?

Perform the postural drainage first and then the breathing exercises; Breathing exercises are recommended for a majority of children with cystic fibrosis (CF), even those with minimal pulmonary involvement. The exercises usually are performed twice daily, and they are preceded by postural drainage. The postural drainage will mobilize secretions, and the breathing exercises will then assist with expectoration. Exercises to assist in assuming correct postures and in maximizing thoracic mobility, such as swinging the arms and bending and twisting the trunk, are included. The ultimate aim of these exercises is to establish a good habitual breathing pattern.

The nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. What is the priority action by the nurse?

Place the infant in a knee-chest position; If a hypercyanotic episode occurs, the infant is placed in a knee-chest position. The knee-chest position is thought to increase pulmonary blood flow by increasing systemic vascular resistance. This position also improves systemic arterial oxygen saturation by decreasing venous return, so that smaller amounts of highly saturated blood reach the heart. Toddlers and children squat to obtain this position and relieve chronic hypoxia.

The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction?

The child is leaning forward, with the chin thrust out; Epiglottitis is a bacterial form of croup. A primary concern is that it can progress to acute respiratory distress. Clinical manifestations suggestive of airway obstruction include tripod positioning (leaning forward while supported by arms, chin thrust out, mouth open), nasal flaring, the use of accessory muscles for breathing, and the presence of stridor.

The clinic nurse is instructing the parent of a child with human immunodeficiency virus (HIV) infection regarding immunizations. The nurse should provide which instruction to the parent?

The inactivated influenza vaccine will be given yearly; Immunizations against common childhood illnesses are recommended for all children exposed to or infected with HIV. The inactivated influenza vaccine that is given intramuscularly will be administered (influenza vaccine should be given yearly). The hepatitis B vaccine is administered according to the recommended immunization schedule. Varicella-zoster virus vaccine should not be given because it is a live virus vaccine; varicella-zoster immunoglobulin may be prescribed after chickenpox exposure.

After a tonsillectomy, a child begins to vomit bright red blood. The nurse should take which initial action?

Turn the child to its side; After tonsillectomy, if bleeding occurs, the nurse immediately turns the child to the side to prevent aspiration and then notifies the HCP. NPO status would be maintained, and an antiemetic may be prescribed; however, the initial nursing action would be to turn the child to the side.

The nurse provides instructions regarding home care to the parents of a 3-year-old child hospitalized with hemophilia. Which statement, if made by the parent, indicates a need for further instructions?

"We will avoid having our child receive immunizations." The nurse needs to stress the importance of immunizations, dental hygiene, and routine well-child care. The remaining options are appropriate. The parents also are instructed in the measures to implement in the event of blunt trauma, especially trauma involving the joints, and taught to apply prolonged pressure to superficial wounds until the bleeding has stopped.

The nurse is monitoring the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse prepares to implement bleeding precautions if the child becomes thrombocytopenic and the platelet count is less than how many cells/mm3?

150,000 mm3 (150 × 109/L); If a child is thrombocytopenic, precautions need to be taken because of the increased risk of bleeding. The precautions include limiting activity that could result in head injury, using soft toothbrushes, checking urine and stools for blood, and administering stool softeners to prevent straining with constipation. Additionally, suppositories and rectal temperatures are avoided. The normal platelet count ranges from 150,000 to 400,000 mm3 (150 to 400 × 109/L).

A school nurse is teaching parents about emergency treatment for epistaxis. Which best action should the nurse take to assist the parents in understanding the emergency treatment?

Ask the parents to demonstrate, on a mannequin, where to apply continuous pressure if a nosebleed occurs; Evaluation of the teaching is done by eliciting feedback to ensure that parents understand the information. Use of a hands-on return demonstration is the best method to encourage mastery of skills and to determine whether the parents have understood what was taught.

The nursing student is assigned to care for a child with hemophilia. The nursing instructor reviews the plan of care with the student. Which intervention on the student written plan of care requires correction?

Blood transfusion of packed red blood cells; Hemophilia is a lifelong hereditary blood disorder associated with deficiency of clotting factors. It is inherited in a recessive manner via a genetic defect on the X chromosome. Hemophilia A results from a deficiency of factor VIII. Hemophilia B (Christmas disease) is a deficiency of factor IX. Blood product transfusion is not the treatment of choice over administering recombinant factors intravenously. Measuring circumference of injured joints is appropriate to assess for enlarging hematomas or bleeding under the skin. The nurse should avoid taking rectal temperatures to decrease the risk for injury.

Laboratory studies are performed for a child suspected to have iron deficiency anemia. The nurse reviews the laboratory results, knowing that which result indicates this type of anemia?

Red blood cells that are microcytic and hypochromic; In iron deficiency anemia, iron stores are depleted, resulting in a decreased supply of iron for the manufacture of hemoglobin in red blood cells. The results of a complete blood cell count in children with iron deficiency anemia show decreased hemoglobin levels and microcytic and hypochromic red blood cells. The red blood cell count is decreased. The reticulocyte count is usually normal or slightly elevated.

A child with β-thalassemia is receiving long-term blood transfusion therapy for the treatment of the disorder. Chelation therapy is prescribed as a result of too much iron from the transfusions. Which medication should the nurse anticipate to be prescribed?

Deferoxamine; The major complication of long-term transfusion therapy is hemosiderosis. To prevent organ damage from too much iron, chelation therapy with either Exjade or deferoxamine may be prescribed. Deferoxamine is classified as an antidote for acute iron toxicity.

A nursing student is assigned to care for a child with sickle cell disease (SCD). The nursing instructor asks the student to describe the causative factors related to this disease. Which statement by the student indicates a need for further research?

If each parent carries the trait, the child will carry the trait, and the probability of the child having the disease is 75%; SCD is an autosomal recessive disease. Children with the HbS trait are not symptomatic. If one parent has the HbS trait and the other parent is normal, there is a 50% chance that each offspring will inherit the trait. If each parent carries the trait, there is a 25% chance that their child will be normal, a 50% chance that the child will carry the trait, and a 25% chance that each child will have the disease.

A child with a diagnosis of sickle cell anemia and vaso-occlusive crisis is complaining of severe pain, selecting number 8 on the 1 to 10 pain scale. Which medication would the nurse expect to be prescribed for pain control?

Morphine sulfate; Morphine sulfate is the medication of choice for severe pain for the child with sickle cell anemia. Opioids such as morphine sulfate provide systemic relief.

The nurse is reviewing the health care provider's prescriptions for a child following a tonsillectomy. Which prescription should the nurse question?

Suction the child frequently if coughing; Following tonsillectomy, suction equipment should be available, but the child is not suctioned unless there is an airway obstruction. Clear, cool liquids are encouraged. Milk and milk products are avoided initially because they coat the throat, causing the child to clear his or her throat and thereby increasing the risk of bleeding. Discharge to home when the child is alert and tolerating fluids is an appropriate intervention following tonsillectomy.

A child is scheduled for a tonsillectomy. The nurse plans care, knowing that which condition would be a priority because it presents the highest risk of aspiration during surgery?

Presence of loose teeth; A tonsillectomy is the surgical removal of the tonsils. In the preoperative period, the child should be observed for the presence of loose teeth to decrease the risk of aspiration during surgery. Bleeding during surgery will be controlled via packing and suction as needed.

The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF?

Tachycardia; HF is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. The early signs of HF include tachycardia, tachypnea, profuse scalp sweating, fatigue and irritability, sudden weight gain, and respiratory distress. A cough may occur in HF as a result of mucosal swelling and irritation, but is not an early sign. Pallor may be noted in an infant with HF, but is not an early sign.

A health care provider has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant?

When drawing blood for electrolyte level testing; Heart failure (HF) is the inability of the heart to pump a sufficient amount of blood to meet the oxygen and metabolic needs of the body. Crying exhausts the limited energy supply, increases the workload of the heart, and increases the oxygen demands. Oxygen administration may be prescribed for stressful periods, especially during bouts of crying or invasive procedures.

The mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant to the clinic for a routine checkup. The health care provider has documented that the infant is asymptomatic for HIV infection. After the checkup, the mother tells the nurse that she is so pleased that the infant will not get HIV infection. The nurse should make which most appropriate response to the mother?

"Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic sometime before they are 3 years old." Acquired immunodeficiency syndrome (AIDS) is caused by HIV infection and characterized by generalized dysfunction of the immune system. Most children infected with HIV develop symptoms within the first 9 months of life. The remaining infected children become symptomatic sometime before age 3 years. With their immature immune systems, children have a much shorter incubation period than adults.

A mother arrives at the hospital emergency department with her child, in whom a diagnosis of epiglottitis is documented. Which prescription, if written by the health care provider, should the nurse question?

Obtain a throat culture; The throat of a child with suspected epiglottitis should not be examined or cultured because any stimulation with a tongue depressor or culture swab could cause laryngospasm, thus completing airway obstruction. Humidified oxygen and antipyretics are components of management. Axillary rather than oral temperatures should be taken to avoid stimulation and resultant laryngospasm.

A child in whom sickle cell anemia is suspected is seen in a clinic, and laboratory studies are performed. The nurse checks the laboratory results, knowing that which value would be increased in this disease?

Reticulocyte count; Sickle cell anemia is a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell. Insufficient oxygen causes the cells to assume a sickle shape, and the cells become rigid and clumped together, obstructing capillary blood flow. A diagnosis is established on the basis of a complete blood count, examination for sickled red blood cells in the peripheral smear, and hemoglobin electrophoresis. Laboratory studies will show decreased hemoglobin level and hematocrit, a decreased platelet count, an increased reticulocyte count, and the presence of nucleated red blood cells. Reticulocyte counts are increased in children with sickle cell disease because the life span of their sickled red blood cells is shortened.

After a tonsillectomy, the nurse reviews the health care provider's (HCP's) postoperative prescriptions. Which prescription should the nurse question?

Suction every 2 hours; A tonsillectomy is the surgical removal of the tonsils. After tonsillectomy, suction equipment should be available, but suctioning is not performed unless there is an airway obstruction because of the risk of trauma to the surgical site. Monitoring for bleeding is an important nursing intervention after any type of surgery. Milk and milk products are avoided initially because they coat the throat, cause the child to clear the throat, and increase the risk of bleeding. Clear, cool liquids are encouraged.

A mother arrives at the clinic with her 3-year-old child. The mother tells the nurse that the child has had a fever and a cough for the past 2 days and that this morning the child began to wheeze. Viral pneumonia is diagnosed. Based on the diagnosis, the nurse anticipates that which will be a component of the treatment plan?

Supportive treatment; With viral pneumonia, treatment is supportive. More severely ill children may be hospitalized and given oxygen, chest physiotherapy, and IV fluids. Antibiotics are not given. Bacterial pneumonia, however, is treated with antibiotic therapy.

An ambulatory care nurse is preparing a list of instructions for the parents of a child who is being discharged after a tonsillectomy. The nurse should place which instructions on the list? Select all that apply.

Avoid hot fluids, avoid raw vegetables, and rest in bed or on a couch for 24 hours; After tonsillectomy, the client is instructed to advance the diet from cool, clear liquids to full liquids. Hot fluids and carbonated beverages should be avoided because they may be irritating to the throat. Milk and milk products (pudding) are avoided because they may cause the client to cough, which could cause pain at the surgical site. Foods and snacks that are rough in texture, such as raw fruits or vegetables, should be avoided for 10 days to protect the operative site and prevent bleeding. The client should be instructed to rest in bed or on a couch for 24 hours after the surgical procedure and gradually resume full activity.

A 12-year-old child with newly diagnosed thalassemia is brought to the clinic exhibiting delayed sexual maturation, fatigue, anorexia, pallor, and complaints of headache. The child seems listless and small for age and has frontal bossing. What should the nurse expect to note on review of the results of the laboratory tests?

Deficient production of functional hemoglobin; Defective hemoglobin is produced as a result of genetically deficient beta-polypeptide. This hemoglobin is unstable, disintegrates, and damages the erythrocytes. Rapid destruction of the red cells stimulates rapid production of immature red cells, and the net gain is less than optimally functioning red cells. Iron from the red blood cell destruction is stored in the tissues, causing multiple problems. In thalassemia, immature erythrocytes proliferate, not mature ones. This is a progressive anemia. The nurse also would note microcytosis and hypochromia.

The pediatric nursing instructor asks a nursing student to prioritize care for a child diagnosed with sickle cell disease. Which student response correctly identifies the priority of care?

Hypoxia; Sickle cell disease is a group of diseases termed hemoglobinopathies, in which hemoglobin A is partly or completely replaced by abnormal sickle hemoglobin S. It is caused by the inheritance of a gene for a structurally abnormal portion of the hemoglobin chain. Hemoglobin S is sensitive to changes in the oxygen content of the red blood cell. Hypoxia causes the cells to assume a sickle shape, and the cells become rigid and clumped together, obstructing capillary blood flow and leading to a vaso-occlusive crisis. All the clinical manifestations of sickle cell anemia result from the sickled cells being unable to flow easily through the microvasculature, and their clumping obstructs blood flow. With reoxygenation most of the sickled red blood cells resume their normal shape. Fatigue is a result of hypoxia; hypoxia should be addressed first. Avascular necrosis of the hips and shoulders and delayed growth are general manifestations of sickle cell disease.