PrepU 4
serum potassium levels serum sodium levels Spironolactone is a potassium-sparing diuretic that competes with aldosterone to result in increased water and sodium excretion (spares potassium). It is used to manage edema due to heart failure and for treatment of hypertension. Serum potassium and sodium levels should be evaluated in someone taking this medication.
A child has been prescribed spironolactone. Which laboratory values should be reviewed when following up on this medication? Select all that apply. serum potassium levels serum sodium levels serum chloride levels serum magnesium levels serum calcium levels
Feeding problems Explanation: The indications of CHF vary in children of different ages. Signs in the infant may be hard to detect because they are subtle, but in infants, feeding problems are often seen. In infants and older children, tachycardia is one of the first signs of CHF. In a child with CHF, tachypnea would be seen, not bradypnea. The heart beats faster in an attempt to increase blood flow. Failure to gain weight, weakness, and an enlarged liver and heart are other possible indicators of CHF but are not as common as tachycardia and may take longer to develop.
A nurse admits an infant with a possible diagnosis of congestive heart failure. Which signs or symptoms would the infant most likely be exhibiting? Feeding problems Bradypnea Bradycardia Yellowish color
There is a partial or complete mechanical obstruction in the intestine. Explanation: Congenital aganglionic megacolon, also called Hirschsprung disease, is characterized by persistent constipation resulting from partial or complete intestinal obstruction of mechanical origin. A narrowing of the lumen of the pylorus is associated with pyloric stenosis in young infants. The telescoping of the bowel is intussusception. The relaxed sphincter in the lower portion of the esophagus is related to gastrointestinal reflux disorder.
What occurs in the gastrointestinal system of the child with Hirschsprung disease? There is a partial or complete mechanical obstruction in the intestine. There is a severe narrowing of the lumen of the pylorus. There is an invagination or telescoping of one portion of the bowel into a distal portion. There is a relaxed sphincter in the lower portion of the esophagus.
jellylike, bloody stools Explanation: This child is presenting with characteristic symptoms of intussusception, including abdominal distention and episodes of abdominal pain/cramping. During these episodes, the child draws legs up followed by vomiting. These occur approximately every 15 minutes, followed by breaks where the child appears normal. Intussusception usually results in jellylike (red currant jelly) mucousy red stools. Foul-smelling, fatty stools are typical of celiac disease. Narrow, ribbon-like stools are typical of Hirschsprung disease (aganglionic megacolon). Loose, watery stools are typical of diarrhea or may occur with irritable bowel disease. Reference:
A 9-month-old infant presents to the emergency department with vomiting and abdominal pain. While assessing the client, the nurse notes the client screaming intermittently and drawing up legs toward chest a palpable mass in upper right quadrant (above). What does the nurse anticipate in this child's stools? narrow, ribbon-like stools loose, watery stools jellylike, bloody stools foul-smelling, fatty stools
Proteinuria, hypoalbuminemia, and hypercholesterolemia Explanation: Proteinuria, hypoalbuminemia, and hypercholesterolemia are diagnostic of a child with nephrotic syndrome. The child will also present symptomatically with a sudden onset of edema. Hematuria is typically seen with glomerulonephritis.
A child is getting a diagnostic work-up for nephrotic syndrome. Which lab results would the nurse expect to see? Proteinuria, hypoalbuminemia, and hypercholesterolemia Hematuria, proteinuria, and hyperalbuminemia Neutropenia, hematuria, and hypocholesterolemia Proteinuria, hyperalbuminemia, and hypocholesterolemia
This test will check how blood is flowing through the heart. Explanation: An echocardiogram (echo) is a noninvasive ultrasound used to assess the heart wall thickness, the size of the heart chambers, the motion of the valves and septa, and the relationship of the great vessels to other cardiac structures. The test evaluates how blood is flowing through the heart and how effective the heart is in pumping. An echo does not check the electrical impulses. This would be done with an electrocardiogram.
A child with a congenital heart defect is getting an echocardiogram. How would the nurse describe this test to the parent? This test will check how blood is flowing through the heart. This noninvasive test will check the electrical impulses in the heart. This test will only determine the size of the heart. This invasive test will measure the blockage in the heart.
Nausea and vomiting Explanation: Digoxin is a cardiac glycoside and antiarrhythmic. It can cause toxicity if the dosages increase due to poor absorption, dehydration, etc. Signs of digoxin toxicity are nausea and vomiting, lethargy, and bradycardia. The apical pulse should be taken for one full minute prior to administering digoxin. The dosage should be held if the pulse rate is less than 60 beats/min in an adolescent or less than 90 beats/min in an infant. The other symptoms listed do not relate to digoxin toxicity and could occur for numerous reasons.
A nurse is administering digoxin to a 3-year-old child. What would be a reason to hold the dose of digoxin? Nausea and vomiting Ataxia Hypertension Fever and tinnitus
1 to 2 week course of antibiotics keeping the client in semi-Fowler position antihypertensive therapy high-protein diet Children with a diagnosis of acute glomerulonephritis usually will have an underlying streptococcal infection requiring a two-week course of antibiotics. Keeping the child in a semi-Fowler position and initiating a high-protein diet to supplement losing large amounts of protein in the urine is indicated. The child will be started on a course of antihypertensive therapy for high blood pressure. Blood glucose monitoring is not indicated.
A nurse is caring for a client with a diagnosis of acute glomerulonephritis. Which intervention would the nurse expect to be included in the treatment plan? Select all that apply. 1 to 2 week course of antibiotics keeping the client in semi-Fowler position antihypertensive therapy high-protein diet blood glucose checks
Monitor output. Explanation: A ureteral stent is placed in the ureter temporarily to aid in the drainage of urine. It is removed via cystoscopy when it is time for discontinuation. The nurse should monitor output carefully when a ureteral stent is in place. This is an indication that the stent is patent and functioning properly. The tubes are inserted into the ureter so they would not dangle on the outside of the body. There is no need to maintain fluid restriction or a low-sodium diet just because of the stent. This would only be necessary if there were other disease processes affecting the child.
A nurse is performing postoperative care on a child with a ureteral stent. Which intervention will help manage tube patency? Monitor output. Allow tubes to dangle freely to encourage flow. Maintain fluid restriction. Provide a low-sodium diet.
Obtain IV access to give fluid resuscitation and correct any electrolyte abnormalities. Explanation: For an omphalocele, protect the bowel by wrapping the exposed viscera with warm saline-soaked gauze and cover and seal with a plastic wrap or place in a "bowel bag" which will contain the defect, torso, and legs, to prevent heat and fluid loss from the exposed viscera. Obtain IV access. Give fluid resuscitation and correct any electrolyte abnormalities. Oral prednisone or prednisolone, or IV methylprednisolone, are administered for irritable bowel syndrome. An NG tube may be placed to decompress the stomach to prevent gastric distention when severe emesis is present with pancreatitis.
A nurse manages the interdisciplinary care for an infant born with an omphalocele. What is an accurate description of the care for an omphalocele? At birth, protect the exposed bowel by gently manipulating it back into the abdominal cavity. Obtain IV access to give fluid resuscitation and correct any electrolyte abnormalities. Administer corticosteroids as prescribed—either oral prednisone or prednisolone or as IV methylprednisolone. Insert an NG tube to decompress the stomach and to prevent gastric distention.
fluid overload Explanation: Many children with nephrotic syndrome develop hypoalbuminemia and require the administration of albumin. Albumin increases the intravascular pressure, causing the movement of fluid from the interstitial space to the intravascular space. As a result, fluid overload can occur. The treatment is to administer furosemide after the albumin infusion is complete. Furosemide is a diuretic that will help excrete the extra fluid from the vascular space, thus preventing fluid overload. Electrolyte imbalances would occur if the low albumin was not treated. The blood pressure and urine output should be assessed during the medication administration to determine renal function.
The nurse is administering an IV infusion of albumin to a child with nephrotic syndrome. What is the primary concern for the nurse when administering this medication to the child? fluid overload electrolyte imbalance increased blood pressure urine output
100 to 120/70 to 80 mm Hg Explanation: The normal adolescent's blood pressure averages 100 to 120/70 to 80 mm Hg. The average infant's blood pressure is about 80/55 mm Hg. The toddler or preschool-age child's blood pressure averages 90 to 110/55 to 75 mm Hg. The normal school-age child's blood pressure averages 100 to 120/60 to 75 mm Hg.
The nurse is assessing the blood pressure of an adolescent. In which range should the nurse expect the blood pressure measurement for a healthy 13-year-old boy? 80 to 90/40 to 64 mm Hg 80 to 100/64 to 80 mm Hg 94 to 112/56 to 60 mm Hg 100 to 120/70 to 80 mm Hg
Apply pressure 1 inch above the site. Explanation: If bleeding occurs after a cardiac catheterization, apply pressure 1 inch above the site to create pressure over the vessel, thereby reducing the blood flow to the area. The nurse should first apply pressure and then notify the physician if this measure is ineffective or the bleeding increases. The child should maintain the leg in a straight position for about 4 to 8 hours. However, this would not address the bleeding assessed at the site. Changing the dressing would not be effective.
The nurse is caring for a 10-year-old boy following a cardiac catheterization. Four hours after the procedure, the nurse notes some minor bleeding at the site. Which action would be most appropriate? Apply pressure 1 inch above the site. Contact the physician. Ensure that the child's leg is kept straight. Change the dressing.
1230 Explanation: The nurse will administer 1230 milligrams to this child is 24 hours. To calculate, first determine how many milligrams are given per dose by multiplying the child's weight (kg) by 15 mg. 15 mg x 20.5 kg = 307.5 mg per dose. The child is prescribed a dose every 6 hours. To determine how many doses the child will get in 24 hours, divide 24 by 6. 24/6 = 4. Now, multiply the number of doses given a day by the milligrams given in each dose to determine the total milligrams given in 24 hours. 4 x 307.5 mg = 1230 mg in 24 hours.
The nurse is caring for a child prescribed vancomycin 15 mg/kg IV every 6 hours for peritonitis. The child weights 45 lb (20.5 kg). How many milligrams will the nurse administer to this child in 24 hours?
PO pain management Explanation: Maintain NPO status and nasogastric tube suction and patency. Administer intravenous fluids to keep the child hydrated and correct any alterations in fluid and electrolyte balance. Pain management is crucial in children with pancreatitis; due to NPO status, medications are typically prescribed intravenously. Serial monitoring of serum amylase levels will determine when oral feeding may be restarted.
The nurse is caring for a teenager diagnosed with acute pancreatitis. Which order would the nurse question? NPO nasogastric tube placed to suction serum amylase levels PO pain management
The child recently had an ear infection. Explanation: In the child with acute glomerulonephritis, presenting symptoms appear 1 to 3 weeks after the onset of a streptococcal infection, such as strep throat, otitis media, tonsillitis, or impetigo. There is not a family history of the disorder, a history of congenital concerns or defects, nor asthma in children with acute glomerulonephritis. Reference:
The nurse is collecting data for a child diagnosed with acute glomerulonephritis. What would the nurse likely find in this child's history? The child has a sibling with the same diagnosis. The child had a congenital heart defect. The child recently had an ear infection. The child is being treated for asthma.
significant cyanosis without the presence of a murmur Explanation: Significant cyanosis without presence of a murmur is highly indicative of transposition. Abrupt cessation of chest output accompanied by an increase in heart rate and filling pressure is indicative of cardiac tamponade. A soft systolic ejection or holosystolic murmur can be found with other disorders, such as hypoplastic left heart syndrome, but is not highly suspicious of transposition.
The nurse is conducting a physical examination of a child with a suspected cardiovascular disorder. Which finding would the nurse most likely expect to assess if the child had transposition of the great vessels? significant cyanosis without the presence of a murmur abrupt cessation of chest output with an increase in heart rate/filling pressure soft systolic ejection holosystolic murmur
Using a double-diapering technique. Explanation: Double diapering is a method used to protect a child's urethra and stent or catheter after surgery and additionally helps to keep the area clean and free from infection. Keeping the drainage tube taped in an upright position, administering antibiotics, and administering analgesics are also important, but double diapering keeps the area clean and helps prevent infection.
The nurse is providing postsurgical care for an infant who has undergone a hypospadias repair. Which action by the nurse would be most important to help keep the area clean while maintaining proper position of the drainage tubing? Keeping the drainage tube taped in an upright position. Administering antibiotics as ordered. Administering analgesics as prescribed. Using a double-diapering technique.
"He gets sweaty when he eats." Explanation: Diaphoresis with nipple feeding indicates heart failure. Shortness of breath would suggest heart failure. Children with heart failure experience subtle signs that suggest that something is wrong. Children with heart failure often display subtle signs such as difficulty feeding
The nurse is taking a health history of a 6-week-old boy with a suspected cardiovascular disorder. Which response by the mother would lead the nurse to suspect that the child is experiencing heart failure? "He gets sweaty when he eats." "He does not seem short of breath." "He does not seem sick." "He seems to have a normal appetite."
management includes administration of aspirin and IVIG. Explanation: Kawasaki disease is an acute systemic vasculitis. It is the most common form of acquired heart disease in children. The treatment is directed to reduce the inflammation in the walls of the coronary arteries and prevent thrombosis. Children are given high-dose aspirin therapy four times a day and they receive an infusion of IV immunoglobulins (IVIG) to prevent cardiac complications. Joint pain is common but not necessarily a permanent problem associated with Kawasaki disease. Antibiotics and steroid creams are not used to treat this disorder.
When caring for a child with Kawasaki disease, the nurse would know that: management includes administration of aspirin and IVIG. joint pain is a permanent problem. antibiotics should be administered every 8 hours by IV. steroid creams are used for the hand peeling.
Ventricular septal defect Patent ductus arteriosus Atrioventricular canal defect Congenital heart defects classified as disorders with increased pulmonary blood flow include ventricular septal defect, patent ductus arteriosus, and atrioventricular canal defect. Pulmonary stenosis and coarctation of the aorta are classified as disorders with obstruction to blood flow.
A health care provider and other health team members are discussing congenital heart disorders that increase pulmonary blood flow. Which disorders are topics for this discussion? Select all that apply. Ventricular septal defect Patent ductus arteriosus Atrioventricular canal defect Pulmonary stenosis Coarctation of the aorta
This is due to a decreased amount of oxygen to the peripheral tissue. Explanation: Cyanosis associated with certain congenital heart defects is due to the body naturally compensating and decreasing the amount of oxygen to the peripheral tissue. This keeps the oxygen with the vital organs to sustain life. The lack of oxygen is not in the brain; it is in the systemic flow of the body. Cyanosis is a common finding with these types of heart defects and, in general, does not usually need immediate surgery nor is it a sign of heart failure.
A mother asks why her infant with a cyanotic heart defect turns blue. What is the nurse's best explanation? This is due to the lack of oxygen to the brain. This is due to a decreased amount of oxygen to the peripheral tissue. This is a sign of heart failure. This is considered a medical emergency and the infant needs immediate surgery.
16-year-old child with a heart rate of 54 beats per minute 2-year-old child whose digoxin level was 2.4 ng/ml from a blood draw this morning 5-year-old child who developed vomiting and diarrhea, and is difficult to arouse Explanation: The nurse should not administer digoxin to children with the following issues: apical pulse under 60 beats per minute, digoxin level above 2 ng/ml, and signs of digoxin toxicity.
The pediatric nurse has digoxin ordered for each of five children. The nurse should withhold digoxin for which children? Select all that apply. 4-month-old child with an apical heart rate of 102 beats per minute 12-year-old child whose digoxin level was 0.9 ng/ml on a blood draw this morning 16-year-old child with a heart rate of 54 beats per minute 2-year-old child whose digoxin level was 2.4 ng/ml from a blood draw this morning 5-year-old child who developed vomiting and diarrhea, and is difficult to arouse
"Breastfeeding is likely to be possible, but check with the surgeon." Explanation: Postoperatively, some surgeons allow breastfeeding to be resumed almost immediately. However, the nurse needs to advise the mother to check with the surgeon to determine when breastfeeding can resume. Telling the mother that she has to wait until the suture line heals may be inaccurate. Telling her to wait and see does not answer her question.
The nurse is caring for a 2-month-old with a cleft palate. The child will undergo corrective surgery at age 3 months. The mother would like to continue breastfeeding the baby after surgery and wonders if it is possible. How should the nurse respond? "There is a good chance that you will be able to breastfeed almost immediately." "Breastfeeding is likely to be possible, but check with the surgeon." "After the suture line heals, breastfeeding can resume." "We will have to wait and see what happens after the surgery."
fluid deficiency risk: dehydration diarrhea and loss of electrolytes the risk for skin maceration in the perineum Four to five loose stools per day are considered diarrhea. The child is at risk for fluid and electrolyte deficiency given the length of time and number of stools per day. The risk for skin maceration can occur in the perianal area because of the prolonged skin exposure to liquid stools. The child does not have malnutrition. Malnutrition is defined as a condition that results from a nutrient deficiency or overconsumption. Parental presence to care for the child can be addressed after the immediate needs of the child are addressed.
The nurse is caring for a 2-year-old child with a gastrointestinal infection resulting in 4 to 5 liquid stools per day over the past 3 days. Based on this information, which important concern(s) will the nurse address in the child's care? Select all that apply. fluid deficiency risk: dehydration diarrhea and loss of electrolytes the risk for skin maceration in the perineum undernourishment risk: malnutrition availability of parents to care for the child
Positive culture for group A streptococcus Explanation: Acute glomerulonephritis may result as an autoimmune response to the invasion of group A streptococcus. This group of streptococci affect the glomeruli of the kidneys. This would be addressed by the health care provider and is the most important of the laboratory results presented. If there is an active strep infection, it would need to be treated with an antibiotic. The white blood cell count is within normal limits. It is good to be negative for respiratory syncytial virus. The urine culture would have to be redone due to contamination. It does not provide an accurate status of the child's urine.
The nurse is caring for a 6-year-old child with acute glomerulonephritis. When reviewing the client's laboratory results, which result is most important to review with the health care provider? White blood cells: 8,000/µL (8.0 ×109/L) Urine culture positive for contaminants Positive culture for group A streptococcus Negative for respiratory syncytial virus (RSV)
furosemide dialysis serum electrolyte levels urinalysis labetalol The child is experiencing complications of the acute kidney injury including oliguria, interstitial fluid shifting, and hypertension. Oliguria is defined as a urine output that is less than 0.5 mL/kg/h in children. The nurse will prepare to administer furosemide to assist with the edema and labetalol to lower the blood pressure. Dialysis may be needed due to the severe oliguria. The client is at risk for electrolyte disturbances and should be monitored closely. A urinalysis may reveal proteinuria or hematuria, which could indicate additional complications.
The nurse is caring for a 6-year-old client diagnosed with acute kidney injury. During assessment, the nurse notes: temperature 99.0°F (37.2°C), urine output less than 0.4 mL/kg/hr, blood pressure 130/88 mm Hg, periorbital edema, and respirations 28 breaths/minute. Which prescription(s) will the nurse anticipate from the primary health care provider? Select all that apply. furosemide dialysis serum electrolyte levels urinalysis labetalol
"He likes to stop and squat wherever he walks." Explanation: The walking toddler may squat periodically to relieve a hypercyanotic spell. This position serves to improve pulmonary blood flow by increasing systemic vascular resistance. Constant movement and quick walking are normal for a toddler. Activity level with a daily nap is typical of a toddler. Difficulty breathing would suggest a problem.
The nurse is taking a health history of a toddler with a suspected congenital heart defect. Which response by the mother could indicate that the child is experiencing hypercyanotic spells? "He likes to stop and squat wherever he walks." "He walks very quickly and never stops moving." "He takes one nap a day and is fairly active." "He does not seem to have difficulty breathing."
Ask the parents if they have any questions regarding the care of their child. Explanation: The family's emotional response to the birth of a child with cleft lip, palate, or both may range from grief to anger to denial. The nurse should encourage the parents to express their feelings and provide the parents with opportunities and support for normal infant-parent interactions.
The nurse observes the interactions of parents with their infant who was born with a cleft lip. The mother is attempting to feed the baby, but does not make eye contact. The father is watching television with his back turned to the mother and baby. What psychosocial nursing intervention would be most helpful to this family? Ask the parents if they have any questions regarding the care of their child. Explain to the parents that surgical intervention will fix the defect in the baby's lip. Teach the mother the appropriate technique for breastfeeding an infant with cleft lip. Refer the family to a social worker or mental health practitioner.
100 beats per minute Explanation: Digoxin is a cardiac glycoside that works by increasing the contractility of the heart muscle. It decreases conduction and increases the force of the heart beat. The result is a slowing of the heart rate. An 8-month-old infant has a normal range of heart rate of 80 to 150 beats per minute while awake and resting, and 80 to 130 beats per minute while sleeping. The accepted practice for this age child is to withhold the digoxin if the heart rate is 90 beats per minute or less. It would be safe to administer the drug if the heart rate is 100 beats per minute. If the child has a heart rate of 150 beats per minute, further assessment should be made prior to administering the drug.
The nurse takes an infant's apical pulse before administering digoxin. What is the usually accepted level of pulse rate considered safe for administering digoxin to an 8-month-old infant? 60 beats per minute 80 beats per minute 100 beats per minute 150 beats per minute
