ALl peds chapter pre u proctor till level 8

CHAPTER 41

Chapter 41

CHAPTER 47

Chapter 47

The nurse begins the physical exam to obtain the child's vital signs. Which would the nurse assess first? respirations pulse temperature blood pressure

answer The child's respirations are measured first before any other measurements that may affect the rate.

The nurse is auscultating the heart of a 6-month-old. Which finding would warrant further investigation? S1 varies in intensity variation in heart rate during the 60 second auscultation heart rate of 120 a split S2 at the apex

answer 1 The S1 should not vary in intensity at a particular point. If it does, this may indicate a cardiac arrhythmia, and the child should be referred for further evaluation. A split S2 at the apex occurs in many infants and young children. The other findings are within the normal range for a child of 6 months.

A nurse is caring for an infant who is experiencing heart failure. What would be the most appropriate care for this infant? Administer antidiuretic. Provide large, less frequent feedings. Restrict fluids. Administer oxygen.

ANSWER 4 If a child is experiencing heart failure, the infant will need oxygen. One of the medications the infant would be on is a diuretic. An infant with heart failure will need smaller, more frequent feedings to conserve energy for feeding. Infants are not usually put on fluid restriction.

chapter 40

chapter 40

chapter 32

chapter 32

A nurse is conducting a physical examination of a 12-year-old girl with suspected systemic lupus erythematosus (SLE). How would the nurse best interview the girl? "Have you noticed any hair loss or redness on your face?" "Have you noticed any new bruising or different color patterns on your skin?" "Do you have any shoulder pain or abdominal tenderness?" "Do you notice any wheezing when you breathe or a runny nose?"

ANSWER

A nurse is taking the history of a 4-year-old child who will undergo a cardiac catheterization. Which statement by the parent may necessitate rescheduling of the procedure? "My child seems listless and slightly warm." "My child is allergic to iodine and shellfish." "My child tells me about headaches because of being scared and nervous about the procedure." "My child kept scratching the chest, so I applied hydrocortisone cream to stop the itching."

ANSWER Fever and other signs and symptoms of infection may necessitate rescheduling the procedure. Although information about allergies is important, not all contrast media contain iodine as a base. The nurse should assess the head pain and the child's fears in a developmentally appropriate way, but fear of the procedure does not warrant rescheduling. The report of itching on the child's chest should be evaluated and reported to the health care provider but does not necessarily warrant cancellation of the procedure unless determined that it is a sign of a viral infection.

A pregnant client tells her nurse that a friend of hers recently gave birth to an infant who was found to have congenital heart disease. She asks the nurse whether there is anything she can do to reduce the risk of this type of condition occurring in her baby. What information should the nurse mention to this client? "Make sure you are fully immunized." "There is really nothing you can do." "Make sure you encourage a low-sodium diet in your child as he grows up." "Make sure that you encourage your child to exercise as he grows up."

ANSWER 1 The cause of congenital heart disease often cannot be documented, although it is associated with familial patterns of inheritance and possibly triggers such as rubella (German measles) and varicella (chickenpox) infection during pregnancy. Women need to enter pregnancy fully immunized to help prevent infection during pregnancy. Encouraging the child to eat a low-sodium diet and exercise as he or she grows up will help prevent acquired heart disease, not congenital heart disease.

Parents are told that their infant has a heart defect with a left-to-right shunt. What is the best way for the nurse to explain this type of shunting to the parents? This type of shunting causes an increase of blood to the lungs. This type of shunting causes an increase of blood to the systemic circulation. This type of shunting causes a decrease of blood to the lungs. This type of shunting causes a decrease of blood to the brain.

ANSWER 1 This type of shunting causes an increase of blood to the lungs. A right-to-left shunt causes an increase in blood to the systemic circulation that is mixed with deoxygenated blood.

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

ANSWER 1-2 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.

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

ANSWER 4 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.

Coarctation of the aorta demonstrates few symptoms in newborns. What is an important assessment to make on all newborns to help reveal this condition? Observing for excessive crying Assessing for the presence of femoral pulses Recording an upper extremity blood pressure Auscultating for a cardiac murmur

ANSWER Coarctation of the aorta is a defect where there is narrowing of the aorta, which is the largest vessel carrying oxygenated blood to the body. As a result of this narrowing, blood flow is impeded causing pressure to increase in the area proximal to the defect and decrease distal to the defect. As a result, the blood pressure will be higher in the upper part of the body and decreased in the lower part of the body. The pulses will be full or bounding in the upper part of the body and weak or absent in the lower part of the body. When assessing an infant with coarctation there may be weak or absent femoral pulses. There will also be differences in the blood pressure readings. These infants may or may not have a murmur and will be no more fussy than other babies.

The infant has been hospitalized and develops hypercyanosis. The physician has ordered the nurse to administer 0.1 mg of morphine sulfate per every kilogram of the infant's body weight. The infant weighs 15.2 lb (6.9 kg). Calculate the infant's morphine sulfate dose. Record your answer using one decimal place.

ANSWER 0.7 The does should be calculated weight in kilograms. The infant weighs 6.9 kg. For each kilogram of body weight, the infant should receive 0.1 mg of morphine sulfate. 6.9 kg x 0.1 mg/1 kg = 0.69 mg. Rounded to the tenth place = 0.7 mg. The infant will receive 0.7 mg of morphine sulfate.

A nurse is caring for an infant who just had open-heart surgery and the parents are asking why there are wires coming out of the infant's chest. What is the best response by the nurse? These wires are connected to the heart and will detect if your infant's heart gets out of rhythm. The wires are measuring the fluid level in the heart. The wires are left in the heart for 1 month after surgery in case of potential arrhythmias. The wires will administer ongoing electrical shocks to the heart to maintain rhythm.

ANSWER 1 Following cardiac repair there is always a possibility of arrhythmias. The wires are placed and connected to an external pacemaker. This is done as a preventive measure and can be used if an arrhythmia occurs. Once it is felt the child is in no danger of an arrhythmia, the wires are removed. There is no set time period in which this occurs. The wires do not deliver ongoing electrical shocks to maintain rhythm. This would be done by a permanent pacemaker implanted under the skin. There is no measurement of fluid in the heart by wires. Any measurements would need to be performed by echocardiogram or cardiac catheterization.

A 5-year-old is being prepared for diagnostic cardiac catheterization, in which the catheter will be inserted in the right femoral vein. What intervention should the nurse take to prevent infection? Avoid drawing a blood specimen from the right femoral vein before the procedure Keep the child NPO for 2 to 4 hours before the procedure Record pedal pulses Apply EMLA cream to the catheter insertion site

ANSWER 1 Because the vessel site chosen for catheterization must not be infected at the time of catheterization (or obscured by a hematoma), never draw blood specimens from the projected catheterization entry site before the procedure (generally a femoral vein). The other interventions listed are performed for reasons other than prevention of infection. Children scheduled for the procedure are usually kept NPO for 2 to 4 hours beforehand to reduce the danger of vomiting and aspiration during the procedure. Be certain to record pedal pulses for a baseline assessment. The site for catheter insertion is locally anesthetized with EMLA cream or intradermal lidocaine

When a child is scheduled for a cardiac catheterization, an important health teaching point for parents is that the: procedure is noninvasive and not frightening for children. child will return with a pressure dressing over the catheter insertion area. child will require a general anesthetic and needs to be prepared for this. child will have to remain NPO for 6 to 8 hours after the procedure to prevent vomiting.

ANSWER 1 Cardiac catheterization is typically performed with the child awake but using moderate sedation. Only under unusual circumstances will the child need general anesthesia. At the completion of the procedure a pressure dressing will be placed over the catheter insertion site. This is to prevent bleeding. The nurse will monitor this dressing every 15 minutes for the first hour and then every 30 minutes for the second hour. A cardiac catheterization is an invasive procedure and any procedure is frightening to children, especially if their parents are not with them. After the child is fully awake from the procedure the diet can resume.

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

ANSWER 1 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 teaching the parents of a child diagnosed with rheumatic fever about prescribed drug therapy. Which statement would indicate to the nurse that additional teaching is needed? "We can stop the penicillin when her symptoms disappear." "If she needs dental surgery, we might need additional medication." "She needs to take the drug for the full 14 days." "To prevent another episode, she'll need preventive antibiotic therapy for at least 5 years."

ANSWER 1 For a child with rheumatic fever, drug therapy must be given for the full 10 to 14 days to ensure complete eradication of the infection. The drug must not be stopped when the signs and symptoms disappear. To prevent recurrent attacks, prophylactic antibiotic therapy is prescribed for at least 5 years or until the child is 18 years old. Additional prophylactic therapy should be instituted when dental or tonsillar surgery is planned.

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.

ANSWER 1 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 in a pediatric cardiovascular clinic is talking with the father of a 5-year-old child who underwent cardiac surgery for a heart defect at the age of 3. The father reports that the child has been having increased shortness of breath, tires easily after playing, and has been gaining weight. The nurse is aware that the child is most likely demonstrating symptoms of which acquired cardiovascular disorder? heart failure infective endocarditis cardiomyopathy Kawasaki Disease

ANSWER 1 Infective endocarditis would present with intermittent, unexplained low-grade fever, fatigue, anorexia, weight loss, or flu-like symptoms. Characteristics of cardiomyopathy include respiratory distress, fatigue, poor growth (dilated), chest pain, dizziness, and syncope. Abdominal pain, joint pain, fever, and irritability are signs of Kawasaki disease.

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.

ANSWER 1 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.

A 1-year-old with tetralogy of Fallot turns blue during a temper tantrum. What will the nurse do first? Place child in the knee-to-chest position. Assess for an irregular heart rate. Listen for an increased respiratory rate. Explain to the child the need to calm down.

ANSWER 1 Tetralogy of Fallot is a cyanotic heart defect. Hypercyanosis can develop suddenly. The symptoms are increased cyanosis, hypoxemia, dyspnea, and agitation. The nurse should use a calm, comforting approach with the child and place child in the knee-to-chest position. This position is the first priority of the child with tetralogy of Fallot. This position increases pulmonary blood flow by increasing systemic vascular resistance. The additional interventions for a hypercyanotic spell are to administer oxygen and give morphine, IV fluids, and propranolol. A child will not understand to calm down and cannot be expected to listen during a temper tantrum. Assessing the child's heart rate and respirations are not priority. Perfusion is priority for this client at this time.

A nurse is examining a 10-year-old girl who has a heart murmur. On auscultation, the nurse finds that the murmur occurs only during systole, is short, and sounds soft and musical. When she has the girl stand, she can no longer hear the murmur on auscultation. Which statement should the nurse make to the girl's mother in response to these findings? "Your daughter has an innocent heart murmur, which is nothing to worry about." "Your daughter has a functional heart murmur; I recommend that you limit her physical activity so that her heart rate is not elevated for long periods of time." "Your daughter has an organic heart murmur, which indicates that she has some degree of heart disease. The doctor will provide a referral to a good cardiologist." Not say anything, as the girl has an insignificant heart murmur and there is no reason to alarm the mother or her.

ANSWER 1 The symptoms described indicate an innocent heart murmur. Although innocent murmurs are of no consequence, parents need to be told when their child has one because this finding will undoubtedly be discovered again at a future health assessment or during a febrile illness, anxiety, or pregnancy. Activities need not be restricted when a child has an innocent murmur and the child requires no more frequent health appraisals than other children. If a murmur is present as the result of heart disease or a congenital disorder, it is an organic heart murmur.

When caring for a child with a congenital heart defect, which assessment finding may be a sign the child is experiencing heart failure? Tachycardia Bradycardia Inability to sweat Splenomegaly

ANSWER 1 Heart failure occurs when the heart has the inability to pump effectively to provide adequate blood, oxygen, and nutrients to the body's organs and tissues. Symptoms occur because of three factors. The neurohormonal influences cause symptoms of tachycardia, pallor, decreased urine output, sweating, hypertension, weight gain and edema. The symptoms seen from systolic dysfunction are dyspnea on exertion, increased work of breathing, and feeding difficulties. Diastolic influences produce hepatomegaly, jugular vein distention and periorbital edema.

The nurse is caring for a child who is preparing to undergo an exercise stress test. Which interventions will be included in the care? Monitor vital signs prior to the start of the test. Monitor vital signs at completion of the test. Remind the child to verbalize any feelings of discomfort during the test. Complete ECG one hour after test is completed. Assess blood glucose level prior to the start of the test and one hour after.

ANSWER 1-2-3 The exercise stress test monitors heart rate, blood pressure, ECG, and oxygen consumption at rest and during exercise. Vital signs are taken prior to, during, and after the test period. An ECG is taken prior to the test. Serum glucose levels are not associated with this test.

The nurse is reviewing nutritional recommendations with the parents of a teen diagnosed with hyperlipidemia. Which statements indicate an understanding of the recommended diet for this condition? Select all that apply. "I should plan to have vegetables with each evening meal served." "Adding fresh fruits to my child's lunch is a good idea." "Cooking with palm oil will be helpful." "I need to limit fat intake in meals to 40%." "My child loves chicken and I can still serve it but I need to remove the skin."

ANSWER 1-2-5 Hyperlipidemia refers to high levels of lipids (fats/cholesterol) in the blood. High lipid levels are a risk factor for the development of atherosclerosis, which can result in coronary artery disease, a serious cardiovascular disorder occurring in adults. Dietary management is the first step in the prevention and management of hyperlipidemia in children older than 2 years of age. The diet should consist primarily of fruits, vegetables, low-fat dairy products, whole grains, beans, lean meat, poultry, and fish. As in adults, fat should account for no more than 30% of daily caloric intake. Fat intake may vary over a period of days, as many young children are picky eaters. Limit saturated fats by choosing lean meats, removing skin from poultry before cooking, and avoiding palm, palm kernel, and coconut oils as well as hydrogenated fats.

A nurse is providing care to a child with Kawasaki disease. Which medication(s) would the nurse expect the health care provider to prescribe? Select all that apply. aspirin ibuprofen abciximab IV immunoglobulin corticosteroids

ANSWER 1-4 Management of the child with Kawasaki disease includes a high dose of IV immunoglobulin therapy to relieve the symptoms and prevent coronary artery abnormalities, along with aspirin to control inflammation and fever. Aspirin may be continued for as long as 1 year in lower doses as an antiplatelet.

A nurse is palpating the pulse of a child with suspected aortic regurgitation. Which assessment finding should the nurse expect to note? appropriate mastery of developmental milestones bounding pulse preference to resting on the right side pitting periorbital edema

ANSWER 2 A bounding pulse is characteristic of patent ductus arteriosus or aortic regurgitation. Narrow or thready pulses may occur in children with heart failure or severe aortic stenosis. A normal pulse would not be expected with aortic regurgitation.

An 8-year-old child is scheduled for an exercise stress test. Which instruction would be most important for the nurse to emphasize? "You need to report any symptoms you are having during the test." "You need to lie very still during this test." "You'll have to wear the monitor for 24 hours." "You get some medicine that will make you sleepy."

ANSWER 2 It is important for the child to report any symptoms felt during the test to help quantify the child's exercise tolerance. Exercise stress testing involves activity. Ambulatory electrocardiographic monitoring is performed over 24 hours. Sedation is not used for an exercise stress test. It is used for an arteriogram.

The nurse is caring for child who present to the emergency department with reports of a fever for 5 days. The nurse notes a diffuse maculopapular rash, reddened cracked lips, erythema of hands, and bilateral conjunctivitis and suspects Kawasaki disease. Which nursing action is priority? Place the child on a soft diet. Initiate intravenous access. Administer acetaminophen. Assess cervical lymph nodes.

ANSWER 2 A child with signs of Kawasaki disease is at risk for dehydration due to a prolonged fever and oral pain. The priority for the nurse is to establish intravenous access to begin IV fluids. Placing the child on a soft diet will be done after ensuring IV access. Pain is not a priority, and children with Kawasaki disease are given aspirin because of the anti-inflammatory properties of aspirin, instead of acetaminophen. Because the child already has the required four signs of Kawasaki disease, assessing cervical lymph nodes is minimally helpful and could be performed later.

An 8-month-old infant has a ventricular septal defect. Which nursing diagnosis would best apply? Ineffective airway clearance related to altered pulmonary status Ineffective tissue perfusion related to inefficiency of the heart as a pump Impaired gas exchange related to a right-to-left shunt Impaired skin integrity related to poor peripheral circulation

ANSWER 2 A ventricular septal defect permits blood to flow across an opening between the right and left ventricles. It results in increased pulmonary blood flow, but it does not cause cyanosis. The blood in the left ventricle, which flows back into the right ventricle, is already oxygenated. Anytime there is an opening between the heart's ventricles, the heart is not as effective as a pump because the pressure gradients are changed. A ventricular septal defect will not cause respiratory problems or problems with peripheral circulation.

Which nursing diagnosis would best apply to a child with rheumatic fever? Ineffective breathing pattern related to cardiomegaly Activity intolerance related to inability of heart to sustain extra workload Disturbed sleep pattern related to hyperexcitability Risk for self-directed violence related to development of cerebral anoxia

ANSWER 2 Acute rheumatic fever affects the joints, central nervous system, skin, and soft tissue. It causes chronic, progressive damage to the heart and valves. Children with rheumatic fever need to reduce activity to relieve stress on the heart and joints during the course of the illness. Rheumatic fever does not produce cardiomegaly nor does it interfere with respirations or the ability to oxygenate the body. Children with rheumatic fever may develop chorea. These movements are involuntary and are not related to hyperexcitability.

A child will be undergoing a Holter monitor test. Which statement by the parent indicates the need for further instruction? "Wearing a snug shirt the day of the test will be helpful." "My child cannot have any thing to eat or drink after midnight the day of the test." "This test will monitor my child for about 24 hours." "We do not need to alter our activities during the testing period."

ANSWER 2 Ambulatory electrocardiographic monitoring (Holter) testing is an exam that spans approximately 24 hours. The test is done to review the activity of the heart. The child is encouraged to follow one's normal activities during the test. There is no need for the child to be NPO prior to or during the test.

When educating the family of an infant with a small, asymptomatic atrial septal defect (ASD), what information would be included in the education? "Surgery is usually performed in the first two months of life for this." "Most infants do not need surgical repair for this." "The medication indomethacin is used to try to close the hole." "The medication prostaglandin E1 is used to try to close the hole."

ANSWER 2 Most infants do not need surgical repair for an ASD unless they are symptomatic. The hole will close spontaneously 87% of the time. The medication indomethacin is used to help close the opening of a PDA, and the medication prostaglandin E1 is used to keep a patent ductus arteriosus (PDA) open. These medications are not used for ASDs.

The child has returned to the nurse's unit following a cardiac catheterization. The insertion site is located at the right groin. Peripheral pulses were easily palpated in bilateral lower extremities prior to the procedure. Which finding should be reported to the child's physician? Select all that apply. The right groin is soft without edema. The child's right foot is cool with a pulse assessed only with the use of a Doppler. The child has a temperature of 102.4° F (39.1° C). The child is reporting nausea. The child has a runny nose.

ANSWER 2-3-4 The following information should be reported to the physician following a cardiac catheterization because they are indicative of possible complications: Negative changes to the child's peripheral vascular circulatory status (cool foot with poor pulse), a fever over 100.4° F (37.8° C), and nausea or vomiting.

A nurse is developing the plan of care for a 7-year-old child diagnosed with congenital heart disease and a history of hypercyanotic spells. Which interventions would the nurse include in the child's plan of care to address these spells? Select all that apply. Place the child in the orthopneic position. Provide supplemental oxygen. Administer oral fluids as prescribed. Give parenteral morphine sulfate. Encourage increased activity.

ANSWER 2-4 For a child experiencing a hypercyanotic spell, the nurse should use a calm, comforting approach and place the child in a knee-to-chest position, provide supplemental oxygen, administer morphine sulfate (0.1 mg/kg IV, IM, or SQ), supply IV fluids, and administer propranolol (0.1 mg/kg IV).

The nurse is caring for a school-age child with reports of generalized joint pain and a pharyngitis. During assessment, the nurse notes a cardiac murmur. Which action by the nurse is priority? Administer penicillin. Assess skin for a rash. Swab throat for culture. Evaluate C-reactive protein.

ANSWER 3 A child with generalized joint pain, pharyngitis, and murmur is exhibiting signs of rheumatic fever. A priority action is to obtain a throat culture to verify presence of a group A streptococcus infection and then administer penicillin. Assessing for a rash is minimally helpful as there is enough assessment data to obtain a throat culture. A high C-reactive protein is an indicator of an active infection, but it will not identify the source of the infection and the necessary pharmacologic therapy.

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

ANSWER 3 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.

A newborn is diagnosed with tetralogy of Fallot. When explaining this condition to the mother, which defect would the nurse's description include? atrial septal defect stenosis of the aorta overriding of the aorta left ventricular hypertrophy

ANSWER 3 One of the components in the tetralogy of Fallot is the overriding of the aorta. Tetralogy of Fallot is a congenital heart disease with four components. The defects in the tetralogy of Fallot include ventricular septal defect, overriding of the aorta, pulmonary stenosis, and right ventricular hypertrophy. Atrial septal defect, stenosis of the aorta, and left ventricular hypertrophy are not components of tetralogy of Fallot.

The parents of a 5-year-old child with a cardiovascular disorder tell the nurse they don't understand why their child isn't gaining weight, "We make sure our child has 3 very nutritious meals every day." How should the nurse respond? "Are you sure you are making nutrient-dense foods?" "Maybe your child doesn't really like the foods your making. This could lead to not gaining sufficient weight." "It's great you are providing nutritious meals, but small, frequent meals will tire your child less and promote weight gain." "It's hard to get your child to eat enough at this age to maintain their weight since they are expending so much energy with the heart condition."

ANSWER 3 Small, frequent feedings will reduce the amount of energy required to feed or eat and prevents overtiring the child. Questioning the parents as to whether they are making nutritious foods or foods preferred by the child does not address the issue of energy expenditure when eating 3 larger meals per day. Just stating that it is "hard to get your child to eat enough" also does not address the situation.

The nurse is assessing the blood pressure of a toddler. Which finding would the nurse document as a normal finding? 80/40 mm Hg 100/60 mm Hg 90/64 mm Hg 110/60 mm Hg

ANSWER 3 The toddler or preschool-age child's blood pressure averages 80 to 100/64 mm Hg. The normal infant's blood pressure is about 80/40 mm Hg. The school-age child's blood pressure averages 94 to 112/56 mm Hg. An adolescent's blood pressure averages 100 to 120/50 to 70 mm Hg.

Which finding(s) is a major criterion used to help the health care provider diagnose acute rheumatic fever in a child? Select all that apply. elevated erythrocyte sedimentation rate temperature of 101.2°F (38.4°C) painless nodules located on the wrists pericarditis with the presence of a new heart murmur heart block with a prolonged PR interval

ANSWER 3-4 Subcutaneous nodules and carditis are considered major criteria used in the diagnosing of acute rheumatic fever. The other options are minor criteria.

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

ANSWER 3-4-8 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 nurse performs a cardiac assessment and notes a loud heart murmur with a precordial thrill. This murmur would be classified as a: Grade I. Grade II. Grade III. Grade IV.

ANSWER 4 A heart murmur characterized as loud with a precordial thrill is classified as Grade IV. Grade II is soft and easily heard. Grade I is soft and hard to hear. Grade III is loud without thrill.

The nurse is assessing an infant and notes brachial pulses of 2+ and femoral pulses of 1+. Which action will the nurse perform first? Contact the health care provider. Apply appropriate oxygen device. Prepare for balloon angioplasty. Assess blood pressure in all extremities.

ANSWER 4 An infant with decreased pulse strength in the lower extremities may have coarctation of the aorta. Assessing blood pressures in all extremities is most helpful in assisting the nurse with gathering assessment data prior to contacting the health care provider. The nurse does not have enough information to apply oxygen at this time or prepare the newborn for balloon angioplasty.

A school nurse is caring for a child with a severe sore throat and fever. What is the nurse's best recommendation to the parent? Give acetaminophen for the fever and pain, and have the child rest. Have the child drink fluids that contain electrolytes. Have the child go to the emergency room. Have the child be seen by the primary care provider.

ANSWER 4 Children with sore throats and fevers should be seen by their primary care provider to rule out strep throat. This is extremely important due to the fact they may contract an acquired heart disease called rheumatic fever. Taking acetaminophen, resting, and drinking fluids are all good recommendations, but the best recommendation is to see the provider. Going to the emergency room is not necessary at this time.

The nurse is caring for a child with congestive heart failure and is administering the drug digoxin. At the beginning of this drug therapy, the process of digitalization is done for which reason? To decrease the pain to a tolerable level To increase the heart rate To establish a maintenance dose of the drug To build the blood levels to a therapeutic level

ANSWER 4 The use of large doses of digoxin at the beginning of therapy, administered to build up the blood levels of the drug to a therapeutic level, is known as digitalization. A maintenance dose is given, usually daily, after digitalization. Digoxin is used to improve the cardiac efficiency by slowing the heart rate and strengthening the cardiac contractility. Digoxin is not indicated for relief of pain.

The nurse is taking vital signs on a group of assigned preschool children. Which assessment finding would indicate the need for further action? heart rate of 89 beats per minute respiratory rate of 24 breaths per minute heart rate of 120 beats per minute respiratory rate of 20 breaths per minute

answer The normal range for heart rate for a preschooler is between 65 and 110 beats per minute. The normal range for respiratory rate for a preschooler is between 20 and 25 breaths per minute. A heart rate of 120 would be abnormal.

The nurse is examining the back and spinal area of a 14-year-old female. A small dimple is noted. What action is most appropriate? Document the finding as normal. Explain to the parents and child that additional studies may be needed to determine if there is cause for concern about the dimple. Question the teen about muscle weakness in the lower extremities. Assess the hips for symmetry.

answer 1 A normal pilonidal dimple is sometimes seen at the base of the spine. This finding should be documented. There is no additional study or evaluation of this area indicated at this time. Muscle weakness and asymmetry are not associated with the presence of the dimple, which is benign.

A child has been admitted to the pediatric unit with pneumonia. The nurse is preparing to administer the prescribed medication to the child to help reduce the viscosity of the child's secretions. Which medication would the nurse most likely give? guaifenesin albuterol dextromethorphan ipratropium

answer 1 An expectorant, such as guaifenesin, reduces viscosity of thickened secretions by increasing respiratory tract fluid. Albuterol is a short-acting beta-adrenergic agonist that acts as a bronchodilator. Dextromethorphan is a cough suppressant. Ipratropium is an anticholinergic agent that acts as a bronchodilator.

The nurse is reinforcing teaching with a group of caregivers of children diagnosed with asthma. Which statement best indicates an understanding of the management and treatment for this diagnosis? "We have taken the carpet out of our house and let my mom take our dog." "He knows how and even when he needs to use his peak flow meter." "Even the babysitter helps us keep up the diary with her symptoms." "The medications she takes are all in one place, ready for her to take at any time."

answer 1 Families must make every effort to eliminate any possible allergens from the home. Prevention is the most important aspect in the treatment of asthma. Learning how to use a peak flow meter, using a peak flow and symptom diary, and having the medications available are important aspects of treatment, but prevention is the best.

A child with asthma has been monitoring his peak expiratory flow rate (PEFR) and has been maintaining it within 90% of his personal best. Today, the child is experiencing symptoms and his PEFR is at 40% of his personal best. The child's mother calls the office and asks the nurse what she should do. What would the nurse instruct the mother to do first? "Have him use his short-acting bronchodilator right away." "You need to take him to the emergency department right away." "Continue to watch his PEFR readings and call back if they go below 40%." "Have him use his low-dose steroid inhaler now and again in 15 minutes."

answer 1 The child's symptoms and drop in PEFR suggest a medical alert or "red" situation, indicating the need for the short-acting bronchodilator and then a trip to the office or emergency department. The child should use his short-acting bronchodilator first and then go to the physician's or nurse practitioner's office or emergency room. Waiting for a greater drop in his PEFR readings would be inappropriate because the child is experiencing an acute condition that warrants immediate attention. The child is experiencing an acute situation and requires immediate attention. A low-dose steroid inhaler would not be appropriate because it would not help his bronchospasm.

Which test in a child with cystic fibrosis would help monitor airway function? Pulmonary function Bronchoprovocation Peak flow measurement Pulse oximetry

answer 1 The pulmonary function tests help measure airway function, lung volumes, and gas exchange. Bronchoprovocation provokes bronchospasms to determine airway constriction. Peak flow measurement measures lung velocity. Pulse oximetry monitors blood level oxygen saturation.

A child with a suspected airway obstruction is brought to the emergency room. He produces a harsh, strident sound on inspiration (stridor). Where is the obstruction likely to be located based on this information? in the larynx lower trachea bronchioles pharynx

answer 1 When the vibrations produced as air are forced past obstructions such as mucus in the nose or pharynx, the noise produced is a snoring sound (rhonchi). If the obstruction is at the base of the tongue or in the larynx, a harsher, strident sound on inspiration (stridor) occurs. If an obstruction is in the lower trachea or bronchioles, an expiratory whistle sound (wheezing) occurs.

The charge nurse observes a new graduate nurse assess the cremasteric reflex in an 8-month-old boy. The new graduate nurse strokes the lateral aspect of the thigh. Which action should the charge nurse take? Demonstrate the appropriate technique. Applaud the good technique. Explain why the technique is incorrect. Counsel the new graduate.

answer 1 A cremasteric reflex is elicited by stroking the medial aspect of the thigh in boys. With this, the testes move perceptibly upward. The presence of this reflex indicates integrity of the first and second lumbar nerves. Abdominal reflexes should be assessed in both sexes. An abdominal reflex is elicited by lightly stroking each quadrant of the abdomen. Normally, the umbilicus moves perceptibly toward the stroke. Presence of this reflex indicates integrity of the 10th thoracic nerve and the first lumbar nerve of the spinal cord. The new graduate nurse needs to be shown the correct aspect of the thigh to stroke so that she/he can perform the technique correctly in the future. Explaining why the technique is incorrect does not show the nurse how to perform the procedure correctly. The charge nurse would not want to applaud an incorrect procedure, nor is this reason to counsel the nurse.

A nurse is performing a health history on a 6-year-old child with asthma. When it comes to identifying if the child is up to date on the immunization schedule, which question would be avoided as it is considered leading? Have you kept the child up to date on all of the immunizations suggested? Do you have the immunization book for us to review? When did the child have his/her last immunization? Were there any side effects from the last immunizations?

answer 1 A leading question supplies its own answer. This question implies that the child should have had the immunizations and perhaps that the parent is a poor caregiver if he or she gives a different answer than yes. Further, the parent may not be aware of all the current immunizations for the child's age and may inadvertently give an incorrect answer. Asking about the last immunizations is appropriate. Offering to review the immunization record is part of anticipatory guidance. It is important to know if the child had any reactions to the last immunizations to determine whether the child should receive that immunization again.

The nurse is weighing a 20-month-old child who is in the clinic for a well-child visit. Which action by the nurse would be most appropriate for weighing this child? The nurse should have the child sit on the scale while keeping a hand close to but not touching the child. The nurse should weigh the parent on a standing scale and then weigh the parent again while holding the child. The nurse should ask the parent to lightly hold the child's hands while the child is sitting on the scale. The nurse should lay the parent on the scale covered with a clean paper and gently hold the child flat against the scale and let go just before reading the weight.

answer 1 The child who is able to sit can be weighed while sitting. Keep a hand within 1 in (2.5 cm) of the child at all times to be ready to protect the child from injury. Weighing the parent alone and then holding the child will not provide an accurate weight. Accurate weights are needed for medications and treatments. Holding the child's hands will cause a change in the weight and should not be done.

When the nurse is reinforcing teaching with the caregiver of a 3-year-old child being discharged following a tonsillectomy, the caregiver states to the nurse, "I understand why there might be bleeding in the first 24 hours, but I do not understand why there might be bleeding in 1 week or so." What is the most appropriate explanation for the nurse to give this caregiver? "Bleeding can occur at this time because the clots dissolve and new tissue is not yet present." "We do not usually do this surgery until the child is older, so postoperative bleeding is a possible complication because of the child's age." "By next week the child will be eating regular foods again, and the salt content may cause bleeding." "The child will have forgotten about the surgery by that time and might start coughing, and the pressure of coughing can cause bleeding."

answer 1 Hemorrhage is the most common complication of a tonsillectomy. Bleeding is most often a concern within the first 24 hours after surgery and up to the 10th postoperative day. Bleeding late postoperatively can occur when the clots dissolve and new tissue is not yet present. A tonsillectomy can be done at any age so stating that bleeding is a complication of age is incorrect. By 10 days postoperatively the child may still have a slight sore throat or have difficulty eating some solid foods so the child has not forgotten about the surgery. The pressure of coughing is most likely to cause bleeding early postoperatively. Salt will not cause bleeding and telling that to a parent is providing false information.

The nurse is performing an examination of the eyes of a 7-year-old child. Which finding would indicate that the third cranial nerve is intact? pupil constriction in response to light pupil dilation in response to light eyelid blinks in response to touching the cornea with a wisp of cotton light of an otoscope reflecting evenly off both pupils

answer 1 If the pupil constricts (reduces in size) in response to the light, it is confirmation the third cranial nerve is intact; it should not dilate. The eyelid blinking in response to touching the cornea with a wisp of cotton is a test of the blink reflex, but should not be performed in children, as it can be painful and frightening to them. During a Hirschberg test, the light of an otoscope should reflect evenly off both pupils if they are in equal alignment.

A female nurse of childbearing ages caring for a 2-year-old child diagnosed with bacterial pneumonia. The child has been placed in a mist tent. In caring for the child, it is important for the nurse to: monitor the child regularly for signs of cyanosis. avoid contact with the mist. use contact transmission precautions. check for hyperthermia related to enclosure in the tent.

answer 1 In some treatment of bacterial pneumonia a croupette or mist tent is used. When a child is in a mist tent, the nurse must be constantly observed for cyanosis. Studies how that children have become cyanotic in mist tents and have suffer subsequent arrest, due to the lack of visibility while in the tent. Treatments for bacterial pneumonia do not carry risk for teratogenicity. Ribavirin is an antiviral drug that may be used to treat certain children with respiratory syncytial virus. It is administered as an inhalant by hood, mask, or tent and has a high risk for teratogenicity. In treating a client with bacterial pneumonia, the client may need to be placed on infection control precautions according to the policy of the health care facility; in most facilities, these will be droplet precautions. Although the nurse should look for hyperthermia related to the infection process, there is no risk for hyperthermia related to the child being enclosed in the tent.

A nurse is teaching a group of parents about possible signs and symptoms of respiratory disorders. The nurse emphasizes that early detection is important in preventing more serious problems. The nurse determines that the teaching was successful when the group identifies which sign as often the first sign of a respiratory illness? increased respirations cough with mucus blue coloring around the lips irregular breathing pattern

answer 1 Often the first sign of respiratory illness in infants and children is tachypnea (increased respiratory rate). Cyanosis is a late sign. A slow or irregular respiratory rate in an acutely ill infant or child is an ominous sign. Cough may or may not be present.

A nurse assesses the skin of a child and documents evidence of plethora. Which finding did the nurse observe? redness of the cheeks and lips bluish coloration of lips and nail beds round flat lesions on the neck black and blue areas on the skin

answer 1 Plethora is used to describe redness of the skin, especially the cheeks and lips. Cyanosis refers to the bluish discoloration of the skin and mucous membranes. Macules are round flat lesions. Ecchymoses are large, diffuse areas of black and blue color.

The nurse is caring for an 11-year-old child with pneumonia who is exhibiting an increased work of breathing. Which intervention is the priority? positioning the child in Fowler position administering intravenous fluids as prescribed providing supplemental oxygen as prescribed administering analgesics as prescribed

answer 1 Positioning the child in Fowler position helps to open the airway and provide more room for lung expansion, resulting in more effective breathing patterns while supplemental oxygen and intravenous fluids are administered. Administering intravenous fluids and administering oxygen are appropriate actions after the child is placed in a comfortable position. Analgesics may be prescribed and administered if the child is experiencing pain from coughing.

A 5-year-old girl who was already admitted to the hospital for an unrelated condition suddenly becomes irritable, restless and anxious. These may be early signs of respiratory distress in a child if accompanied by: tachypnea. retractions. cyanosis. clubbing of fingers

answer 1 Restlessness, irritability, and anxiety result from difficulty in securing adequate oxygen. These might be very early signs of respiratory distress, especially if accompanied by tachypnea (an increased respiratory rate). Retractions can be a sign of airway obstruction but occur more commonly in newborns and infants than in older children. Cyanosis (a blue tinge to the skin) indicates hypoxia, which may be a sign of airway obstruction but would not be the first. Children with chronic respiratory illnesses often develop clubbing of the fingers, a change in the angle between the fingernail and nailbed because of increased capillary growth in the fingertips. Clubbing would not occur in an acute airway obstruction, as is indicated in the scenario above.

When performing a physical examination on a child, the nurse notes a mirror image in the shape and position of the child's chest and abdomen. Which nursing action is appropriate? Document the finding in the medical record. Notify the primary health care provider. Measure each with a tape measure. Assess the child's bowel sounds.

answer 1 The mirror image in shape and position from one side of the body to the other is known as symmetry and is an expected finding. The nurse would document the finding and continue with the assessment. There is no need to notify the provider, measure the chest or abdomen, or assess bowel sounds based on this finding.

A 3-year-old child with asthma and a respiratory tract infection is prescribed an antibiotic and a bronchodilator. The nurse notes the following during assessment: oral temperature 100.2°F (37.9°C), respirations 52 breaths/minute, heart rate 90 beats/minute, O2 saturation 95% on room air. Which action will the nurse take first? Administer the bronchodilator via a nebulizer. Give the antibiotic as prescribed. Apply oxygen at 2 liters via a nasal cannula. Apply a cardiac monitor to the child.

answer 1 The nurse would first administer the bronchodilator to open the child's airway and facilitate breathing. Once the airway was open, the nurse could administer oxygen, if indicated. At this time, the child's saturation level is normal but it should be monitored. The nurse would then administer the antibiotic medication. The heart rate is within normal range for a child of this age (65 to 110 beats/minute); therefore, a cardiac monitor is not needed at this time.

The nurse is caring for a 6-week-old with symptoms of irritability, nasal stuffiness, difficulty drinking and occasional vomiting. Which assessment finding produces important information regarding the medical and nursing treatment plan? Obtain testing for respiratory syncytial virus. Screen for the "allergic salute." Obtain vital signs to determine an infection. Draw a blood count to see if the client is septic.

answer 1 The symptoms presented are of acute nasopharyngitis. Many times this is viral in nature and can be common in the very young from respiratory syncytial virus (RSV). RSV is tested by obtaining nasal secretions and sending to the lab. A 6-week-old may rub his/her face but is too young for the "allergic salute," which is done to relieve itching and open nasal pathways. Vital signs can be helpful to note the beginning of an infectious process.

An 18-month-old infant is brought to the emergency room and the nurse notes a strong camphor-like smell. What should the nurse do first? Determine the type of ingestion. Call poison control. Initiate a nasogastric tube. Administer activated charcoal.

answer 1 Utilizing the sense of smell during a health assessment helps the nurse to focus on finding a source for the odor and the potential cause of the odor. When the smell of camphor is present the nurse should evaluate for the ingestion of mothballs. Urine that smells like maple syrup is a symptom of a protein metabolic condition. A sweet smell is associated with a pseudomonas infection. A putrid smell can be associated with fat in the stool from inadequate absorption. Prior to initiating any treatment it is important to find what the child has ingested if at all possible. The poison control center can provide antidotes and treatment protocols for all types of ingestion. The nasogastric tube and/or activated charcoal may or not be needed depending on the type of ingestion that has occurred.

A 6-month-old infant is admitted to the hospital because of a fever. When the nurse obtains a health history, what data would be obtained first? Details about the fever Family profile History of past illnesses Review of systems

answer 1 When the child has an acute problem, it is important to first obtain the chief complaint. This is the reason the child is brought to the health care provider. The nurse would then ask further questions about the onset, the duration, the characteristics and the course of the problem. The family history, history of past illnesses, and a review of the systems would come later in the process of obtaining the health history.

The young child has been diagnosed with group A streptococcal pharyngitis. The physician orders amoxicillin 45 mg/kg in three equally divided doses. The child weighs 23 lb (10.45 kg). Calculate how many milligrams the child will receive with each dose of amoxicillin. Record your answer using a whole number.

answer 157 Dose should be calculated using weight kilograms. 10.45 kg x 45 g/kg = 470.45 mg 470.45 mg/3 = 156.82 mg Rounded to 157 mg per dose

Upon providing discharge instructions home after a tonsillectomy and adenoidectomy, which is most important? Provide acetaminophen for pain. Note any frequent swallowing. Allow the child an age-appropriate, quiet plan. Stress regular fluid consumption.

answer 2 A complication of a tonsillectomy and adenoidectomy is bleeding. If the child is bleeding he or she must be brought to the emergency room immediately. To determine if a child is bleeding, the parents must assess for frequent swallowing. All of the other discharge instructions are appropriate, but noting any frequent swallowing is the priority.

A 15-year-old client tells the nurse about being worried that something is wrong because the left breast is bigger than the right breast. What is the best response by the nurse? "I am sure it must be concerning to you. I will let your health care provider know about the difference in the size." "As your breasts continue to develop it is not unusual to have one breast larger than the other." "Are you taking any kind of medication over the counter, like anabolic steroids or weight loss pills?" "Let's ask if your mother has always noticed the difference in your breast size."

answer 2 Breast development may begin as early as age 8 but starts by age 13 in most clients. Breast development then continues in a characteristic, but usually asymmetric pattern, with one breast larger than the other throughout the lifespan.

A nurse is caring for an infant admitted with a diagnosis of bronchiolitis. After completing an assessment, the nurse creates a plan of care for the infant. Which client goal would be priority in the plan of care? The infant will attain oxygen saturation of 90% on room air. The infant's airway will remain clear and free of mucus. The infant's breathing will be less labored. The infant will have decreased nasal stuffiness.

answer 2 Keeping the infant's airway clear is the top priority. An O2 saturation of 90% on room air is minimally acceptable. It is important that the infant's breathing be less labored and that there is decreased nasal stuffiness, but having the airway clear and free of mucus is most important.

The nurse is assessing the cardiac sounds of a child. Which action would the nurse incorporate into the assessment? Auscultate the heart sounds with the child in both the upright and the prone positions. Auscultate the heart rate at the point of maximal impulse (PMI) to best interpret the cardiac sounds. Auscultate the apical heart rate for 30 seconds and multiply by 2 to obtain the beats/minute. Auscultate the cardiac sounds over the three prominent valvular areas on the chest.

answer 2 The nurse would auscultate the child's heart sounds in the area of the PMI. The nurse would listen for a full minute, not 30 seconds x 2, which is not as accurate. The nurse would assess the child's heart sounds in the upright position and in the reclined position. The nurse would assess over four valvular areas of the heart, not three.

The parents bring the child for a health exam. After eliciting a chief concern from the parents, the nurse continues gathering information about related and other health concerns. Why is it important for the nurse to ask a second time at the end of the interview if there are other concerns? Parents always have more than one concern. Parents will not always reveal their most important concern in the initial minutes of the interview. The nurse should help assuage any parental fears before ending the interview. Parents might have concerns that are not so important and should accurately be addressed at the end of the interview.

answer 2 After documenting the chief concern, the nurse should ask about a second or other problem. The nurse should not assume, however, that parents will always reveal their most important concerns in the initial minutes. They also might not speak openly if they do not trust the caregiver. Therefore, it is helpful to repeat the question about a second concern once more at the very end of the interview. Many parents will focus on the reason they brought their child in for care and not other issues with the child. Asking if there are other concerns allows the parent to reveal the other issues that might need care or guidance.

A community health nurse is conducting a parenting class on respiratory syncytial virus (RSV). What statement made by a parent indicates that the teaching has been successful? "RSV season occurs primarily April through September." "Exposure to second- or thirdhand smoke increases the risk for developing RSV." "Infants are less affected by RSV than older children." "Early initiation of antibiotics can lessen the severity of the infection."

answer 2 An infant exposed to second- or thirdhand smoke is at risk for developing RSV. RSV season runs from September through April. Current treatment recommendations for RSV do not include antibiotics. Infants are susceptible to RSV much more than older children.

Which electrolyte does the client with cystic fibrosis need in abundance? Potassium Sodium Chlorine Magnesium

answer 2 Dietary intake of sodium is encouraged due to increased sodium losses. Clients are especially encouraged to eat salty pretzels, potato chips, etc. during hot weather or when sodium losses are anticipated.

The registered nurse (RN) will intervene if the unlicensed assistive personnel (UAP) is noted performing which task? obtaining an infant's apical pulse while the infant is asleep in the crib pulling the earlobe down and back while checking a school-age client's tympanic temperature counting the respirations on a preschool-age client for a full minute obtaining blood pressure reading on a toddler admitted for recurrent urinary tract infections

answer 2 The RN would intervene if the UAP pulled the earlobe down and back as this is only done when the child is younger than 3 years of age. For a school-age child, the nurse would pull back on the ear. A pulse should be obtained while an infant is resting or asleep to get an accurate reading as the pulse will increase with anxiety. Respirations should be counted for a full minute. Clients younger than 3 years should have their blood pressure monitored if certain risk factors are present, which include recurrent urinary tract infections.

A 4-year-old is ordered to have a hearing test. How should the nurse best prepare the child for this exam? Explain the procedure to the child. Allow the child to play with the tuning fork. Demonstrate the procedure on the mother. Explain that no pain is involved.

answer 2 To conduct the Weber test for hearing function the nurse would strike a 500-Hz tuning fork and hold the stem of it against the top of the child's head. The child with normal hearing in both ears will hear the sound equally well with both ears. If the child has an air conduction loss in one ear, the child will hear the sound better in that ear rather than the good ear. The test is used in conjunction with other evaluation tools because if the sound is intensified in one ear, it may mean that there is no hearing perception (i.e., there is nerve loss) in the opposite ear. Explaining and demonstrating the procedure to the child may be important, but developmentally the child needs to be able to see, feel, and hear all equipment being used.

A 10-year-old has braces on her teeth. What is most important for the nurse to assess when inspecting the mouth? Dental caries Pinpoint ulcers on the gums Reddened mucous membranes Loose hardware

answer 2 When assessing a child with orthodontic appliances such as braces, assess carefully for pinpoint ulcers on the gum line. The cause could be wires that are too tight, causing discomfort or infection. The child should be assessed for dental caries, redness in the mouth and any loose hardware but these are not the priority assessment.

When assessing the eyes of a toddler, the nurse notes the sclera shows above the pupil. Based on this finding what action should the nurse take? Document the finding as normal. Report the finding to the health care provider. Refer the child to an ophthalmologist. Instruct the mother on eye muscle exercises.

answer 2 When assessing the eyes, asses that no sclera shows above the pupil. If it does this is termed "sunset sign." It is a possible indication of increased intracranial pressure or trisomy 21. This finding is abnormal and should be reported to the health care provider. Documenting the finding as normal would be incorrect because the finding is abnormal. The nurse would not refer the child to the ophthalmologist without orders from the health care provider. Eye muscle exercises are not warranted in this situation.

When obtaining information from a teen concerning the reason for seeking health care, which question would be most important? "Have you been feeling well lately?" "What health concerns are you having?" "Do you have any health concerns?" "How long have you been ill?"

answer 2 When obtaining data from a client, using the appropriate questions is important. Questions should be open-ended to yield the most information. Making questions direct will further refine the information made available. It is important that when interviewing the teen the nurse not promote a condition. Assuming the teen is ill is not appropriate.

The nurse is assessing a newborn. The child's mother asks about small pink area on the bridge of the child's nose. What would be the appropriate response by the nurse? "It is called strawberry hemangioma. It usually fades in time, typically by the time the child turns 9." "It is called a nevus flammeus. It typically fades over time but may never go away." It's called a salmon nevi or a stork bite. They typically fade over time but may never go away totally." "The medical term for the spot is ecchymosis. It's harmless."

answer 3 Light pink macule typically found on the eyelids, nasal bridge, or back of neck are called salmon nevi (or, more commonly, "stork bites"). They usually fade over time, but may never go away completely. An infantile (strawberry) hemangioma is a raised reddish papule made of blood vessels. They recede over time, usually by age 9 years. A nevus flammeus is a dark purple-red flat patch and grows with the child. It is more commonly known as a port-wine stain. Ecchymosis is a purplish discoloration that is more commonly known as a bruise.

The nurse is measuring the vital signs of a group of assigned children. Which action(s) would demonstrate the correct technique? Select all that apply. The nurse measures the radial pulse of a 16-month-old child for 1 full minute. The nurse listens to the 12-month-old child's heart for about 20 seconds before beginning to count the rate. The nurse auscultates a 7-year-old's apical pulse for 60 seconds. The nurse watches the chest rise and fall when assessing the respiratory rate of a 9-month-old child. The nurse assesses the child's rectal temperature by gently inserting a lubricated thermometer rectally.

answer 2-3-5 The radial pulse is difficult to palpate accurately in children younger than 2 years of age because the blood vessels lie close to the skin surface and are easily obliterated. Infants and young children are often nervous or fearful, causing the heart rate to elevate; therefore, the nurse will listen to the heart a few minutes before counting the pulse. For children younger than 10 years of age, the nurse will auscultate the apical pulse with the stethoscope for 1 full minute. Infants' respirations are primarily diaphragmatic, so the nurse will count the abdominal movements. The rectal thermometer should be gently inserted and lubricated.

The nurse has administered an intradermal injection of 0.1 ml of purified protein derivative. During which time frame will the nurse evaluate the site for reactions? Within 15 minutes Not before 24 hours Within 48 to 72 hours After 1 week

answer 3 Clients who have had a tuberculin skin test will need to return to the facility to have the site evaluated for a reaction within 48 to 72 hours. Redness, swelling, induration, and itching are signs of a positive reaction.

The pediatric unit has multiple clients experiencing upper respiratory system complications. Which pediatric client is at the highest risk for respiratory distress? 3-year-old child with croup 11-month-old infant with nasopharyngitis 2-year-old child with epiglottitis 16-year-old adolescent with asthma

answer 3 Epiglottitis is a medical emergency due to the swelling of the epiglottis covering the larynx. This client needs frequent assessment for respiratory distress, especially since young children have smaller, more compliant airways. The 3-year-old child has more developed respiratory passages than a 2-year-old child, and although croup may cause respiratory distress, the likelihood of airway obstruction is lower when compared to epiglottitis. The 11-month-old infant has a common cold, typically from a virus. The 16-year-old adolescent with asthma has fully developed respiratory airways, which are less likely to be obstructed.

The nurse is collecting data on a child with a diagnosis of tonsillitis. Which clinical manifestation would likely have been noted in the child with this diagnosis? bark-like cough hoarseness erythema of the pharynx inability to make audible voice sounds

answer 3 The child with tonsillitis may have a fever of 101°F (38.4°C) or higher, a sore throat, often with dysphagia (difficulty swallowing), hypertrophied tonsils, and erythema of the pharynx. The child with spasmodic laryngitis has a bark-like cough, hoarseness, and an inability to make audible voice sounds.

The nurse is assessing a newborn child. The mother asks why the feet are blue. What is the best response by the nurse? "A blue tint to skin means that there is a lack of oxygen. I will need to notify the physician of this immediately." "When a foot or hand is blue, it's called peripheral cyanosis. Peripheral cyanosis is not normal in newborns." "Blueness of hands and feet is a common finding in newborns. It is a result of their circulatory system switching from being in the womb to life outside the mom's body." "Blueness in the feet of a newborn is called pallor. This is a normal finding in babies up to several days old."

answer 3 Blueness of the hands and feet, known as acrocyanosis, is normal in babies up to several days of age and results from an immature circulatory system completing the switch from fetal to extrauterine life. Although blueness in hands and feet may indicate a lack of oxygen and may be called peripheral cyanosis, acrocyanosis is a normal finding in a newborn. Pallor is defined as paleness, not blueness of skin.

The nurse notices that a child is spitting up small amounts of blood in the immediate postoperative period after a tonsillectomy. What would be the best intervention? Suction the back of the throat. Encourage the child to cough. Continue to assess for bleeding. Notify the health care immediately.

answer 3 Children will have a small amount of blood mixed with saliva following a tonsillectomy. Suctioning or coughing could irritate the surgical site and cause hemorrhage.

The nurse is assisting with the physical examination on a sleeping 10-month-old infant being held by the parent against the parent's shoulder. In what sequence would the nurse complete the assessment? head and neck; eyes, ears, nose, mouth; then the back and extremities back and extremities; eyes, ears, nose, mouth; then the head and neck back and extremities; head and neck; then the ears, nose, mouth, and eyes eyes, ears, nose, mouth; back and extremities; then the head and neck

answer 3 Data are collected by examination of the body systems. Often the exam for an infant is not done in a head-to-toe manner, as is done with adults, but rather in an order that takes the infant's age and developmental needs into consideration. Because the infant is asleep and held against the parent's shoulder, the nurse would begin by assessing the infant's back and extremities. The infant's eyes would be inspected last to allow the infant to be most comfortable until the end of the assessment. Aspects of the examination that might be more traumatic or uncomfortable for the infant are completed last.

The nurse is caring for a child immediately following a tonsillectomy. The child requests something to drink. Which action by the nurse is best? Inform the child he or she can have nothing to drink for a few hours. Provide the child with a red popsicle to eat. Give the child a few ice chips to consume. Assess the child's gag reflex before giving oral fluids.

answer 3 Ice chips are soothing and appropriate for the child at this time. The child should not consume anything red to limit confusion between red coloring and blood. Otherwise, a popsicle would be allowed. The child does not have to wait hours following the procedure to drink. Once the child is awake, ice chips may be offered and the diet increased as tolerated, based on the prescription. The nurse would not assess the gag reflex; nothing should be placed in the child's mouth/throat as this would increase the risk of hemorrhage and infection.

A 15-year-old female is being seen for an annual physical examination. The teen asks the nurse if what they talk about will be kept private. What is the appropriate response by the nurse? "Until you are 16 years of age you will not be afforded total privacy from your parents with regard to your health care concerns." "Privacy is important and I will not share anything we talk about with your parents." "There are some things I may need to share with your parents or physician." "Since you are 15 there are some things we can keep private if you wish."

answer 3 Teens value privacy. The determination of what may and may not be kept confidential is based on individual state laws. The nurse may need to divulge certain things. It is best to be honest with a teen concerning the privacy of the interview, assessment and care.

Which clinical manifestation of acute nasopharyngitis is more of a concern for the infant than the older child? Fever Vomiting Nasal congestion Diarrhea

answer 3 The infant has smaller airways, making it more difficult to breathe when nasal congestion occurs. The older child can tolerate the congestion better than the infant with smaller airways. Depending upon the age of the child, younger infants are afebrile. Vomiting and diarrhea can occur at any age as the mucus from the nasal drainage enters the gastrointestinal tract.

The nurse has assessed four clients. Which assessment finding warrants immediate action? 4-year-old child with enlarged tonsillar and adenoidal tissue 10-year-old child with extreme sinus pressure and headache 1-week old newborn with nasal congestion 6-year-old child who is consistently mouth breathing

answer 3 Until 4 weeks of age, newborns are obligatory nose breathers and breathe only through their mouths when they are crying. The newborn cannot automatically open the mouth to breathe if the nose is obstructed; therefore, a newborn with nasal congestion needs immediate action. Also, the newborn and young infant have very small nasal passages, so when excess mucus is present, airway obstruction is more likely. Mouth breathing may occur when a large amount of nasal congestion is present. Although this finding is abnormal and warrants follow up, in a 6-year-old child this finding does not warrant immediate action. Through early school-age, children tend to have enlarged tonsillar and adenoidal tissue even in the absence of illness; therefore, this finding is normal in a 4-year-old child and does not warrant immediate follow up. The frontal sinuses and the sphenoid sinuses develop by age 6 to 8 years; therefore a 10-year-old child may develop a sinus infection. Although these symptoms warrant follow up, immediate action is not necessary.

The nurse is caring for a newly admitted 3-year-old child who has been diagnosed with tuberculosis. When reviewing the child's records which finding(s) is consistent with this disease? Select all that apply. The child currently lives at home with parents and one sibling. The child has been experiencing a sore throat for the past few weeks. The child has been experiencing night sweats. The child and the family were homeless for a period of time in the past 3 months. The child has had recent weight loss.

answer 3-4-5 Tuberculosis is a highly contagious respiratory infection. A child who has been living in crowded locations, who is impoverished, or homeless is at an increased risk. Signs and symptoms of the disease include weight loss, night sweats, anorexia and pain. A child living in a household with parents and one sibling does not have an increased risk for infection. A sore throat is not associated with tuberculosis.

The young child is wearing a nasal cannula. The oxygen is set at 3 L/minute. Calculate the percentage of oxygen the child is receiving. Record your answer using a whole number.

answer 33 Room air is 21%. Each 1 liter of oxygen flow is equal to an additional 4% of oxygen. The child is receiving 3 liters of oxygen. 21% (room air) + 3(4%) = 33% of oxygen.

A 2-year-old toddler is seen for acute laryngotracheobronchitis. What observation would lead the nurse to suspect airway occlusion? The toddler states being tired and wanting to sleep. The respiratory rate is gradually increasing. The cough is becoming harsher. The nasal discharge is increasing.

answer 4 Acute laryngotracheobronchitis is also know as croup. It produces edema of the larynx, trachea, and bronchi. An increasing respiratory rate, retractions, and nasal flaring are signs of major respiratory distress and occlusion. The toddler is breathing faster because less air is received with each breath. Nasal discharge is generally not seen with croup. The cough of croup is due to the inflammation in the larynx and trachea and it is a barking cough (sounds like a seal). A 2-year-old toddler will become tired and fall asleep or be irritable and unable to fall asleep. This age group is unable to verbalize being tired and wanting to sleep.

The nurse is taking a health history for a 3-year-old girl suspected of having pneumonia who presents with a fever, chest pain, and cough. Which information places the child at risk for pneumonia? The child is a triplet. The child was a postmaturity date infant. The child has diabetes. The child attends day care.

answer 4 Attending day care is a known risk factor for pneumonia. Being a triplet is a factor for bronchiolitis. Prematurity rather than postmaturity is a risk factor for pneumonia. Diabetes is a risk factor for influenza.

A 14-year-old male adolescent is brought to the clinic by his parent who is concerned the adolescent is developing an excessive amount of breast tissue. The examination confirms that the adolescent has slight enlargement of the breast tissue. What information should be relayed to the adolescent and his parent? The adolescent will need to have hormonal levels assessed for the presence of estrogen. Hormone therapy may be initiated to resolve the condition. This is a normal and transient condition of adolescent males. This growth is abnormal but cannot be managed until the adolescent's growth has stopped.

answer 4 Breast growth in adolescent males may occur in response to hormonal levels. This condition will self resolve as hormones become more balanced. Therapy and laboratory studies are not indicated at this time.

The nurse has assessed a 6-year-old child as having respiratory distress due to swelling of the epiglottis and surrounding structures. Which signs and symptoms would support this assessment? The child is pale and has vomited. The child has pale, elevated patches on the skin. The child is irritable and tachycardiac. The child is in tripod position.

answer 4 Inflammation and swelling of the epiglottis and surrounding structures are common in children ages 2 to 7 years. The child will attempt to improve his/her airway by sitting forward and extending the neck forward with the jaw up, in a "sniffing position" (tripod position). Being pale, vomiting, and having elevated patches on the skin are not associated with epiglottis. Stridor, tachycardia, and the rapid onset are classical signs of epiglottitis.

When preparing to examine a 2-year-old child, which action by the nurse will best establish rapport? Ask to hold the child prior to performing the examination. Perform the examination prior to obtaining the health history. Give the child a small toy to play with. Bend down to the child's eye level to establish contact.

answer 4 Making eye contact with the child is beneficial to establishing rapport prior to the examination. Two-year-old children may not appreciate being held by a stranger. The parents should be allowed to hold the child as much as possible during the examination to relay a sense of security to the child. A toy may be appreciated by the child, but it does not promote a therapeutic rapport for the examination.

What is a symptom of allergic rhinitis (hay fever)? purulent secretions difficulty breathing laryngitis sinus pain

answer 4 Rhinosinusitis is a bacterial infection of the paranasal sinuses. It can be an acute disorder or children may develop it as a chronic condition. The child will exhibit a cough, fever, halitosis (especially in preschoolers and older children), facial pain, eyelid edema, irritability, and poor appetite. Pharyngitis would occur if there was a throat infection, not a sinus infection. The drainage from the infected sinuses will generally be thick but it is not purulent. Respiratory difficulty is not seen because only the sinuses are involved.

The mother of a child with asthma tells the nurse that she occasionally gives her child the steroid medicine she takes for her rheumatoid arthritis when the child has a "flare-up" of asthma. "It's easier than going to the hospital or doctor every time a flare-up happens," the mother says. What is the best response by the nurse? "I understand that appointments can be annoying but steroid use can cause your child to have high blood sugar, peptic ulcers, slowed growth rate, and various other problems." "An adult should never give a child their medication. The doses may be very different." "As long as you only occasionally give your child the medication it shouldn't be a problem." "I'm sure it must be difficult to cope with the flare-ups, but there are many side effects from steroid use and the physician needs to monitor your child's asthma symptoms."

answer 4 Showing empathy for the parent is important when explaining the possibility of the steroid's side effects and the importance of the physician monitoring the child's asthma. Just listing all of the side effects of the steroid is not therapeutic communication and doesn't address the need for the child to be seen by the physician. Scolding the parent by telling her that she should never give her child her medication does not encourage good rapport. Giving the child the mother's medication even "occasionally" is not advisable.

The nurse is conducting a physical examination of a 10-year-old child. The nurse whispers the child's name from behind the child so that the child does not see the nurse's lips moving. Which cranial nerve is the nurse assessing? V IV III VIII

answer 4 Testing a child's hearing by observing a response to a whisper without a visual clue assesses cranial nerve VIII, the acoustic nerve. Nerve V is the trigeminal nerve and is tested by having the child bite down and by evaluating the corneal reflex and also sensory response with a cotton wisp. Cranial nerve IV is the trochlear and is tested by having the child move the eyes downward and inward. Cranial nerve III is the oculomotor nerve and is testing by evaluating pupil reactivity and the six cardinal positions of gaze.

The nurse is examining a child and asks the child to show all of the teeth. For which cranial nerve would the nurse be testing? cranial nerve V cranial nerve II cranial nerve IV cranial nerve VII

answer 4 The nurse would be testing to see if cranial nerve VII was intact. This is the facial nerve and can be tested by asking to see a child's teeth, or having the child smile or lift an eyebrow. In infants facial symmetry would be assessed. Cranial nerve V is tested to determine the muscles of mastication and sensation of light touch on the face. Cranial nerve II assesses the optic nerve. Cranial nerve IV is assessed by having the child follow the light through the six cardinal positions of gaze.

The nurse is conducting a skin assessment of a newborn. The examination reveals a light pink macule on the back of the neck. The nurse understands that this is a normal variation and is most likely which type of birthmark? salmon nevus nevus flammeus petechiae purpura

answer1 A light pink macule on the back of the neck is a salmon nevus or "stork bite." A nevus flammeus (port wine stain) is dark purple-red. It is a flat patch that grows with the child. Petechiae are pinpoint reddish macules that do not blanch when pressed. Purpura are large purple macules created by bleeding under the skin.