ATI Capstone- Nursing Care of Children
A nurse receives a call from a parent of a child who has Von Willebrand disease and is having a nosebleed. Which of the following instructions should the nurse give the parents? "Place your child in a sitting position with her head tilted back." "Apply ice at the base of the nose for 5 min and then check for bleeding." "Place your child in a supine position with a pillow under her back." "Have your child sit with her head tilted forward and hold pressure on her nose for 10 minutes."
"Have your child sit with her head tilted forward and hold pressure on her nose for 10 minutes."; The nurse should instruct the parent to have the child sit up with her head tilted forward to reduce the risk of aspiration. The parent should apply pressure with the thumb and forefinger to the child's nose for 10 min and then check for further bleeding.
A nurse is caring for a child who has influenza. The nurse should identify that which of the following statements by the parent indicates the child has and increased risk for Reye syndrome? "I give my child ibuprofen when his muscles are aching." "I am encouraging my child to drink grapefruit juice." "I give my child aspirin to reduce his fever." "I am leaving a humidifier on in my child's room when he naps."
"I give my child aspirin to reduce his fever."; The administration of aspirin for fever associated with a viral illness increases the child's risk for Reye syndrome. Reye syndrome is a metabolic encephalopathy with manifestations of cerebral edema and fatty changes in the liver.
A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client should indicate to the nurse a need for further teaching? "I only need to catheterize myself twice every day." "I carry a water bottle with me because I drink a lot of water." "I use a suppository every night to have a bowel movement." "I do wheelchair exercises while watching TV."
"I only need to catheterize myself twice every day."; The client has paralysis from the level of the defect down. In the majority of cases, this condition affects bladder and bowel continence. Catheterization should be performed every 4 hr. Infrequent emptying of the bladder can result in stasis and urinary tract infections.
A nurse is providing teaching about self-administration of insulin to the parent of a school-age child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parents indicates a need for further teaching? "I will be sure my child aspirates before injecting the insulin." "The insulin can be injected anywhere there is adipose tissue." "I will be sure my child rotates sites after 5 injections in one area." "The insulin should be injected at a 90-degree angle."
"I will be sure my child aspirates before injecting the insulin."; It is not necessary to aspirate before injecting the insulin.
A nurse is providing teaching about safe sleep practices for the guardian of a 1-month-old infant. Which of the following statements by the guardian indicates an understanding of the teaching? "If my baby has a stuffy nose, I should put a pillow under their head." "I will offer my baby a pacifier anytime they are placed in the bed to sleep." "If my baby has been vomiting, I should place them on their belly to sleep." "My baby can nap on the couch if I surround them with rolled blankets."
"I will offer my baby a pacifier anytime they are placed in the bed to sleep."; The nurse should recommend the use of a pacifier when the infant is sleeping. Research has demonstrated that pacifier use is associated with a decrease in the risk for SUID. Studies show that even if the pacifier is dislodged during sleep, it arouses the infant, thereby decreasing the likelihood of SUID.
A nurse is teaching new parents the proper way to use an infant safety seat. Which of the following should indicate to the nurse a need for further teaching? "I will dress my baby in a one piece outfit so I can use the harness to secure her in the car seat." "My baby will be able to watch me drive while sitting in the back seat." "I will place the infant safety seat in the middle of the back seat, away from the windows." "We will need to go by the weight and height of the child when deciding to change to a booster seat."
"My baby will be able to watch me drive while sitting in the back seat."; The safest area for a car seat is in the back seat. Infants should travel in a rear-facing position for the best protection from airbags and neck and head injury. While in a rear-facing position, the back of the car seat supports the infant's weak neck muscles, soft fontanels, and spine in the event of a frontal motor vehicle crash.
A nurse is teaching the mother of a child who has cystic fibrosis and has a prescription for pancreatic enzymes three times per day. Which of the following statements indicates that the mother understands the teaching? "My child will take the enzymes to improve her metabolism." "My child will take the enzymes following meals." "My child will take the enzymes to help digest the fat in foods." "My child will take the enzymes 2 hours before meals."
"My child will take the enzymes to help digest the fat in foods."; Pancreatic enzymes help the body to digest fat in foods.
A nurse is educating new parents about risk factors for sudden infant death syndrome(SIDS). Which of the following statements should indicate to the nurse the need for additional teaching? "Our baby will sleep in our bed because I am breastfeeding." "We will give my baby a pacifier during naps and at bedtime." "We will place my baby on her back when sleeping." "We will remove blankets and toys from the crib."
"Our baby will sleep in our bed because I am breastfeeding."; Allowing an infant to sleep in the same bed as an adult can lead to suffocation and falls. The parent should place the infant back in her crib or bassinet after breastfeeding.
When administering ear drops to a toddler. The nurse pulls the auricle down and back. The mother asks "why are you pulling the ear that way?" Which of the following is an appropriate response by the nurse? "This technique opens the ear canal, allowing medication to reach the inner ear region." "When this technique is used, the toddler experiences less pain." "This is the safest and easiest way to administer this medication." "When this technique is used, the medication will not run out of the ear."
"This technique opens the ear canal, allowing medication to reach the inner ear region."; For children younger than 3 years old, the auricle should be pulled down and back to fully open the ear canal. This technique allows the correct dose of medication to enter the ear.
A nurse is providing teaching for the parent of a preschooler who has pinworms. Which of the following instructions should the nurse provide? "Give your child a tub bath daily." "Dress your child in two-piece sleeping outfits." "Trim your child's fingernails short." "Repeat your child's treatment in 4 weeks."
"Trim your child's fingernails short."; The nurse should instruct the parent to trim the child's fingernails short to reduce the collection of eggs under the fingernails when scratching, thereby reducing the chance of reinfection.
A nurse is teaching about car seat safety to the guardians of a preschooler. Which of the following instructions should the nurse include? "Use a car seat until your child is a minimum of 145 cm (57 in) tall." "Place a small pillow behind your child's head for comfort." "Use a no-back belt positioning seat if the vehicle does not have a headrest." "Stretch the shoulder-lap safety belt across your child's abdomen."
"Use a car seat until your child is a minimum of 145 cm (57 in) tall."; The nurse should instruct the guardians that the child should remain in a specially designed car seat until they are at least 145 cm (57 in) or 8 to 12 years of age. They should also be reminded to use the car seat each time the car is moving, even for short distances.
A nurse is providing teaching to the parents of a child who has streptococcal pharyngitis about ways to prevent disease transmission. Which of the following responses by the parents indicates an understanding of the teaching? "We'll continue to encourage him to drink lots of fluids." "We'll take his temperature every 4 hours." "We'll give him Tylenol for the pain." "We'll discard his toothbrush and buy another."
"We'll discard his toothbrush and buy another."; Children who have positive throat cultures for streptococcal infection should replace their toothbrush after they have been taking antibiotics for 24 hr. Using a contaminated toothbrush can re-introduce the bacteria and spread it to others if others handle the toothbrush.
A nurse is providing teaching to the parents of an infant who has rotavirus. Which of the following statements should the nurse make? "Your baby will have an increased appetite." "Your baby will need to take antibiotics." "Your baby will experience diarrhea for up to 7 days." "Your baby will need a high-carbohydrate formula for 2 to 3 days."
"Your baby will experience diarrhea for up to 7 days."; The nurse should inform the parents that rotavirus is a viral infection that is spread by the fecal-oral route, which affects the small intestines. Rotavirus causes foul-smelling diarrhea that can last up to 7 days. Other manifestations include fever and vomiting.
A nurse is providing health promotion teaching to an adolescent. Which of the following information should the nurse include in the teaching? "Share piercing needles only with close friends you trust." "Limit your caloric intake to avoid becoming overweight." "Your need for sleep will increase during periods of growth." "Tanning beds are much safer then lying in the sun."
"Your need for sleep will increase during periods of growth."; The nurse should inform the adolescent that sleep needs increase during growth spurts. Adequate sleep and rest during the adolescent period is important for optimal health.
A nurse is providing discharge instructions to a parent and his school age child who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include? Encourage the child to take a 45 min nap daily. Allow the child to stay at home on days when her joints are painful. Apply cool compresses for 20 min every hour. Administer prednisone on an alternate-day schedule.
Administer prednisone on an alternate-day schedule; Prednisone is an effective anti-inflammatory agent that can have serious adverse effects. Taking prednisone on an alternate-day schedule can help maintain joint mobility and minimize adverse effects.
A nurse int he emergency department is caring for a child who is experiencing an acute asthma attack, which of the following medications should the nurse expect to administer first? Fluticasone Budesonide Montelukast Albuterol
Albuterol; Albuterol is considered a "rescue" medication due to its rapid onset of action. Asthma is a chronic inflammatory disorder of the airways. Asthmatic episodes are associated with airflow limitation or reversible obstruction. Albuterol is a beta2 adrenergic agonist used for the treatment of acute exacerbations of asthma by promoting bronchodilation and suppressing histamine release in the lungs. This medication can be given by inhalation, orally, or as a parenteral preparation. The inhaled medication has a more rapid onset of action than the oral form and also reduces the risk for the adverse effects of irritability, tremor, nervousness, and insomnia.
A nurse is preparing to suction a client's tracheostomy. Which of the following actions should the nurse take? Allow 60 seconds for ventilation between each pass of the catheter. Use clean technique throughout the procedure. Apply suction while inserting the catheter into the tracheostomy. Use intermittent suction for at least 20 seconds.
Allow 60 seconds for ventilation between each pass of the catheter; The nurse should allow 60 seconds for adequate ventilation between each pass of the suction catheter to prevent hypoxia.
A nurse is teaching home management to the parents of a preschooler who has cystic fibrosis. Which of the following instructions should the nurse include? Limit the child's intake of foods containing protein. Avoid administration of live virus vaccines. Administer pancrelipase 1 hr after each meal and snack. Allow the child to participate in physical activities with peers.
Allow the child to participate in physical activities with peers; The nurse should instruct the parents that physical exercise and physical activities are beneficial for a child who has cystic fibrosis, because they assist in improving lung function, cardiovascular health, and peer socialization.
A nurse is preparing to provide discharge teaching. A school age child was admitted to the pediatric unit 3 days ago with a runny nose, fever, and vomiting. Viral respiratory infection was suspected. The child has a history of sickle cell disease. Click to specify if the discharge teaching is anticipated or contraindicated for the client. Encourage at least 64 oz of fluid daily. Schedule administration of 23-valent pneumococcal vaccine series Reinforce how to measure ibuprofen with a teaspoon Continue penicillin V potassium prophylaxis Keep home environment <68 °F
Anticipated: -Schedule administration of 23-valent pneumococcal vaccine series -Continue penicillin V potassium prophylaxis Contraindicated: -Encourage at least 64 oz of fluid daily. -Reinforce how to measure ibuprofen with a teaspoon -Keep home environment <68 °F Schedule administration of 23-valent pneumococcal vaccine series is anticipated. Administering the pneumococcal vaccine lowers the incidence of pneumococcal disease and prevents exacerbation of sickle crisis. Continue penicillin V potassium prophylaxis is anticipated. Administering the penicillin V potassium prophylaxis lowers the incidence of pneumococcal disease and prevents exacerbation of sickle crisis. Keep home environment <68 °F is a contraindicated action. The home environment should be maintained at a stable temperature between 68-72°F to prevent cold sensitivity in clients with sickle cell anemia. Exposure to a cold environment can lead to sickle cell exacerbation. Encourage at least 64 oz of fluid daily is contraindicated. 64 oz of fluid is too much for a four-year-old. For infants 3.5 to 10 kg the daily fluid requirement is 100 mL/kg. For children 11-20 kg the daily fluid requirement is 1000 mL + 50 mL/kg for every kg over 10. For children >20 kg the daily fluid requirement is 1500 mL + 20 mL/kg for every kg over 20, up to a maximum of 2400 mL daily. This child weighs 16.4 kg so adequate fluid intake would be 1320 ml daily or 44 ounces or approximately 5.5 cups of fluid per day. Reinforce how to measure ibuprofen with a teaspoon is contraindicated. Do not use household teaspoons, which can vary in size. Provide parents with a 3 ml oral syringe to measure the dose.
A nurse is providing teaching about home care to the parents of an infant who has diaper dermatitis. Which of the following instructions should the nurse include? Use an antiseptic wipe as needed to remove urine from the infant's skin. Use a hair dryer on the lowest setting to dry the infant's skin. Apply warm compresses to the infant's rash several times daily. Apply a zinc oxide ointment to the infant's skin with each diaper change.
Apply a zinc oxide ointment to the infant's skin with each diaper change; The nurse should instruct the guardian to apply a zinc oxide ointment or petroleum jelly to the infant's skin with each diaper change. This action will protect the infant's skin from retaining moisture, which will promote healing and prevent further irritation. Also, the guardian should refrain from removing the barrier ointment with each diaper change. If removal is necessary, the nurse should instruct the guardian to use mineral oil and avoid brisk rubbing.
A nurse is caring for a toddler who is 24hr post-op cleft palate repair. Which of the following interventions should the nurse include in the plan of care? Feed the infant with a spoon for 48 hr. Apply and release elbow restraints every hour. Keep the infant supine. Suction the mouth with an oral suction tube.
Apply and release elbow restraints every hour; It is essential to apply elbow restraints after surgery to keep the infant from placing her hands in and around her mouth. The nurse should remove them periodically to inspect the skin and allow the infant to exercise her arms.
A home health nurse is teaching a child's parents about endotracheal suctioning. Which of the following information should the nurse include in the teaching? Apply suction when inserting the catheter. Apply suction for less than 10 seconds. Set the suction pressure to 110 mm Hg. Allow the child to rest for 10 to 15 seconds after each suctioning attempt.
Apply suction for less than 10 seconds; Prolonged suctioning can cause damage to tissues and induce hypoxia. Hypoxia can interfere with stages of respiration, cellular absorption, and blood transport.
A nurse is caring for a child that has red marks across his cheeks. What is the most appropriate action for the nurse to take? Assess the rest of the child's body for a rash. Refer the family to child protective services. Question the parents about how the marks occurred on the child's cheeks. Obtain the child's temperature.
Assess the rest of the child's body for a rash; Fifth disease presents with erythema on the face, which resembles slap marks. The nurse should further assess the child's body and extremities to determine if the child has Fifth disease.
A nurse is reviewing the lab results for a school age child who has acute glomerulonephritis. Which of the following results should the nurse report to the provider? BUN 25 mg/dL (5 to 18 mg/dL) Urine specific gravity 1.003 (1.005 to 1.03) Albumin 6.2 g/dL (4 to 5.9 g/dL) Hemoglobin 16 g/dL (10 to 15.5 g/dL)
BUN 25 mg/dL (5 to 18 mg/dL); The nurse should identify that a BUN of 25 mg/dL is above the expected reference range of 5 to 18 mg/dL for a school-age child. An elevated BUN is a common laboratory finding associated with acute glomerulonephritis. The finding indicates azotemia as a result of damaged glomerular filtration. Therefore, the nurse should report this laboratory result to the provider as a finding consistent with the child's diagnosis
A nurse in an Emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss? Body weight Skin integrity Blood pressure Respiratory rate
Body weight; Body weight is the most reliable indicator of fluid loss for infants and young children.
A nurse is assessing a 4-year-old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe? Child can build a tower using 10 cubes Parent reports their child is very dependent Child speaks a vocabulary of 300 words Parent reports their child displays temper tantrums
Child can build a tower using 10 cubes; Building a tower using 10 cubes is an expected finding for a preschooler. This is part of fine motor development during the preschool years.
A nurse is providing teaching about a ketogenic diet to the guardian of a child who has epilepsy. Which of the following information should the nurse include? Provide concentrated carbohydrates as the primary food on this diet. Avoid giving your child foods containing gluten. Excessive weight gain is an adverse effect of this diet. Choose high-fat, protein-rich foods for your child.
Choose high-fat, protein-rich foods for your child; A ketogenic diet consists of high-fat, high-protein, and low-carbohydrate foods. This diet has demonstrated effectiveness in controlling seizures in some children. Butter is an example of a high-fat food that has long-chain triglycerides and is recommended for those who have a prescription for a ketogenic diet.
A nurse is creating a plan of care for a child who was placed in a halo brace 4 days ago. Which of the following actions should the nurse plan to take? Clean the pin sites once daily. Ensure that the sling is secured under the child's knee. Remove the traction weights prior to repositioning the child. Maintain the traction device at a 45° angle.
Clean the pin sites once daily; A halo brace is a type of traction that is used for cervical immobilization. The halo device is attached to the skull with screws, connected by bars, and is worn around the chest. The nurse should clean the pin sites once daily after the first 72 hr to prevent infection.
A nurse is caring for a toddler who has acute laryngotracheobronchitis and has been placed in a cool mist tent. Which of the following indicates treatment is effective? Barking cough Improved hydration Decreased stridor Decreased temperature
Decreased stridor; Laryngotracheobronchitis, or croup, is a condition caused by an infection of the upper airway (larynx, trachea, and bronchus) and is characterized by a barking cough. Edema and obstruction in the upper airways cause the characteristic cough and stridor (noisy breathing). The direct purpose of a cool mist tent is to humidify the inspired air, which decreases respiratory effort.
A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vasoocclusive crisis (VOC). Which of the following actions should the nurse take? Initiate contact precautions. Apply cold compresses to affected areas. Encourage bed rest. Provide maximum fluid intake of 1L/day.
Encourage bed rest; The nurse should encourage bed rest for adolescents who have sickle cell anemia and are experiencing a VOC. A VOC is a non-life-threatening, painful episode, which is caused by ischemia and can last from several minutes to several days. Manifestations include generalized migratory pain, acute abdominal pain, and increased body temperature. Bed rest decreases pain and promotes tissue perfusion, which minimizes deoxygenation.
A nurse is caring for a 3-year-old client whose parents report that she has an intense fear of painful procedures, such as injections.Which of the following strategies should the nurse add to the child's plan of care? (Select all that apply) Have a parent stay with the child during procedures. Cluster invasive procedures whenever possible. Perform the procedure as quickly as possible. Allow the child to keep a toy from home with her. Use mummy restraints during painful procedures.
Have a parent stay with the child during procedures. Perform the procedure as quickly as possible. Allow the child to keep a toy from home with her; Have a parent stay with the child during procedures is correct. Maintaining parent-child contact is one of the most supportive interventions for toddlers and preschoolers undergoing painful procedures.Cluster invasive procedures when possible is incorrect. Clustering creates an unnecessarily lengthy and painful period for the client, which is likely to increase her fear.Perform procedures as quickly as possible is correct. Moving quickly through the steps of a painful procedure is a supportive intervention for children undergoing painful procedures.Allow the child to keep a toy from home with her is correct. Having familiar and cherished objects nearby is therapeutic for children during their hospitalization.Use mummy restraints during painful procedures is incorrect. Mummy restraints help to immobilize very young children and keep them safe during procedures, but it is likely to increase fear in toddlers and preschoolers.
A nurse is assessing an adolescent who has an exacerbation of Graves disease. Which of the following findings should the nurse expect? Weight gain Bradycardia Lethargy Heat intolerance
Heat intolerance; An exacerbation of Graves' disease can cause heat intolerance due to an increased metabolic rate, which leads to warm flushed moist skin and extreme diaphoresis.
A nurse is assessing a 3-month-old infant. Which of the following findings should the nurse report to the provider? Inability to raise head when in prone position Inability to sit without support Inability to pick up an object with her fingers Inability to bring an object to her mouth
Inability to raise head when in prone position; A 3-month-old infant should be able to raise her head and shoulders from prone position; therefore, the nurse should report this finding to the provider.
A nurse is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation which of the following intervention should the nurse include in the plan of care? Keep the head of the bed at a 30° angle. Reposition the client by log rolling every 4 hr. Place the client in protective isolation. Initiate the use of a PCA pump for pain control.
Initiate the use of a PCA pump for pain control; The nurse should initiate the use of a PCA pump for an adolescent who is postoperative following scoliosis repair. The PCA pump allows the client to control the delivery of pain medications.
A nurse is preparing to perform an abdominal assessment on a child. Identify the sequence the nurse should follow. Deep palpitation Auscultation Inspection Superficial palpitation
Inspection Auscultation Superficial palpitation Deep palpitation When performing an abdominal assessment on a child, the nurse should first inspect the abdomen without touching and observe for anything that could indicate a medical concern. Because palpation prior to auscultation can alter the bowel sounds, the nurse should auscultate the abdomen for bowel sounds next. Then, the nurse should palpate the abdomen superficially so the child won't tense her abdominal muscles. Finally, the nurse should perform a deep palpation of the abdomen, making sure to palpate any painful areas last.
A nurse is caring for a 12-month-old toddler who is hospitalized and confined to a room with contact precautions in place. Which of the following toys should the nurse recommend in order to meet the developmental needs of the client? Large building blocks Hanging crib toys Modeling clay Crayons and a coloring book
Large building blocks; Large building blocks are age-appropriate toys for a 12-month-old toddler.
A nurse is preparing to perform a heel stick on a 3-day old infant. Which non-pharmacological method of pain management should the nurse use to decrease the infant's pain? Offer the infant a sucrose pacifier. Hold a cold vibration device on the heel for 5 min. Promise a reward after the procedure. Place the infant in a prone position.
Offer the infant a sucrose pacifier; The nurse should offer the infant a sucrose pacifier to decrease their pain level. Nonnutritive sucking is a non-pharmacological intervention that can help soothe an infant before, during, and after a painful procedure, such as a heel stick.
A nurse is assessing a school aged child who has diabetes mellitus and is experiencing hypoglycemia. Which of the following findings should the nurse expect? Pallor Kussmaul respirations Excessive thirst Abdominal pain
Pallor; Pallor is a manifestation of hypoglycemia. Other findings include sweating, hunger, tremors, irritability, and difficulty concentrating. These manifestations are the result of a decrease in the amount of glucose being directed to the cells and the body's attempt to correct this discrepancy.
A nurse is caring for an infant who has intussusception. After the infant's parents discuss treatment options with the provider. Which of the following information should the nurse plan to discuss with the parents? Postprocedural care following the placement of tympanostomy tubes Postprocedural care following a pneumoenema administration Initiation of contact precautions Initiation of gastrostomy feedings
Postprocedural care following a pneumoenema administration; After the provider discusses treatment options with the parents, the nurse should plan to discuss postprocedural care following the administration of a pneumoenema. This is a nonsurgical procedure that is performed by a radiologist to relieve the obstruction and push the bowels back into an extended position.
A nurse is planning care for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac? Which of the following interventions should the nurse include in the plan of care? Maintain the infant in the supine position. Initiate contact precautions. Provide a latex-free environment. Limit visitors to immediate family members.
Provide a latex-free environment; Children who have spina bifida have a very high risk for developing a latex allergy, which can be life-threatening. The specific cause is unknown. However, because the incidence of latex allergy increases with repeated exposure to latex products, it is critical for the nurse to eliminate every possible exposure to supplies and equipment that contain latex.
A nurse is teaching a group of guardians about fire safety in the home. Which of the following actions should the nurse instruct the guardians to take first if a child's clothing catches fire and the child is burned? Cover the burn injury with a clean, dry cloth. Monitor the condition of the child. Roll the child in a blanket. Remove the child's burned clothing.
Roll the child in a blanket; Using evidenced-based practice, the first action the guardian should take is to place the child in a horizontal position and roll the child in a blanket or rug to smother the flames. This stops the burning process and prevents the spread of flames.
The nurse is assessing a 3-year-old child at a routine wellness checkup. Which of the following findings should the nurse expect? Skips and hops on one foot Has a vocabulary of 1,500 words Walks backwards heel to toe Stands on one foot for a few seconds
Stands on one foot for a few seconds; The nurse should expect a 3 year-old-child to be able to stand on one foot for a few seconds, ascend stairs on alternate feet, and jump off of the bottom step.
A nurse is caring for a 6-week-old infant who has a ventricular septal defect (VSD). Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The nurse should assess the apical pulse for 1 full min and assess the rhythm strip for a prolonged P-R interval because the infant is most likely experiencing digoxin toxicity. The manifestations of digoxin toxicity that are seen in infants most commonly include vomiting, poor feeding, and bradycardia. The P-R interval is also prolonged if digoxin toxicity is occurring. It is critical the nurse quickly identifies and reports these symptoms to the provider for treatment of digoxin toxicity. Furosemide is a potassium wasting diuretic and can cause hypokalemia. Hypokalemia increases the potential for digoxin toxicity. The nurse should continue to monitor the infant's heart rate and withhold digoxin per the provider's prescription. It may be necessary to treat the digoxin toxicity with the antidote digoxin immune fab fragment. It is important to continue to monitor digoxin level as treatment is initiated.
A nurse is assessing a preschooler. Which of the following findings should indicate to the nurse a need for speech therapy? (Select all that apply) The preschooler stutters when speaking. The preschooler mispronounces words. The preschooler speaks in three word sentences. The preschooler talks to himself when reading. The preschooler speaks in a nasally tone.
The preschooler mispronounces words. The preschooler speaks in a nasally tone; The preschooler stutters when speaking is incorrect. Stuttering is expected in the preschooler. Stuttering or stammering is common for a preschool-age child who is learning to form new words into sentences.The preschooler mispronounces words is correct. Language begins to increase with toddlers as development progresses towards two to three word phrases. Mispronounced vowels and consonants occur between ages 24 and 36 months. The nurse should expect a toddler to mispronounce words.The preschooler speaks in three word sentences is incorrect. Three to four word sentences (telegraphic speech) is expected for preschoolers. Preschoolers ask many questions and often continue talking when no-one is listening. The preschooler talks to himself when reading is incorrect. During preschool development, the child experiences a vivid imagination that is expressed through imitative and dramatic play. In discovering books, the child becomes engaged in the story and might talk to himself. Speaking in a nasally tone is correct. A child who speaks with a nasally tone might have a neurogenic speech disorder that is caused by weakened muscles of the tongue, soft palate, and face. A speech therapist can evaluate the child and determine exercises to improve the articulation, voice, pitch quality, and volume.
The nurse should include the following interventions in the plan of care for an adolescent who has scoliosis and is postoperative following a spinal fusion. Which of the following interventions should the nurse include? Use a log-rolling technique to reposition the adolescent. Monitor the lower extremity pulses every 4 hr for the first 24 hr Clean the screw sites with diluted hydrogen peroxide. Maintain the client on strict bed rest for 5 to 7 days following surgery.
Use a log-rolling technique to reposition the adolescent; The nurse should include the need to use a log-rolling technique when repositioning the adolescent. After surgery, the adolescent must lay flat and be log-rolled by two staff members every 2 hr to promote respiratory function and clearance. Also, the head of the bed should not be elevated due to the implantation of surgical steel rods into the vertebrae.
A nurse is preparing to administer a vaccine to a 4 year old child. Which of the following vaccines should the nurse administer? Haemophilus influenza type b (Hib) Hepatitis B (HepB) Varicella (VAR) Meningococcal (MCV4)
Varicella (VAR); The child should have received the first dose between 12 to 15 months of age. The child should then receive a second dose between 4 and 6 years of age.
A nurse is assessing a 12 month old during a well child visit. Which of the following findings should the nurse report to the provider? Absent Babinski reflex Weight is double the birth weight Walks only if holding onto furniture Vocabulary consists of 3 to 5 words
Weight is double the birth weight; The nurse should report this finding to the provider. The weight should have tripled from the birth weight by the time the infant reaches 1 year of age.
A nurse is caring for a child on the oncology unit. The child's parents are asking the nurse about the cancer diagnosis. Which of the following information should the nurse provide the parents about the most common malignant renal and intra-abdominal tumor of childhood? Ewing sarcoma Osteosarcoma Neuroblastoma Wilms' tumor
Wilms' tumor; Wilms' tumor, or nephroblastoma, is the most common malignant renal and intra-abdominal tumor of childhood.
