Ch. 35 Key Pediatric Nursing Interventions

The nurse is caring for a child prescribed ophthalmic drops. Place the steps in the order the nurse will complete them when administering the ophthalmic medication to the child. -Wipe any excess medication from the skin -Place the prescribed number of drops into the lower eyelid -Retract the lower conjunctival sac -Place the child in the supine position, slightly hyperextending the neck with the head lower than the body -Instruct the child to gently close the eyes`

1. Place the child in the supine position, slightly hyperextending the neck with the head lower than the body 2. Retract the lower conjunctival sac 3. Place the prescribed number of drops into the lower eyelid 4. Instruct the child to gently close the eyes 5. Wipe any excess medication from the skin

A child weighs 18 pounds. The nurse is making sure the intravenous (IV) infusion is flowing at the correct rate. After determining fluid requirements for this child for a 24-hour period, the nurse should be sure that the IV is infusing at how many milliliters per hour?

34 The child's weight must be converted to kilograms (18 lb divided by 2.2 kg = 8.18 kg). This kilogram weight is multiplied by 100 (8.18 x 100 = 818.18 ml) to determine the 24-hour fluid requirement. The 24-hour fluid requirement is divided by 24 (hours)= 34.09 (34 ml/hr).

Parents asks the nurse why their premature infant is receiving a feeding through the mouth rather than the nose. What is the best explanation by the nurse? a. It is equally acceptable to use either insertion site. b. Orogastric tube insertion can cause inflammation and obstruction of the nares. c. Nasogastric tubes decrease the possibility of striking the vagal nerve. d. Newborns are obligate nose breathers so nasogastric may obstruct their breathing.

Ans D Whether enteral catheters should be passed through the nares or the mouth is controversial. Because newborns are obligate nasal breathers, passing a catheter through the nose may obstruct their breathing space, and repeated insertion of a nasogastric tube can cause inflammation and obstruction of the nose; thus most tubes are inserted orally in small infants. Orogastric insertion can also decrease the possibility of striking the vagal nerve in the back of the throat and causing bradycardia, whereas nasogastric tubes increase the possibility of striking the vagal nerve.

The site most often used when administering a medication using the intradermal route is the: a. forearm. b. deltoid. c. abdomen. d. thigh.

Ans A Intradermal injections deposit medications just under the epidermis. They are most often used for tuberculosis screening and allergy testing. The forearm is the site most often used. The anterior thigh, lateral upper arms, and abdomen are the preferred sites for subcutaneous administration. The deltoid, vastus lateralis and the ventrogluteal are the preferred sited for intramuscular injections.

A 5-year-old boy is receiving an analgesic intravenously while in the hospital. What should the nurse do to determine whether the drug is being properly excreted from this child? a. Monitor the child's fluid intake and output. b. Ask the child to describe his pain level. c. Assess the child's blood pressure level. d. Measure the child's respiration rate.

Ans A Monitoring intake and output is important in children receiving drugs to be certain urine excretion or an outlet for drug metabolites is adequate. The other interventions listed are not typically used to determine whether drug excretion is occurring.

When preparing to administer medication to an infant, the nurse should utilize which device? a. measured medication spoon b. oral syringe without a needle c. infant formula and bottle d. medicine cup

Ans B When administering medication to an infant, an oral syringe without a needle or a dropper may be used. Medication should not be mixed with the infant's formula. Toddlers and older children may use a measured medication spoon or cup.

A child is receiving intravenous fluids for dehydration. The nurse notes coarse breath sounds and increased pulse and blood pressure. What does the nurse do first? a. Assess intake, output, and weight. b. Contact the health care provider. c. Request a chest X-ray for evaluation. d. Discontinue the IV infusion.

Ans D Signs of fluid overload are those of congestive heart failure and include coarse breath sounds, increased pulse rate, and increased blood pressure. These are not symptoms of extravasation because this would be swelling of fluid around the IV site. The nurse would need to stop the IV infusion, then assess weight, intake, and output. The nurse would then contact the health care provider.

An infant is scheduled to have a painful procedure performed. Which nursing action provides the best support for the parents and infant? a. Explain to the parents that infants do not experience pain. b. Allow the parents to hold the infant during the procedure. c. Have the parents remain outside the room while the procedure is occurring. d. Ask the parents to hold the child down during the procedure.

Ans B It is important for the nurse to advocate for parents to remain in the procedure room to provide support to the infant. The parent may choose to hold the infant during a painful procedure, but it is best that the parent not restrain the infant during the procedure. Their role should be supportive and comforting, not one that causes pain. Having the parents remain outside the room leaves the infant without needed support. Infants experience pain but express it differently than adults.

Included in the nursing care plan for the child receiving total parenteral nutrition (TPN) will be which intervention? a. Regularly monitoring the child's blood glucose b. A daily stool softener c. Keeping the child nothing by mouth (NPO) d. Flushing the peripheral catheter delivering the TPN solution regularly with saline

Ans A Monitoring the blood glucose is important with TPN since the glucose content of the solution is high and can cause hyperglycemia. The need for a stool softener would be determined on an individual basis. Children receiving TPN may or may not be taking food and fluids orally. The catheter delivering the TPN solutions will be centrally placed to accommodate the concentrated TPN solution (larger vessel with more rapid blood flow).

The nurse is assessing a child who is receiving TPN. The nurse determines the TPN bag was hung 24 hours ago. What initial action by the nurse is indicated? a. Discontinue the TPN bag and notify the physician. b. Document the amount of solution left in the bag and continue the administration. c. Hang a new bag of TPN. d. Increase the rate of the TPN to complete the bag.

Ans C TPN bags should not hang over 24 hours. The nurse should discontinue the current bag and hang a new one. There is no need to notify the physician. The rate of the TPN should never be changed without a physician's order.

When administering medications to an infant, what information will the nurse consider? a. The infant will take medications more readily if he or she is allowed to move the head as desired. b. The oral medication should be directed toward the side of the mouth when using a syringe or dropper. c. The infant will take oral medications more readily after he or she has been fed. d. The infant will take a medication more readily if the flavor is disguised.

Ans B A syringe or dropper should be directed toward the side of the mouth with the infant in the upright position when administering an oral medication. The other choices would be inappropriate and may result in the child not receiving the full dose.

Which assessment is most important for determining an accurate dose of a pediatric medication? a. Body mass index b. Body surface area c. Age d. Height

Ans B Body surface area (BSA) is the most accurate measure for dosing medications for children. In pediatrics, there are no standard amounts of a drug given per age; rather, dosage is based on weight using an established amount of the drug per body weight. Body mass index is not considered when determining pediatric medication dosing.

The nurse is educating the parents of a 5-month-old on how to administer an oral antibiotic. Which response indicates a need for further teaching? a. "We can mix the antibiotics into his formula or food." b. "We can follow his medicine with some applesauce or yogurt." c. "We can place the medicine along the inside of his cheek." d. "We should not forcibly squirt the medication in the back of his throat."

Ans A Never mix a medication with formula or food. The child may associate the bitter taste with the food and later refuse to eat it.

The nurse is preparing to administer medication to a 5-month-old client. The nurse is aware that at least two different client identifiers must be used. Which identifiers could the nurse use? Select all that apply. a. birthday b. full name c. parent's name d. hospital ID number e. room number

Ans A, B, D Client identifiers include such things as the client's full names, birth dates, and hospital ID numbers. Client room numbers and parents' names should not be used as identifiers.

When determining the correct therapeutic dose of most medications for children, what is the most important assessment to make? a. chronological age b. length or height c. weight d. developmental age

Ans C Pediatric medication dosage is based on weight using an established amount of the drug per body weight. In pediatrics, there are no standard amounts of a drug given per developmental age, chronological age, length, or height.

The nurse is teaching parents of a 12-year-old child how to administer otic medication. Which statement by the parent indicates a need for further education? a. "I will pull the outer ear down and back before administering the medication." b. "After removing the medication from the refrigerator, I need to roll it gently in my palms to warm it." c. "After administering the drops, I will ask my child to remain side-lying for several minutes." d. "I will hold the dropper 0.5 in (1.25 cm) above the ear canal and be certain not to touch the ear with the dropper."

Ans A The proper technique to instill ear drops in a child older than 3 years of age involves pulling the pinna up and back. Otic medication should not be administered if it is cold. Cold medication may cause discomfort and produce vomiting or vertigo in the child. If an otic medication must be refrigerated, it should be warmed in the palms of the hands. Proper otic administration technique involves holding the dropper 0.5 in (1.25 cm) above the ear canal and being careful not to touch the dropper to the ear to prevent contamination of the dropper with microorganisms. The child should remain in a side-lying (or supine) position for several minutes after administration.

The nurse is preparing to administer a medication via a syringe pump as ordered for a 2-month-old girl. Which is the priority nursing action? a. Wash hands and put on gloves. b. Gather the necessary equipment and supplies. c. Gather the medication. d. Verify the medication order.

Ans D The priority nursing action is to verify the medication ordered. The first step in the eight rights of pediatric medication administration is to ensure that the child is receiving the right medication. After verifying the order, the nurse would then gather the medication, the necessary equipment and supplies, wash hands, and put on gloves.

A 3-year-old client is being admitted for a tonsillectomy. The nurse notes the client is fussy, crying, and appears nervous about the procedure. Which action by the nurse will be most helpful in alleviating the child's anxiety? a. Have another client who had the procedure done yesterday talk to the child. b. Explain the procedure to the child using dolls and medical equipment. c. Encourage the child to perform deep-breathing exercises. d. Show the child a video about the procedure and give the child a tour of the operating room.

Ans B The nurse will explain the procedure to the client using dolls and medical equipment to help the child understand what will happen. This is most appropriate for a client this age. It is appropriate to provide a tour of the operating room, but not show a video due to the child's developmental age. Deep-breathing exercises are not appropriate for a preschool-age client, nor is having another client talk with the child.

The nurse is working to gain a preschooler's cooperation to swallow an oral medication. What would be the nurse's best approach? a. ask if the child would like to take the medicine in a cup or through an oral syringe b. leave the medicine on the night stand so the child can take it independently c. compare the taste of the medicine to a chocolate bar d. offer to play a game with the child if the child takes the medicine

Ans A The preschool age is when the child develops initiative. This is the sense that the child is helping. Thus, the nurse should allow the child to participate in the medication task. The instructions and choices need to be simple. The nurse can ask if the preschooler would like to take the medicine in a cup or through an oral syringe. Medicine never should be compared to candy or any other foods. Doing so can present a safety problem if the child gets into the medication cabinet at home thinking he or she is getting candy. Children cannot be depended on to take medicine without supervision, so leaving the medication on the night stand would not only be ineffective it would also be dangerous. Bribing is ineffective. A preschooler is not going to do a task he or she does not like and the medication is needed to make the child well. The nurse should be gentle but firm in the administration of the medication.

The nurse administers an antipyretic rectal suppository. The child has a bowel movement 15 minutes later. What is the appropriate nursing action? a. Wait to readminister the medication until the next scheduled dose. b. Examine the stool for the presence of the suppository. c. Administer another suppository, and then hold the child's buttocks together. d. Recheck the child's temperature to determine if the suppository is needed. e. Immediately notify the physician or nurse practitioner.

Ans A The stool should be examined for the suppository that may have been expelled with the bowel movement. If it is found, the physician or nurse practitioner can be notified to determine if the suppository should be repeated. The nurse should not administer another dose without examining the stool or contacting the physician or nurse practitioner. Rechecking the child's temperature would provide little useful information since only a very limited time has elapsed since the temperature was last checked.

The nurse is preparing to administer regular insulin to a nonverbal pediatric client. Which action will the nurse perform prior to administering the medication? a. Check the full name and birth date on the client's wristband with the medication administration record. b. Check the full name and room number on the client's wristband with the medication administration record. c. Check the birth date and full name on the client's wristband with the medication administration record and have another nurse verify. d. Check the full name and age on the client's wristband with the medication administration record and have the parent verbally confirm.

Ans A When administering medications to a child, the nurse needs to use at minimum two client identifiers that are directly associated with the client and the medication to be given, such as full name, client ID number, and birth date. The nurse will take the medication administration record to the room to perform a "double-identifier" check. A client's identity must be verified with two acceptable identifiers, not just one. There is no need to have another nurse verify or have the parent state the client's information. A room number or a bed number is not an acceptable identifier.

A nurse is preparing a dose of insulin to give the client. Which action takes priority when preparing and administering this medication? a. Double-check the math calculations. b. Double-check the dose with another RN before giving. c. Have another RN witness the injection given to the client. d. Ask the client if he or she has had any adverse reactions to insulin in the past.

Ans B Insulin is a high-alert medication and the dosage must be checked with another RN before administering. All rights of medication administration should be adhered to. Insulin dosages come in units and the prescription is to administer a specific number of units; thus, no calculations of dosages are needed. Insulin injections do not have to be witnessed. Insulin is not known for having adverse reactions, but it is always a good practice to ask the client if he or she has experienced any problems receiving insulin.

The nurse is preparing to give a 4-month-old an oral medication. Which technique demonstrates the nurse's accurate knowledge of the infant's developmental level? a. Place the medication in a bottle with a small amount of the infant's formula and feed the bottle to the infant in an upright position. b. Position the infant upright, offer the infant a bottle of formula, remove the bottle and squirt the medication on the side of the tongue toward the cheek, then offer the infant the bottle again. c. Position the infant supine in bed, and squirt the medication on the tongue toward the cheek. d. Place the medication in a bottle with a small amount of juice, then feed the infant the bottle in an upright position.

Ans B Proper medication administration for an infant includes the following: Position the infant upright, present a pleasant- or neutral-tasting substance to ensure that the child is awake and swallowing, give the medication slowly enough to allow the child to swallow and prevent any risk of aspirating, and give a pleasant-tasting "chaser." An infant should not be placed supine since this would increase the risk of aspiration. Medications should not be placed in a client's staple food to avoid an aversion to the food in the future.

The nurse is administering a gavage feeding through a nasogastric feeding tube. Which nursing intervention is the highest priority? a. The nurse documents how the child tolerated the feeding. b. The nurse verifies the position of the feeding tube. c. The nurse positions the child in a sitting position. d. The nurse replaces stomach content that has been aspirated.

Ans B Verifying the position of the tube to ensure that the tube is in the stomach by aspirating stomach contents is the highest priority. This is a top priority because of the danger of aspiration if the tube is not in the stomach but rather in the esophagus or the lung.

A 4-year-old child is admitted to the hospital for surgery. Before the nurse administers medicine, the best way to identify the child would be to: a. call the child's name and see if he or she answers. b. tell the child to state his or her nickname. c. read the child's armband. d. ask the child to state his or her name.

Ans C A child may answer to the wrong name or deny his or her identity to avoid an unpleasant situation or if scared of the unknown. If the child is avoiding the situation he or she may fail to answer. Using the child's nickname is okay in conversation but it is not a legal identification of the child. To verify the correct identity the nurse should verify the child's armband and the correct name with the child's caregiver. Bar code scanning the child's armband would also be a correct method of identification.

A child needs a peripheral IV start as well as a venous blood sample for a laboratory test. The nurse will take what action? a. Place the IV and start intravenous fluids promptly; then request the laboratory obtain the blood specimen. b. Delay both the IV start and blood draw until the child is well hydrated orally. c. Coordinate placing the peripheral IV and the lab blood draw. d. Make sure the laboratory specimen is drawn prior to placing the IV access device.

Ans C Coordinate the IV placement and lab blood draw to minimize the number of venipunctures for the child. Gaining venous access for each purpose separately does not do this and is not necessary. Having a well-hydrated child makes venous access easier, but oral hydration will take some time, thus delaying needed treatment.

The mother of a 9-year-old girl calls the physician's office complaining that her daughter continues to vomit soon after being given an oral amoxicillin capsule for her strep throat. The nurse recognizes that the child's vomiting will interfere with which pharmacokinetic process? a Distribution b. Excretion c. Absorption d. Metabolism

Ans C Drug absorption (transfer of the drug from its point of entry in the body into the bloodstream) is influenced by the route of administration as well as by the concentration and acidity of the drug. Vomiting and diarrhea, frequent symptoms of childhood illnesses, interfere with absorption because a drug does not remain in the gastrointestinal tract long enough to be absorbed. Distribution refers to the movement of the drug through the bloodstream to a specific site of action. Metabolism involves conversion of the drug into an active form (biotransformation) or an inactive form (inactivation). Excretion is the elimination of raw drug or drug metabolites, a process that largely prevents properly administered drugs from becoming toxic.

An infant is to have a scalp-vein intravenous infusion begun. What is an advantage of this insertion site? a. Glucose is absorbed best from scalp veins. b. The child will not feel pain from the needle insertion. c. The scalp veins are easily visualized. d. Infiltration cannot occur with this insertion site.

Ans C Peripheral IVs can be inserted in neonates and infants. The scalp veins are easily visualized, being covered only by a thin layer of subcutaneous tissue. These veins do not have valves, so the device may be inserted in either direction, although the preference would be in the direction of blood flow. Unless the area has been numbed before the procedure, the child will feel the pain of insertion. Infiltration can occur at any site a peripheral catheter has been inserted. Glucose can be absorbed from any vein from which it is infusing.

The nurse enters the room to give a subcutaneous injection of insulin to a 6-year-old child with diabetes. What is the best method of medication administration? a. Tell the child that the client is to remain very still and not cry. b. Ask the child if it is okay to give the injection now. c. Announce to the child that it is time for insulin and give the injection matter-of-factly. d. Ask the child where the child would like to have the injection.

Ans D Asking the client to choose where to receive the injection gives a degree of control. Announcing that it is time for the medication does not give any sense of control to the child. Asking permission to give a medication to a child is not appropriate—a child should not be given the opportunity to decline a medication. It is not appropriate to tell a child not to cry during a painful procedure. The child should be given permission to yell out or cry if he or she feels the need to.

The nurse is preparing to administer an IV antibiotic to a child. After calculating the recommended dose with the child's weight, the nurse discovers the prescribed dose exceeds the safe dose range in a pediatric drug book. The medication has been given to the child at this dose for 3 days. What action should the nurse take next? a. Give the prescribed dose since the child has been receiving that dose for 3 days. b. Call the pharmacy. c. Ask the child's parents if this dose has been given all week. d. Verify the dose with the prescribing health care provider.

Ans D Medication calculations should always be checked before giving the dose. When a medication dose is found to be outside of the safe dose range, the dose should be verified with the prescribing health care provider. Doses that exceed the recommended range should always be verified, even if they have been given before. The parents did not prescribe this medication. Even if the medication has been given for 3 days, it does not make the dose correct. Calling the pharmacy can only verify if the dose is out of the safe range. The pharmacy did not prescribe the medication nor does it know the child's medical background.

A parent informs the nurse about having a hard time getting her 6-year-old child to take the liquid medication at home. Which would be the best suggestion for the nurse to offer the parent to help correct this concern? a. Tell the parent to tell the child, "It tastes just like candy!" b. Tell the parent to say calmly, "Can you drink this for me?" c. Tell the parent to ask the child nicely, "Will you drink this for me?" d. Tell the parent to state firmly, "It's time for you to drink your medicine."

Ans D The best guideline for the parent to help in getting a child to take the liquid medication is to state firmly, "It's time to take your medication." Asking or pleading with the child does not work. Firmness is required. The child can be, however, allowed to choose what liquid to use to help swallow the medication. This helps with self-esteem and independence. The parent should also be honest about the taste of the medication. Adults also should never refer to medicine as candy. If a child happens to like a particular medicine, he or she may help themselves to it, and consuming too much can be fatal.

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? a. Apply a cardiac monitor to the child. b. Give the antibiotic as prescribed. c. Apply oxygen at 2 liters via a nasal cannula. d. Administer the bronchodilator via a nebulizer.

Ans D 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.

A neonate is to receive a hepatitis B vaccine within a few hours after birth. What is the best approach for the nurse to take when giving this medication? a. Administer the medication in the dorsogluteal with a 25-gauge needle. b. Administer the medication in the deltoid muscle with a 20-gauge needle. c. Administer the medication in the vastus lateralis with a 20-gauge needle. d. Administer the medication in the neonate's vastus lateralis with a 25-gauge needle.

Ans D The vastus lateralis site is a safe choice for intramuscular (IM) injections in a neonate. A 22- to 25-gauge needle is recommended for neonates, but the nurse must assess the neonate's size before determining needle size to use. The 25-gauge needle is recommended for neonates. The dorsogluteal site should not be used until school age. Neither the deltoid muscle nor the dorsogluteal muscle are recommended IM sites for neonates. These muscles should not be used until toddler age or older. The volume of the medication should not exceed 0.5 ml per injection until the child is preschool age.