CH. 44 MATERNAL PREP U
A nurse is providing care to a child who is to receive a blood transfusion. The health care provider has prescribed the infusion to run at a rate of 5 ml/kg/hour. The child weighs 55 lb (25 kg). At what rate should the nurse set the infusion pump? Record your answer using a whole number.
125 The nurse will use the child's weight in kilograms, and multiply weight by the prescribed milligrams per hour. 25 kg × 5 ml = 125 ml/hour
An 8-month-old girl appears pale, irritable, and anorexic. On blood testing, the red blood cells are hypochromic and microcytic. The hemoglobin level is less than 5 g/100 mL, and the serum iron level is high. Which symptom should the nurse most expect as a result of excessive iron deposits? An enlarged thyroid gland An enlarged spleen Enlarged lymph nodes An enlarged heart
Correct response: An enlarged spleen
A nurse is preparing a teaching plan for a child with hemophilia and his parents. Which information would the nurse be least likely to include to manage a bleeding episode? Elevate the injured area such as a leg or arm. Apply heat to the site of bleeding. Apply direct pressure to the area. Administer factor VIII replacement.
Correct response: Apply heat to the site of bleeding. Explanation: Ice or cold compresses, not heat, would be applied to the site of bleeding. Direct pressure is applied until the bleeding stops. The injured part is elevated unless elevating would contribute to further injury. Factor VIII replacement is given to replace the missing clotting factor.
The nurse is assessing a child and notices pinpoint hemorrhages appearing on several different areas of the body. The hemorrhages do not blanch on pressure. The nurse documents this finding as: ecchymosis. poikilocytosis. petechiae. purpura.
Correct response: petechiae.
A nurse is reviewing laboratory test results from several children, looking specifically at their thrombocyte levels. The nurse would identify that the child with which platelet level might be at risk for bleeding? Select all that apply. 287,000 per cubic millimeter 110,000 per cubic millimeter 175,000 per cubic millimeter 80,000 per cubic millimeter 234,000 per cubic millimeter
Correct response: 80,000 per cubic millimeter 110,000 per cubic millimeter Explanation: Normal thrombocyte level ranges from 150,000 to 300,000 per cubic millimeter. Therefore, a child with a thrombocyte level of 80,000 and 110,000 per cubic millimeter would be at risk for bleeding.
Individuals with hemophilia B have a deficiency in factor IX, which can cause excessive blood loss. What is another name for this clotting factor? Proconvertin Antihemophilic factor Stuart factor Christmas factor
Correct response: Christmas factor Explanation: Factor IX is also known as plasma thromboplastin component or Christmas factor. Its function is to activate factor X. Factor X is the Stuart factor. Stuart factor's function is to activate factor II in the clotting cascade. Factor VIII is the antihemophilic factor. It is a platelet cofactor and also helps activate factor X. Factor VII is proconvertin. It is considered a stable factor and also acts to activate factor X.
The nurse is assisting with the circumcision of a male infant. What assessment finding, 1 hour after the circumcision, indicates the greatest need for further assessment? The infant has bruising at the site of the circumcision. The infant has frank bleeding at the circumcision site. The infant has increased tone in the lower extremities. The infant's pulse is recorded as 110 beats/min. The infant's temperature is 99.9°F (37.7°C) rectally.
Correct response: The infant has frank bleeding at the circumcision site. Explanation: The infant with bleeding following circumcision would be further assessed. The other findings may indicate the need for follow-up, but bleeding is of the highest concern. Reference:
A toddler who is beginning to walk has fallen and hit his head on the corner of a low table. The caregiver has been unable to stop the bleeding and brings the child to the pediatric clinic. The nurse is gathering data during the admission process and notes several bruises and swollen joints. A diagnosis of hemophilia is confirmed. This child most likely has a deficiency of which blood factor? Factor X Factor XIII Factor VIII Factor V
Factor VIII
The nurse is developing a plan of care for a child who is to have a transfusion. Which would the nurse expect to administer because it is the most common form of transfusion? Packed red blood cells Plasma factors Washed red blood cells Whole blood
Correct response: Packed red blood cells
After teaching the parents of a child diagnosed with pernicious anemia about the disorder and treatment, the nurse determines that the teaching was successful when the parents state: "He might get constipated from the supplement." "He'll need to have those vitamin shots for the rest of his life." "He needs to eat more green leafy vegetables to cure the anemia." "We'll need to plan for a bone marrow transplant soon."
Correct response: "He'll need to have those vitamin shots for the rest of his life." Explanation: Monthly injections of vitamin B12 are required for life. Although diet is important, diet alone will not cure the anemia. Iron used to treat iron-deficiency anemia can lead to constipation. Bone marrow transplant is used to treat aplastic anemia.
While assessing an adolescent, the nurse notes pallor and a beefy red tongue. Upon questioning, the adolescent reports eating a vegetarian diet to help with weight loss. Which health care provider prescription will the nurse anticipate? hydroxyurea orally ferrous sulfate daily vitamin B12 injections folic acid supplement
Correct response: vitamin B12 injections Explanation: Children with pernicious anemia have a vitamin B12 deficiency and have symptoms such as pallor, irritability, beefy red tongue, and diarrhea. Children with iron-deficiency anemia require ferrous sulfate. Folic acid is needed for children with macrocytic anemia. Hydroxyurea could be prescribed for a child with sickle cell anemia.
A 10-month-old has been admitted to the hospital with severe hemolytic anemia and chronic hypoxia. The nurse notes conjunctival icterus, jaundice of the skin, and frontal and maxillary bossing. The nurse interprets these findings as most likely indicating: sickle cell anemia. hemophilia. β-thalassemia major. von Willebrand disease.
Correct response: β-thalassemia major. Explanation: Severe hemolytic anemia and chronic hypoxia, conjunctival icterus, jaundice of the skin, and frontal and maxillary bossing are signs and symptoms of β-thalassemia major. Hemophilia is manifested by clotting dysfunctions and von Willebrand disease is manifested by abnormal clotting. Sickle cell anemia involves abnormal hemoglobin that leads to significant anemia and acute and chronic symptoms.
The nurse is caring for a 10-year-old boy with hemophilia. He asks the nurse for suggestions about appropriate physical activities. Which activity would the nurse most likely recommend? Wrestling Soccer Football Baseball
Correct response: Baseball
Which site is most frequently used to perform a bone marrow aspiration? Iliac crest Humerus Femur Rib cage
Correct response: Iliac crest
A nurse is teaching a school-aged child with iron-deficiency anemia and her parents about dietary measures to increase iron intake. The nurse determines that the teaching was successful when they state which food is high in iron? Select all that apply. Citrus fruits Eggs Fortified cereal Milk Green leafy vegetables
Correct response: Eggs Fortified cereal Green leafy vegetables Explanation: Foods high in iron include meat, cheese, eggs, green leafy vegetables, and fortified cereal. Citrus fruits and milk are not iron-rich foods.
The nurse is caring for a client who was diagnosed with a sickle cell crisis and currently reports acute back and joint pain. Upon examination, the nurse noted the following assessments: dry mucous membranes; poor skin turgor; poor capillary refill, and pale nail beds. Which nursing concern will the nurse identify as the priority? peripheral tissue perfusion impairment related to the effects of sickled cells fluid volume underload related to clustering of sickled cells altered skin integrity risk related to decreased mobility secondary to pain acute pain related to effects of sickling
Correct response: acute pain related to effects of sickling Explanation: Although all the noted concerns apply, acute pain is the priority for this child. Once pain is relieved, the child will be able to relax, thus reducing the metabolic demand for oxygen and helping to end the sickling. A child with sickle cell pain generally does not like to move because movement increases the oxygen demand of the body that results in the sickling of more cells. The increased sickling of cells causes an increase in pain. This decreased mobility increases the risk of developing pressure injuries.
While inspecting the skin of a child, the nurse notes blotchy areas of hemorrhage. When notifying the health care provider, the nurse would identify the client's skin as having: purpura. petechiae. hematomas. ecchymoses.
Correct response: ecchymoses. Explanation: Blotchy areas of hemorrhage in the skin are ecchymoses and suggest a vascular disorder. Petechiae are small reddish purplish spots (macules) appearing on the skin. Purpura is purplish or reddish-brown discoloration easily visible through the epidermis; it includes petechiae, ecchymoses, and hematomas. A hematoma is a localized collection of blood creating an elevated ecchymosis.
Which of the following would the nurse be least likely to assess in a child with a hematologic disorder? abnormal hemostasis anemia neutropenia fever
Correct response: fever Explanation: Pediatric hematologic alterations usually are characterized by atypical hemostasis, anemia, and/or neutropenia. Fever suggests infection, which may or may not be present with a hematologic disorder.
The nurse is reviewing the chart of a child scheduled for a stem cell transplant. The child will be receiving a syngeneic transplant. The nurse understands that which of the following would be the donor? national registry donor identical twin sibling child himself
Correct response: identical twin Explanation: Syngeneic transplantation involves a genetically identical donor and recipient (i.e., identical twins). Allogeneic transplantation involves the transfer of stem cells from an immune-compatible (histocompatible) donor, usually a sibling, although a national registry allows compatible volunteer donors to be located. Autologous transplantation involves the use of the child's own stem cells.
The nurse is providing care to a child with disseminated intravascular coagulation and is preparing to administer heparin. The parent asks why the heparin is being given. Which response by the nurse would be most appropriate? "Heparin provides a stimulus for clotting factor production." "It helps to counteract the clotting cascader." "It reduces the risk for significant hemorrhage." "Heparin helps to reduce the consumption of platelets."
Correct response: "Heparin helps to reduce the consumption of platelets." Explanation: Heparin reduces platelet consumption, thereby resulting in improved platelet counts. It does not counteract the clotting cascade. It is an anticoagulant and, as such, increases the risk for bleeding and hemorrhage. Heparin does not stimulate clotting factor production.
The child is prescribed liquid ferrous sulfate. The nurse should encourage the child to take which action immediately after each dose to best eliminate possible side effects? Not eat or drink for one hour Remain in an upright position for at least 15 minutes Drink a glass of milk Brush his or her teeth
Correct response: Brush his or her teeth
A nurse is preparing a 7-year-old girl for bone marrow aspiration. Which site should she prepare? Iliac crest Sternum Femur Anterior tibia
Correct response: Iliac crest
A nurse is leading a discussion with a group of new mothers about newborn nutrition and its importance for growth and development. One of the mothers asks, "Doesn't the baby get iron from me before birth?" Which response by the nurse would be most appropriate? "The iron you give him before birth is different from what he needs once he is born." "If the baby didn't use up what you gave him before birth, he excretes it soon after birth." "Because the baby grows rapidly during the first months, he uses up what you gave him." "You give the baby some iron, but it is not enough to sustain him after birth."
Correct response: "Because the baby grows rapidly during the first months, he uses up what you gave him."
A nursing instructor describes what happens to the red blood cell after it disintegrates and how bilirubin is formed. Place the events in the order that the instructor would discuss from first to last. 1conversion to direct bilirubin 2excretion in bile 3break down into indirect bilirubin 4degradation of heme portion 5conversion to protoporphyrin
Correct response: degradation of heme portion conversion to protoporphyrin break down into indirect bilirubin conversion to direct bilirubin excretion in bile Explanation: As the heme portion is degraded, it is converted into protoporphyrin. Protoporphyrin is then further broken down into indirect bilirubin. Indirect bilirubin is fat soluble and cannot be excreted by the kidneys in this state. It is therefore converted by the liver enzyme glucuronyl transferase into direct bilirubin, which is water soluble. This is then excreted in bile.
The nurse is reinforcing teaching with a group of caregivers of children diagnosed with iron-deficiency anemia. One of the caregivers tells the group, "I give my child ferrous sulfate." Which statement made by the caregivers is correct regarding giving ferrous sulfate? "My husband gives our daughter orange juice when she takes her ferrous sulfate, so she gets Vitamin C." "We watch closely for any diarrhea since that usually happens when he takes ferrous sulfate." "When I give my son ferrous sulfate I know he also needs potassium supplements." "I always give the ferrous sulfate with meals."
My husband gives our daughter orange juice when she takes her ferrous sulfate, so she gets Vitamin C." Explanation: When ferrous sulfate is administered, it should be given between meals with juice (preferably orange juice, because vitamin C aids in iron absorption). For best results, iron should not be given with meals. Ferrous sulfate can cause constipation or turn the child's stools black.
The nurse is caring for a child who had a stem cell transplant and is being monitored for engraftment. Which nursing action is priority? Ensure neutropenic precautions are in place. Monitor daily complete blood count (CBC). Remind parents to contact the child's school. Encourage therapeutic play activities.
Correct response: Ensure neutropenic precautions are in place. Explanation: With stem cell transplants, children are at greatest risk for infection and sepsis. The nurse should ensure neutropenic precautions are used to reduce the change of infection. Monitoring laboratory values, reminding the parent to contact the school, and encouraging therapeutic play are important, but preventing infection in the immunocompromised child is a priority.
The nurse is caring for a child with a hematologic disorder. When educating the family about oral corticosteroid administration at home, which education by the nurse is most important? "Corticosteroids can cause a decreased immune system in children." "Some children think the medication can have an unpleasant taste." "You will need to give this medication every day until discontinued." "Once your child is better, you can stop giving the corticosteroid."
Correct response: "You will need to give this medication every day until discontinued." Explanation: Because parents may stop giving corticosteroids when the child appears to be well, it is important for the nurse to educate the family about the importance of continuing medications regardless of how the child appears. The nurse should avoid telling the family the child can stop taking corticosteroids once the child is better because parents may interpret this to mean the medication can be discontinued once the child appears well. Corticosteroids may have an unpleasant taste and can decrease the immune system; however, this is not as important as providing education about continuing the medication.
A nursing instructor is describing childhood hematologic disorders to students. Which would the instructor include as being commonly affected by hematologic disorders? Select all that apply. Leukocytes Erythrocytes Plasma Thrombocytes Whole blood
Correct response: Erythrocytes Leukocytes Thrombocytes Explanation: The formed elements, the erythrocytes, leukocytes, and thrombocytes are the portions of the blood most commonly affected by hematologic disorders in children. Plasma and whole blood are not major sites of hematologic disease.
The nurse is caring for a toddler taking ferrous sulfate for severe iron-deficiency anemia. Which report by the parent is most concerning? "I mix ferrous sulfate with milk in a bottle." "My child's stools are darker than usual." "My child takes ferrous sulfate after meals." "I brush my child's teeth once every day."
Correct response: "I mix ferrous sulfate with milk in a bottle." Explanation: Ferrous sulfate may not be absorbed if taken with milk or tea, and if the parent mixes the medicine with milk in a bottle, there is also concern that if the child does not drink the entire amount of medication. Ferrous sulfate may be taken after meals to prevent gastrointestinal irritation. Dark stools are a common side effect of ferrous sulfate. Parents should be encouraged to brush the child's teeth thoroughly to prevent teeth staining.
The nurse is teaching an in-service program to a group of nurses on the topic of children diagnosed with sickle cell disease. The nurses in the group make the following statements. Which statement is most accurate regarding this condition? "The disease is most often seen in individuals of Asian decent." "If the trait is inherited from both parents the child will have the disease." "The trait or the disease is seen in one generation and skips the next generation." "Males are much more likely to have the disease than females."
Correct response: "If the trait is inherited from both parents the child will have the disease."
A mother asks the nurse why her infant who was born at 34 weeks' gestation is being prescribed ferrous sulfate. Which response by the nurse is most appropriate? "Infants with pyloric stenosis require ferrous sulfate." "Preterm infants are at risk for iron-deficiency anemia." "Ferrous sulfate helps improve red blood cell formation." "Your infant may have been having excessive diarrhea."
Correct response: "Preterm infants are at risk for iron-deficiency anemia." Explanation: Infants born prematurely are at risk for iron-deficiency anemia because iron stores are built during the last few weeks of gestation. Although some infants with pyloric stenosis may require an iron supplement, such as ferrous sulfate, not all infants will. Infants with excessive diarrhea may develop iron-deficiency anemia, and ferrous sulfate helps improve red blood cell formation, but this does not explain why a preterm infant is being prescribed an iron supplement.
A couple is expecting a child. The fetus undergoes genetic testing and the couple discover the fetus has sickle cell disease. The couple ask the nurse how most commonly happens. Which statement is accurate for the nurse to provide? "Sickle cell disease is passed to a fetus when both parents have the gene." "Sickle cell diseas can be passed to the fetus in many ways. We will know more at birth." "Sickle cell disease occurs from a random genetic mutation." "Sickle cell disease is passed to a fetus when one of the parents has the gene."
Correct response: "Sickle cell disease is passed to a fetus when both parents have the gene."
A 5-year-old girl is diagnosed with iron-deficiency anemia and is to receive iron supplements. The child has difficulty swallowing tablets, so a liquid formulation is prescribed. After teaching the parents about administering the iron supplement, which statement by the parents indicates the need for additional teaching? "We need to measure the liquid carefully so that we give her the correct amount." "We will place the liquid in the front of her gums, just below her teeth." "We'll try to get her to drink lots of fluids throughout the day." "She needs to eat foods that are high in fiber so she doesn't get constipated."
Correct response: "We will place the liquid in the front of her gums, just below her teeth."
A nurse is conducting a physical examination of a 5-year-old with suspected iron-deficiency anemia. How would the nurse evaluate for changes in neurologic functioning? "Do you have any bruises on your feet or shins?" "Let me see the palms of your hands and soles of your feet." "Will you show me how you walk across the room?" "Open your mouth so I can look inside your cheeks and lips."
Correct response: "Will you show me how you walk across the room?" Explanation: Neurologic effects of iron deficiency may be demonstrated when the child's ability to sit, stand, and walk are impaired. Inspecting the mouth, looking for bruises, and checking the hands and feet provide information about signs of petechiae, purpura, or pallor.
A toddler who is beginning to walk has fallen and hit his head on the corner of a low table. The caregiver has been unable to stop the bleeding and brings the child to the pediatric clinic. The nurse is gathering data during the admission process and notes several bruises and swollen joints. A diagnosis of hemophilia is confirmed. This child most likely has a deficiency of which blood factor? Factor XIII Factor V Factor X Factor VIII
Correct response: Factor VIII Explanation: The most common types of hemophilia are factor VIII deficiency and factor IX deficiency, which are inherited as sex-linked recessive traits, with transmission to male offspring by carrier females.
When evaluating the hemogram of an 8-month-old infant, the nurse would identify which type of hemoglobin as being the predominant type? Hemoglobin F Hemoglobin A Hemoglobin A2 Hemoglobin S
Correct response: Hemoglobin A Explanation: Three types of normal hemoglobin are present at any given time in the blood: A, F, and A2. By 6 months of age, hemoglobin A is the predominant type. Hemoglobin S is associated with sickle cell disease.
When assessing a child for a possible hematologic disorder, which would the nurse need to keep in mind as most important? Sequelae are rare with chronic problems. A child's nutritional status is key. Demographic data is of little relevance. Multiple body sites can be affected.
Correct response: Multiple body sites can be affected. Explanation: The nurse needs to keep in mind that hematologic alterations can affect multiple body sites, so assessment needs to address all body systems. A child's nutritional status may be helpful in assessing certain hematologic disorders such as iron deficiency anemia, but this information is not the most important to remember. Sequelae commonly occur with hematologic alterations, especially chronic conditions such as hemophilia or sickle cell disease. The child's demographic data are important, because some hematologic diagnoses are more commonly associated with a certain age group, sex, race, or geographic location.
A child diagnosed with hemophilia presents with warm, swollen, painful joints. Which action will the nurse take first? Notify the client's primary health care provider Document the presence of hemarthrosis in the client's chart Assess the client's urine and stool for blood Prepare to administer factor replacement medication
Correct response: Prepare to administer factor replacement medication Explanation: Many clients with hemophilia have repeated episodes of hemarthrosis or bleeding into the joints, and develop functional impairment of the joints, despite careful treatment. To assist in limiting impairment, the nurse would prepare to administer factor replacement medications, such as plasma, recombinant clotting factor VIII, or a clotting promotor medication. The nurse would document the finding, notify the health care provider, and assess the client for additional symptoms after limiting the amount of blood loss.
The mother of a 5-year-old girl brings the child to the clinic for an evaluation. The mother tells the nurse, "She seems to be so tired and irritable lately. And she looks so pale." Further assessment reveals pale conjunctiva and oral mucous membranes. The nurse suspects iron-deficiency anemia. Which additional finding would help provide additional evidence for this suspicion? Bradycardia Negative splenomegaly Oxygen saturation: 99% Spooned nails
Correct response: Spooned nails Explanation: Spooning or concave shape of the nails suggests iron-deficiency anemia. Other findings would include decreased oxygen saturation levels, tachycardia, and possible splenomegaly.
The nurse is caring for a child admitted to the hospital for an open fracture of the femur following a motor vehicle accident. The nurse notes the following lab values: white blood cells 10,000/mm3, hemoglobin 7.9 g/dl (79 g/L), hematocrit 28%, platelets 151,000/mm3. Which nursing action is priority? Transfuse 1 unit of packed red blood cells. Administer antibiotics intravenously stat. Ask the child to rate pain on a scale 0 to 10. Provide the family with preoperative instructions.
Correct response: Transfuse 1 unit of packed red blood cells. Explanation: In a situation where the child exhibits signs of anemia related to acute hemorrhage, the nurse should anticipate administering a transfusion of packed red blood cells to improve oxygenation and circulation. Administration of antibiotics, pain assessment, and family education can be performed after the beginning the blood transfusion.
The nurse will select which meal as the best choice for a child with iron-deficiency anemia? chicken breast, French fries, and sweetened tea peanut butter sandwich, cheese stick, and applesauce cheeseburger, broccoli, and fresh strawberries two slices of pepperoni pizza and a glass of skim milk
Correct response: cheeseburger, broccoli, and fresh strawberries Explanation: Children with iron-deficiency anemia require diets rich in iron and vitamin C (vitamin C enhances iron absorption). Meats are excellent sources of iron. Broccoli is a good source of iron, and strawberries are a good source of vitamin C. To help the body absorb the most iron from the meal, tea and foods rich in calcium (such as milk and cheese) should be avoided.
The nurse develops a meal plan for a child with iron-deficiency anemia. Which meal would the nurse teach the parent has the highest amount of iron? chicken, corn, brown rice, and oranges red meat, eggs, oatmeal, and dried fruit pork, broccoli, white rice, and strawberries tuna salad with eggs, whole wheat crackers, and blueberries
Correct response: red meat, eggs, oatmeal, and dried fruit Explanation: Iron-deficiency anemia occurs when the blood does not have enough iron to produce hemoglobin. The anemia can be corrected via iron supplementation, nutrition, and even blood transfusion if the anemia is severe. Foods that have the highest sources of iron include red meat, tuna, eggs, tofu, enriched grains, dried beans and peas, dried fruits, green leafy vegetables and iron-fortified breakfast cereals. The nurse should teach the meal containing red meat, eggs, oatmeal, and dried fruit has the highest amount of iron. Chicken has less iron than red meat, and corn has only a small amount. All the fruits listed have iron, but when dried, the iron levels increase. Pork has a limited amount of iron, and white rice contains almost no iron. Brown rice and whole grains
The nurse is caring for a 12-year-old boy with idiopathic thrombocytopenia. The nurse is providing discharge instructions about home care and safety recommendations to the boy and his parents. Which response indicates a need for further teaching? "Our son cannot take any antihistamines." "Swimming would be a great activity." "We should avoid aspirin and drugs like ibuprofen." "He can resume participation in football in 2 weeks."
Correct response: "He can resume participation in football in 2 weeks." Explanation: The nurse must emphasize to the parents that they need to prevent trauma to their son by avoiding activities that may cause injury. Participation in contact sports like football is not recommended. Aspirin, nonsteroidal anti-inflammatory drugs, and antihistamines should be avoided because they could precipitate anemia. Swimming, a noncontact sport, is an appropriate choice.
The parents of a 6-year-old child with idiopathic thrombocytopenic purpura (ITP) ask the nurse conducting an assessment of the child what causes the disease. What is the nurse's best response? "ITP is a serious bleeding disorder characterized by a decreased, absent, or dysfunctional procoagulant factor." "ITP is primarily an autoimmune disease in which the immune system attacks and destroys the body's own platelets, for an unknown reason." "ITP is characterized by the loss of surface area on the red blood cell membrane." "ITP occurs when the body's iron stores are depleted due to rapid physical growth, inadequate iron intake, inadequate iron absorption, or loss of blood."
Correct response: "ITP is primarily an autoimmune disease in which the immune system attacks and destroys the body's own platelets, for an unknown reason."
The nurse is caring for a child recently diagnosed with glucose-6-phosphate dehydrogenase (G-6-PD) deficiency. The nurse is teaching the parents about triggers that may result in oxidative stress. Which response indicates a need for further teaching? "I doubt he will ever eat fava beans, but they could trigger hemolysis." "My son can never take penicillin for an infection." "He must avoid exposure to naphthalene, an agent found in mothballs." "He must never take methylene blue for a urinary tract infection."
Correct response: "My son can never take penicillin for an infection." Explanation: The nurse should emphasize that penicillin is not a known trigger that may result in oxidative stress and hemolysis. Fava beans, naphthalene, and methylene blue can trigger oxidative stress.
The nurse is preparing a child for discharge following a sickle cell crisis. Which statement by the mother indicates a need for further teaching? "I put her legs up on pillows when her knees start to hurt." "She has been down, but playing in soccer camp will cheer her up." "She loves popsicles, so I'll let her have them as a snack or for dessert." "I bought the medication to give to her when she says she is in pain."
Correct response: "She has been down, but playing in soccer camp will cheer her up."
A nurse is conducting a class to a group of parents on sickle cell anemia. Which statement by a parent indicates teaching has been effective? "The sickle shape of red blood cells decreases oxygen to tissues." "Fluid restriction is necessary to control sickle cell anemia." "This is a hereditary disease that is transmitted by one affected gene." "Sickle cell anemia is common in people of Asian descent."
Correct response: "The sickle shape of red blood cells decreases oxygen to tissues." Explanation: The sickle shape of the red blood cells impedes the flow of blood through the vessels, thus causing hypoxia to the tissues. Sickle cell anemia is a hereditary disease but it is autosomal recessive, meaning it requires two genes in order for the disease to be transmitted. Sickle cell anemia is common in people of African, Mediterranean, and Indian descent. Hydration is important to controlling sickle cell anemia. Dehydration is a trigger for sickle cell crisis.
The nurse is educating parents of a child with acute renal disease about expected outcomes for erythropoietin treatment. Which statement by the parents indicates that further education is needed? "We may notice an improved activity tolerance." "This will cause increased urine production." "Erythropoietin works by stimulating bone marrow." "Our child's red blood cells will increase."
Correct response: "This will cause increased urine production." Explanation: Renal failure can cause decreased production of erythropoietin, which results in decreased production of red blood cells. Erythropoietin is a hormone released by the kidneys that works by stimulating bone marrow to produce red blood cells, which can improve activity tolerance. Erythropoietin will not improve the renal disease or increase urine production.
The nurse is caring for a 13-year-old girl with von Willebrand disease. After teaching the adolescent and her parents about this disorder and care, which response by the parents indicates a need for additional teaching? "We should administer desmopressin as often as needed." "We should be aware that she may suffer from menorrhagia." "We need to administer Stimate (desmopressin) prior to dental work." "We understand that she may have frequent nosebleeds."
Correct response: "We should administer desmopressin as often as needed." Explanation: The parents need to know that desmopressin spray Stimate is used for controlling bleeding; the other brands are used for homeostasis and enuresis. Additionally, Stimate should only be used for 3 days in a row as lessening of the response (tachyphylaxis) occurs with frequent use. Stimate should be used before dental work. Menorrhagia and nosebleeds may occur.
The caregiver of a child with sickle cell disease asks the nurse how much fluid her child should have each day after the child goes home. In response to the caregiver's question, the nurse would explain that for the child with sickle cell disease, it is best that the child have: 2,500 to 3,200 ml of fluid per day. 1,500 to 2,000 ml of fluid per day. 1,000 to 1,200 ml of fluid per day. 300 to 800 ml of fluid per day.
Correct response: 1,500 to 2,000 ml of fluid per day. Explanation: Prevention of crises is the goal between episodes. Adequate hydration is vital; fluid intake of 1,500 to 2,000 ml daily is desirable for a child weighing 20 kg and should be increased to 3,000 ml during the crisis.
The nurse is reviewing the results of a clotting study for a healthy 6-year-old. What would the nurse document as a normal prothrombin finding? 16.0 to 18.0 seconds 21.0 to 35.0 seconds 11.0 to 13.0 seconds 6.0 to 9.0 seconds
Correct response: 11.0 to 13.0 seconds Explanation: The nurse would identify a prothrombin time of 11.0 to 13.0 seconds as normal for a healthy child. A result of 21.0 to 35.0 seconds would be the expected range for partial thromboplastin time and activated partial thromboplastin time. Findings of 6.0 to 9.0 seconds and 16.0 to 18.0 seconds are outside the normal range.
The nurse is working with a child who is in sickle cell crisis. Treatment and nursing care for this child include which actions? Select all that apply. Maintaining fluid intake Administering analgesics Promoting exercise and activity Administering oxygen Administering platelets
Correct response: Administering oxygen Administering analgesics Maintaining fluid intake Explanation: A vaso-occlusive crisis occurs when sickle-shaped cells are clumped together in a joint or organ. This causes severe pain and hypoxia to the tissues. The management for a vaso-occlusive crisis is to provide adequate pain relief, oxygen to correct the hypoxemia, and increased IV fluids to thin out viscosity and allow the cells to flow in the vascular system. Platelet administration is not indicated as part of the treatment. Children and adults experiencing a sickle cell crisis experience a high degree of pain, so exercise and activity is postponed until the crisis is over. Activity is encouraged when the child is not in crisis as it promotes growth and a positive self-image.
A 9-year-old boy will be undergoing a hematopoietic stem cell transplantation, with donor cells being provided by his 12-year-old sister. The nurse recognizes that this type of transplantation is: Autologous Syngeneic Allogeneic Heterologous SUBMIT ANSWER
Correct response: Allogeneic Explanation: Stem cell transplantation can be allogeneic, syngeneic, or autologous. Allogeneic transplantation is the transfer of stem cells from an immune-compatible (histocompatible) donor, usually a sibling, or from a national cord blood bank or national volunteer donor registry. Syngeneic transplantation (rare) involves a donor and recipient who are genetically identical (are identical twins). Autologous transplantation involves use of the child's own stem cells removed from cord blood banked at the time of the child's birth. Heterologous is not a type of stem cell transplantation.
The nurse is caring for clients receiving anticoagulant therapy for embolism prevention. Which factors are a part of the intrinsic pathway for coagulation? Select all that apply. Hageman factor Stable factor Stuart factor Christmas factor Antihemophilic factor
Correct response: Antihemophilic factor Christmas factor Hageman factor Explanation: Effective blood coagulation depends on a complex series of events including a combination of blood and tissue factors released from the plasma (the intrinsic pathway) and from injured tissue (the extrinsic pathway). The plasma-released factors are factors VIII, IX, and XII. Factors released from injured tissues are a tissue factor (an incomplete thromboplastin or factor III), plus factors VII and X.
The nurse is caring for a 10-year-old girl with iron toxicity. What would the nurse expect the physician to order? Succimer Deferasirox Dimercaprol Edetate calcium disodium
Correct response: Deferasirox Explanation: Deferasirox is indicated for iron toxicity. It binds with iron, which is removed via the kidneys. Dimercaprol is indicated for blood lead levels greater than 45 mcg/dl. It removes lead from soft tissues and bone, allowing for its excretion via the renal system. Edetate calcium disodium is indicated for blood lead levels greater than 45 mcg/dl. The medication removes lead from soft tissues and bone, allowing for its excretion via the renal system. Succimer is indicated for blood lead levels greater than 45 mcg/dl; it removes lead from soft tissues and bone, allowing for its excretion via the renal system.
A client with severe chronic anemia is receiving ongoing transfusion therapy. The nurse frequently assesses the client for what major complication of this therapy? Development of toxic iron overload Development of fibrin clots Chronic idiopathic thrombocytic purpura Vaso-occlusive crisis
Correct response: Development of toxic iron overload Explanation: The major complication of an ongoing transfusion therapy program is the development of toxic iron overload, which leads to pathologic changes in body systems, including the hepatic, endocrine, and cardiac systems. If too much iron accumulates, chelation therapy would be needed. A vaso-occlusive crisis develops because of the sickled cells in sickle cell disease. ITP is associated with a low platelet count, causing bleeding. Transfusion therapy will not cause fibrin clots.
A nurse caring for an 8-year-old with a bleeding disorder documents the following nursing diagnosis: ineffective tissue perfusion related to intravascular thrombosis and hemorrhage. This diagnosis is most appropriate for a client with: Hemophilia von Willebrand disease Disseminated intravascular coagulation Iron-deficiency anemia
Correct response: Disseminated intravascular coagulation Explanation: Disseminated intravascular coagulation (DIC) is an acquired coagulopathy that, paradoxically, is characterized by both thrombosis and hemorrhage. The goal is for the child to maintain adequate tissue perfusion of all body systems affected by DIC and regain adequate laboratory values for hemostasis. Hemophilia and von Willebrand disorders are genetic and symptoms are caused by a deficiency in a factor needed for clotting. Iron-deficiency anemia occurs when there is not enough iron for adequate hemoglobin capacity in the red blood cells.
Assessment of a 6-year-old child reveals a purpural rash on the buttocks and upper thighs that had become hemorrhagic before starting to fade and leaving brown macular spots. The child also has gross hematuria. A diagnosis of Henoch-Schonlein syndrome is made. When reviewing the child's laboratory test results, which would the nurse anticipate? Select all that apply. Neutropenia Elevated white blood cell count Elevated platelet count Elevated eosinophil count Reduced sedimentation rate
Correct response: Elevated white blood cell count Elevated eosinophil count Explanation: Laboratory studies show a normal platelet count and elevated sedimentation rate, elevated white blood cell count, and elevated eosinophil count.
A 3-year-old child is hospitalized with a diagnosis of sickle cell anemia and is experiencing a pain crisis. Using the FACES scale, the nurse assesses the child's pain to be a 10 on a scale of 1 to 10. The child is receiving intravenous fluids and oxygen at 2 L/min via nasal cannula. The parent is at the bedside holding the child's hand and has a concerned look. What is the nurse's priority in caring for the child? Ask the parent if he or she has questions about the plan of care. Provide diversional activities for the child. Implement strategies to address the child's pain. Contact the health care provider to meet with the parent.
Correct response: Implement strategies to address the child's pain. Explanation: In this case, the nurse's priority is to address the child's pain. The child is already receiving IV fluids and oxygen. That, in combination with analgesia, will assist in resolving the crisis. Asking the parent if he or she has questions, asking the health care provider to meet with the parent, and providing distraction for the child are all appropriate interventions, but the priority is to address the child's pain.
A nurse is teaching the parents of a child with sickle cell disease about factors that predispose the child to a sickle cell crisis. The nurse determines that the teaching was successful when the parents identify what as a factor? Pallor Infection Fluid overload Respiratory distress
Correct response: Infection Explanation: Factors that may precipitate a sickle cell crisis include: fever, infection, dehydration, hot or humid environment, cold air or water temperature, high altitude, or excessive physical activity. Respiratory distress and pallor are general signs and symptoms of a sickle cell crisis.
The nurse is caring for a child who has been admitted for a sickle cell crisis. What would the nurse do first to provide adequate pain management? Administer a nonsteroidal anti-inflammatory drug (NSAID) as ordered. Initiate pain assessment with a standardized pain scale. Use guided imagery and therapeutic touch. Administer meperidine as ordered.
Correct response: Initiate pain assessment with a standardized pain scale. Explanation: The nurse should first initiate pain assessment with a standardized pain scale upon admission and provide frequent evaluations of pain. Administering NSAIDs or meperidine and the use of nonpharmacologic pain management techniques are all appropriate. However, the first action is to assess the child's pain to provide a baseline for future comparison.
The nurse is caring for a child who has been admitted for a sickle cell crisis. What would the nurse do first to provide adequate pain management? Administer meperidine as ordered. Initiate pain assessment with a standardized pain scale. Administer a nonsteroidal anti-inflammatory drug (NSAID) as ordered. Use guided imagery and therapeutic touch.
Correct response: Initiate pain assessment with a standardized pain scale. Explanation: The nurse should first initiate pain assessment with a standardized pain scale upon admission and provide frequent evaluations of pain. Administering NSAIDs or meperidine and the use of nonpharmacologic pain management techniques are all appropriate. However, the first action is to assess the child's pain to provide a baseline for future comparison.
A nurse is providing care to a child with idiopathic thrombocytopenic purpura with a platelet count of 18,000/mm3 μl (18,000 x 109/L). Which medication would the nurse most likely expect to be ordered? Folic acid Dimercaprol Deferoxamine Intravenous immune globulin
Correct response: Intravenous immune globulin Explanation: Intravenous immune globulin would be used to treat idiopathic thrombocytopenic purpura. Folic acid is used to treat folic acid deficiency anemia. Dimercaprol is used to remove lead from the soft tissue and bone to allow for excretion by the kidneys. Deferoxamine is used to treat iron toxicity.
The nurse treating clients with hemophilia knows that if bleeding is not treated effectively, which body part is at greatest risk for the development of chronic, disabling disease? Liver Heart Kidneys Joints
Correct response: Joints Explanation: Regardless of the type of hemophilia, if bleeding is not treated effectively, target joints are particularly at risk for deterioration and the development of chronic, disabling hemophilic arthropathy (joint disease). Major bleeds to the joints will limit the range of motion in the joint and the function of the joint. Bleeding can occur in any body organ but the kidneys, liver, and heart are muscles and do not bear weight or have range of motion.
A 6-year-old boy has a rash on his buttocks, posterior thighs, and the extensor surface of his arms and legs. His joints are tender and swollen. The healthcare provider diagnoses him with Henoch-Schönlein syndrome. The nurse should anticipate what laboratory results? Elevated platelet count Decreased white blood cell count Normal platelet count Decreased platelet count
Correct response: Normal platelet count Explanation: In Henoch-Schönlein syndrome, laboratory studies show a normal platelet count. Sedimentation rate, WBC count, and eosinophil count are elevated.
A 5-year-old boy is diagnosed with congenital aplastic anemia. Which symptoms should be considered when developing the plan of care? Select all that apply. Pallor Fatigue Cyanosis Easy bruising Bradypnea Bradycardia
Correct response: Pallor Fatigue Easy bruising Cyanosis Explanation: When symptoms begin, a child appears pale, fatigues easily, and has anorexia from the lowered RBC count and tissue hypoxia. Because of reduced platelet formation (thrombocytopenia), the child bruises easily or develops petechiae (pinpoint, macular, purplish-red spots caused by intradermal or submucous hemorrhage). A child may have excessive nosebleeds or gastrointestinal bleeding. As a result of a decrease in WBCs (neutropenia) a child may contract an increased number of infections and respond poorly to antibiotic therapy. Observe closely for signs of cardiac decompensation such as tachycardia (not bradycardia), tachypnea (not bradypnea), shortness of breath, or cyanosis from the long-term increased workload of all these effects on the heart.
When developing the postoperative plan of care for a child with sickle cell anemia who has undergone a splenectomy, which would the nurse identify as the priority? Impaired skin integrity Risk for infection Risk for delayed growth and development Deficient fluid volume
Correct response: Risk for infection Explanation: Removal of the spleen places the child at significant risk for infection. Although the child's skin integrity is disrupted due to the surgery, this is not the priority nursing diagnosis. Loss of fluids occurs during surgery and adequate hydration is important to prevent a sickle cell crisis, but this diagnosis is not the priority in the postoperative period. Although the child is at risk for delayed growth and development, the priority postoperatively is to prevent infection.
The nurse begins administering blood to a pediatric client with hemoglobinopathy. During the transfusion, the nurse notes: a rash on the child's chest, face, and extremities; temperature 101.8°F (38.8°C); respirations 34 breaths/minute; and the child reports nausea. Which actions will the nurse take? Select all that apply. Assess the child's vital signs. Administer only IV normal saline (NS). Stop the blood transfusion. Monitor the child's urine output. Call the child's primary health care provider.
Correct response: Stop the blood transfusion. Administer only IV normal saline (NS). Assess the child's vital signs. Monitor the child's urine output. Call the child's primary health care provider. Explanation: Based on the findings, the nurse would suspect an adverse reaction to the blood transfusion. The nurse would immediately stop the transfusion, administer NS IV to the client, send the blood and tubing to the laboratory, and notify the health care provider. The nurse would continue to monitor the child by assessing vital signs and monitor urine output as a decrease in kidney function could indicate acute kidney failure.
The nurse is collecting data from the caregivers of a child brought to the clinic setting. The parents tell the nurse that the child's skin seems to be an unusual color. The nurse notes that the child's skin appears bronze-colored and jaundiced. This observation alerts the nurse to the likelihood that this child has which disorder? Kawasaki disease Hemophilia Sickle cell disease Thalassemia
Correct response: Thalassemia Explanation: In the child with thalassemia the skin may appear bronze-colored or jaundiced. The child with hemophilia may have bruised areas on the skin. The skin color in children with sickle cell disease may be pale in color, and with Kawasaki disease the child may have a rash on the trunk and extremities.
A child with iron-deficiency anemia is prescribed ferrous fumarate, 3 mg/kg/day in two divided doses. What does this prescription indicate to the nurse? The child has severe iron deficiency. The child has mild to moderate iron deficiency. The child requires a prophylactic dose of iron. The child is being prepared for packed red blood cell administration.
Correct response: The child has mild to moderate iron deficiency. Explanation: The recommended dosage for iron supplementation for a child with mild to moderate iron deficiency is 3 mg/kg/day of ferrous fumarate. A prophylactic dose is 1 to 2 mg/kg/day of up to a maximum of 15 mg elemental iron per day. Severe iron deficiency requires 4 to 6 mg/kg/day of elemental iron in three divided doses. Transfusion of packed red blood cells is reserved for the most severe cases. Prior to the transfusion of packed red blood cells, the nurse would follow specific blood bank guidelines.
In caring for a child with sickle cell disease, the highest priority goal is: The child's fluid intake will improve. the caregiver's anxiety will be reduced. the family will verbalize understanding of the disease crisis. the child's skin integrity will be maintained.
Correct response: The child's fluid intake will improve. Explanation: The highest priority goals for this child are maintaining comfort and relieving pain. The child is prone to dehydration because of the kidneys' inability to concentrate urine, so increasing fluid intake is the next highest priority. Other goals include improving physical mobility, maintaining skin integrity, reducing the caregiver's anxiety, and increasing the caregiver's knowledge about the causes of crisis episodes — but these goals are not the highest priority.
A 13-year-old, diagnosed with beta-thalassemia major is seen in the pediatric clinic. The nurse completes an assessment and notes that the client is below the 10th percentile in height for age. What assumption can the nurse make based on this information? The client is due for a growth spurt and should catch up in height. Further assessment of the nutritional status is warranted. This finding is a common manifestation of the client's diagnosis. The client should be referred for further evaluation.
Correct response: This finding is a common manifestation of the client's diagnosis. Explanation: Short stature is a common manifestation of thalassemia major. Because short stature is a common manifestation of the disorder, a nutritional assessment is not warranted. While growth spurts can occur at this age, the client will probably not catch up, because the short stature is due to the thalassemia.
A 14-year-old girl who is a vegetarian has recently developed anemia. Blood smear results show large, fragile, immature erythrocytes. She claims to take an iron supplement regularly and is surprised to learn that she is anemic, as she is otherwise healthy. The nurse recognizes that the likely cause of this type of anemia is: Vitamin B12 deficiency. iron deficiency. sickle-cell disorder. acute blood loss.
Correct response: Vitamin B12 deficiency. Explanation: Vitamin B12 is necessary for the maturation of RBCs. Pernicious anemia results from deficiency or inability to use the vitamin, resulting in RBCs that appear abnormally large and are immature megaloblasts (nucleated immature red cells). Thus, pernicious anemia is one of the megaloblastic anemias. In children, the cause is more often lack of ingestion of vitamin B12 rather than poor absorption. Adolescents may be deficient in vitamin B12 if they are ingesting a long-term, poorly formulated vegetarian diet as the vitamin is found primarily in foods of animal origin.
A nurse is teaching parents of a child with iron-deficiency anemia how to administer ferrous sulfate. The nurse determines that the teaching was successful when they make which statements? Select all that apply. "He has to make sure that he brushes his teeth well." "We'll have him take the liquid medicine with some orange or pineapple juice." "We can mix the liquid form of the drug with milk." "He might get constipated, so we'll try to get him to eat some more fiber." We'll give him the medicine before he eats his meals."
Correct response: We'll give him the medicine before he eats his meals." "He has to make sure that he brushes his teeth well." "He might get constipated, so we'll try to get him to eat some more fiber." "We'll have him take the liquid medicine with some orange or pineapple juice." Explanation: Ferrous sulfate should be given on an empty stomach with water to enhance absorption. If the child develops gastrointestinal distress, then it can be given after meals. Iron can stain the teeth; therefore, thorough brushing is needed. Ferrous sulfate causes constipation, so the parents should encourage high-fiber foods to reduce the risk. Iron is best absorbed in an acidic environment, so giving the drug with a citrus juice is appropriate. The drug should not be given with milk, eggs, coffee, or tea. The liquid form should be mixed with water or juice to mask the taste and prevent staining of the teeth.
A nurse is providing care for a child with disseminated intravascular coagulation (DIC). What would alert the nurse to possible neurologic compromise? Petechiae Widely fluctuating blood pressure Hematuria Equal pupillary response
Correct response: Widely fluctuating blood pressure Explanation: A key aspect of the nurse's role is to assess the child for signs and symptoms of impaired tissue perfusion in the various body systems that may be affected by DIC. Unstable or abnormal blood pressure (such as wide BP fluctuations) or unequal pupil size may suggest neurologic compromise. Hematuria would suggest renal compromise. Petechiae would be indicative of bleeding into the skin.
Which lab values will the nurse expect to observe in a child with a hemolytic blood transfusion reaction? Select all that apply. white blood cells 20,000/mm3 prothrombin time 15 seconds bilirubin 10 mg/dl (171 µmol/L) hemoglobin 8 mg/dL (80 g/L) red blood cells 3 million/mm3
Correct response: bilirubin 10 mg/dl (171 µmol/L) hemoglobin 8 mg/dL (80 g/L) red blood cells 3 million/mm3 Explanation: A child with hemolysis of red blood cells (RBCs) will exhibit decreased red blood cells, increased bilirubin related to hemolyzed RBCs, and a decreased hemoglobin. An elevated white blood cell count indicates infection or other hematologic disorder. An increased prothrombin time (PT) indicates difficulty forming a clot.
When caring for a 7-year-old client diagnosed with sickle cell anemia, which clinical manifestation will the nurse report to the health care provider first? facial droop dactylitis of the hands and feet hemoglobin level of 10 g/dl (100 g/l) respiratory rate 23 breaths/min
Correct response: facial droop Explanation: The nurse would first report any signs or symptoms which can indicate a life-threatening situation is occurring. A facial droop is a potential sign of a stroke or silent cerebral ischemia, which is life-threatening and requires emergent care. Sickle cell disease causes chronic anemia, with a hemoglobin level of 6 to 9 g/dl (60 to 90 g/l) with a normal level in a child at 11 to 13 g/dl (110 to 130 g/l). The chronic anemia causes the child to have a poor appetite and severe, acute abdominal pain (caused by sludging, which leads to enlargement of the spleen), swelling of the hands and feet (dactylitis), and increased respirations.
The nurse is providing care for a 13-year-old child diagnosed with iron-deficiency anemia. The client's current hemoglobin level is 11 g/dL (110 g/L). Which intervention will the nurse anticipate including in the client's care? packed red blood cell transfusions increasing the daily intake of fresh fruits and vegetables providing a high dose of intravenous immunoglobulin weekly giving ferrous sulfate with orange juice between meals
Correct response: giving ferrous sulfate with orange juice between meals Explanation: Treatment for iron-deficiency anemia is the administration of ferrous sulfate for a 13-year-old client with a hemoglobin at 11 g/dL (110 g/L). It should be administered with orange juice, because vitamin C helps absorb iron. It should not be taken with milk. It can cause teeth staining in children and should be given with a straw. Intravenous immunoglobulin would be administered for idiopathic thrombocytopenic purpura. The client's hemoglobin level is not severe enough to warrant blood transfusions at this time. There is also no indication the child is symptomatic. Anemia is generally diagnosed for a hemoglobin less than 12 g/dL (120 g/L) in children 12 to 14 years of age. The normal level for children 12 to 18 years of age is 14 g/dL (140 g/L). While increasing fresh fruits and vegetables is good for the client's overall health, this client needs foods specifically high in iron. These include broccoli, bananas, tomatoes, spinach, liver, nuts, dates, legumes, beef, eggs, and pork.
The nurse is assessing a child in the pediatric intensive care unit. Which assessment finding(s) warrants immediate action? Select all that apply. clubbing of the nail beds painful joints petechiae increased D-dimer assay persistent oozing from venipuncture site
Correct response: increased D-dimer assay petechiae persistent oozing from venipuncture site Explanation: In disseminated intravascular coagulation (DIC), thrombin is generated, fibrin is deposited into the circulation, and the platelets are consumed. Diagnostic testing is positive for the disorder if there is an increased D-dimer assay, a decreased antithrombin III, increased fibrinogen/fibrin degradation products, and an increased fibrinopeptide A level. Assessment findings for DIC include signs of bleeding such as petechiae or purpura, blood in the urine or stool, or persistent oozing from venipuncture. Painful joints and clubbing of the nail bed are not assessment findings consistently associated with DIC and are not assessment findings that warrant immediate action but do warranted further follow up.
A child diagnosed with idiopathic thrombocytopenic purpura (ITP) is scheduled to receive an infusion of intravenous immunoglobulin (IVIG) due to low platelet counts. Prior to the infusion, the nurse administers acetaminophen to the child. The nurse would explain to the parents that acetaminophen is administered to obtain which expected outcome? to relax the child during drug infusion to reduce any pain at infusion site to decrease fever produced from the medication to prevent chills from developing
Correct response: to decrease fever produced from the medication Explanation: For the child with ITP, the administration of IVIG is warranted, if the platelet counts decrease below 10,000 mm3 (10 ×109/L). IVIG produces large amounts of antibodies and will improve the platelet count. IVIG is considered a blood product. During administration, antipyretics may be given to reduce fever and pain from the flulike symptoms that can develop. Antihistamines are given to prevent or reduce chills. The nurse would monitor fever, vital signs, and any other adverse reactions that could occur from this medication or any blood product.
A nurse is describing the process of hemostasis to the parents of a child with a bleeding disorder. Which of the following would the nurse describe as the first major event? vasoconstrictive response activation of platelets formation of fibrin mesh release of fibrin degradation products
Correct response: vasoconstrictive response Explanation: Hemostasis comprises four major events that occur in a set order following loss of vascular integrity: (1) injury to a blood vessel evokes a vasoconstrictive response that slows blood loss from the damaged vessel; (2) platelets become activated by thrombin and aggregate, leading to the formation of a platelet plug at the site of injury; (3) a fibrin mesh (called a clot) forms and entraps the plug, ensuring the stability of the initially loose platelet plug; (4) once bleeding is controlled, plasmin degrades and dissolves the clot and releases fibrin degradation products. This final step enables normal blood flow to resume following tissue repair.
What nursing action should the nurse take when caring for a child with aplastic anemia? provide toys that do not have sharp corners or edges encourage visits from friends and family assess the child's blood pressure every hour assure the child is offered a low-fiber diet
Correct response: • provide toys that do not have sharp corners or edges Explanation: For a child with aplastic anemia, safety is of the utmost concern, with injury prevention essential to prevent hemorrhage. Toys and games with sharp edges/corners may injure the child during play. The low level of platelets would cause bleeding. High-fiber foods would be offered to prevent anal fissures associated with constipation. The child's blood pressure would not be assessed every hour because the inflation of the cuff would cause bruising/injury. Visitors would be limited to avoid exposing the child to visitors who are sick or ill.
