CH 48: Endocrine-Peds
A 2-year-old client and the parents are at the office for a follow-up visit. The client has had excessive hormone levels in the recent blood work, and the parents question why this was not found sooner. How should the nurse respond? a."Have there been signs and symptoms that you should have reported to the doctor?" b."Endocrine disorders are hard to detect and you are lucky that we have found it when we did." c."It takes time to determine the level of functioning of endocrine glands." d."As endocrine functions become more stable throughout childhood, alterations become more apparent."
"As endocrine functions become more stable throughout childhood, alterations become more apparent." Rational:The endocrine glands are all present at birth; however, endocrine functions are immature. As these functions mature and become stabilized during the childhood years, alterations in endocrine function become more apparent. Thus, endocrine disorders may arise at any time during childhood development. The other statements would not be appropriate and address the parents concern.
During a visit to the clinic, the adolescent client with hypothyroidism tells the nurse that she takes her levothyroxine "whenever I think about it...sometimes I miss a dose, but not very often." What is the best response by the nurse? a."If you forget a dose you can double up the next day. We just want your thyroid level to be maintained since you don't produce enough thyroid hormone." b."As long as you are missing multiple doses it should be fine. Just as long as you take the levothyroxine at some point each day." c."Maybe you could do something to remind yourself to take the medication on a daily basis." d."I know it's hard to remember medicines, but it is really important for you to take it before breakfast each day to control your hypothyroidism."
"I know it's hard to remember medicines, but it is really important for you to take it before breakfast each day to control your hypothyroidism." Rationale: Levothyroxine is a thyroid hormone replacement used to treat hypothyroidism. It is important to maintain a consistent thyroid hormone level by taking the medication at the same time each day (preferably 30 minutes prior to breakfast for best absorption). Toxicity can occur if the dose is doubled. Suggesting the client "do something" to remember does not highlight the importance of taking it correctly.
A school-age child is seen in the family clinic. The parents ask the nurse if their child should start taking growth hormones to help the child grow because the parents are short. What is the best response by the nurse? a."Will your child be able to swallow oral pills every day?" b."Growth hormones work only if the child has short bones." c."How tall would you like your child to be?" d."Research shows that there must be a diagnosis of deficiency before growth hormones can be started at this age."
"Research shows that there must be a diagnosis of deficiency before growth hormones can be started at this age." Rational:The nurse should educate the parents about growth hormones before asking questions. The nurse needs to explain that a diagnosis of deficiency must be documented before growth hormones can be used. Only the long bones are affected. Growth hormone is given orally, IM, and SC.
After explaining the causes of hypothyroidism to the parents of a newly diagnosed infant, the nurse should recognize that further education is needed when the parents ask which question? a.Are you saying that hypothyroidism is caused by a problem in the way the thyroid gland develops?" b."Do you mean that hypothyroidism may be caused by a problem in the way the body makes thyroxine?" c."So, hypothyroidism can be only temporary, right?" d."So, hypothyroidism can be treated by exposing our baby to a special light, right?"
"So, hypothyroidism can be treated by exposing our baby to a special light, right?" Rational:Congenital hypothyroidism can be permanent or transient and may result from a defective thyroid gland or an enzymatic defect in thyroxine synthesis. Only the last question, which refers to phototherapy for physiologic jaundice, indicates that the parents need more information.
A 9-year-old was just diagnosed with type 1 diabetes. The parents state, "We hope our child won't have to take insulin injections." How should the nurse respond? a."Sometimes oral hypoglycemic agents are all that is necessary. Hopefully that will be the case with your child." b."The pancreas doesn't produce insulin in Type 1 diabetes, so it is likely that insulin injections will be necessary." c."It is very early in the diagnosis process. Let's wait to see if insulin will be necessary." d."You will have to trust whatever the doctor decides to order."
"The pancreas doesn't produce insulin in Type 1 diabetes, so it is likely that insulin injections will be necessary." Rational:Since the diagnosis has been made for type 1 DM, insulin will be necessary. Insulin is used for DM to replace the body's natural insulin, which is necessary for proper glucose use.
The nurse is reviewing the recommended diet with the parents and child who was diagnosed with type 2 diabetes. The nurse determines that the parents and child understand the information when they identify that they will restrict carbohydrate intake to which amount at each of the three main meals? a. 60g b.45g c. 15g d. 30g
45g Rationale: Typically, carbohydrate intake is restricted to 45 grams at each of the three main meals of the day.
The nurse is caring for an obese 15-year-old girl who missed two periods and is afraid she is pregnant. Which finding indicates polycystic ovary syndrome? a.blurred vision and headaches b. increased respiratory rate c. Hypertrophy and weakness d. Acanthosis nigricans
Acanthosis nigricans Rationale: Observation of acanthosis nigricans in addition to obesity and amenorrhea is a further indication of polycystic ovary syndrome. Reports of blurred vision and headaches are signs and symptoms of diabetes. Increased respiratory rate on auscultation points to diabetes insipidus. Hypertrophy and weakness on palpation are typical of hypothyroidism.
A newborn is discovered to have congenital adrenogenital hyperplasia. What will the nurse most likely observe when assessing this client? a.Small for gestational age b.Abnormal facial features c.Enlarged clitoris d.Divergent vision
Enlarged Clitoris Rational: Congenital adrenal hyperplasia is a syndrome that is inherited as an autosomal recessive trait, which causes the adrenal glands to not be able to synthesize cortisol. Because the adrenal gland is unable to produce cortisol, the level of adrenocorticotropic hormone (ACTH) secreted by the pituitary in an attempt to stimulate the gland to increase function is increased. Although the adrenals enlarge under the effect of ACTH, they still cannot produce cortisol but rather overproduce androgen. Excessive androgen production during intrauterine life masculinizes the genital organs in a female fetus so that the clitoris is so enlarged it appears to be a penis. This disorder does not cause divergent vision. The child will not be born small for gestational age. This disorder does not cause abnormal facial features.
A 12-year-old child has hyperthyroidism. The nurse understands that the most common cause of hyperthyroidism in children is: a.Addison disease. b.Graves disease. c.Cushing syndrome. d.Plummer disease.
Graves Disease Rational: Hyperthyroidism occurs less often in children than hypothyroidism. Graves disease is the most common cause of hyperthyroidism in children. Hyperthyroidism occurs more often in females, and the peak incidence occurs during adolescence. Addison disease refers to chronic adrenocortical insufficiency. Cushing syndrome results from excessive levels of circulating cortisol. Plummer disease is a less common cause of hyperthyroidism.
During an assessment of an adolescent child, the nurse notes that the child has a protuberant tongue, fatigued appearance, poor muscle tone, and exophthalmos. What medical diagnosis would the nurse expect the child to have? a.diabetes b.syndrome of inappropriate antidiuretic hormone secretion (SIADH) c.Cushing disease d.Graves disease
Graves disease Rational: Symptoms of Graves disease include an increased rate of growth; weight loss despite an excellent appetite; hyperactivity; warm, moist skin; tachycardia; fine tremors; an enlarged thyroid gland or goiter; and ophthalmic changes including exophthalmos. These are not symptoms of Cushing disease, diabetes, or SIADH.
A child is diagnosed with hyperthyroidism. What finding would the nurse expect to assess? a.Constipation b.Facial edema c.Heat intolerance d.Weight gain
Heat intolerance Rational: Hyperthyroidism is manifested by heat intolerance, nervousness or anxiety, diarrhea, weight loss, and smooth velvety skin. Constipation, weight gain, and facial edema are associated with hypothyroidism.
The nurse is caring for a child diagnosed with low functioning parathyroid. Which is a treatment goal of a child with hypoparathyroidism? a.Provide the child and parent with a referral to a pediatric gastrointestinal specialist. b. Assure the parents have a plan in place for periods of low glucose levels if noted. c.Maintain the child's calcium level at a normal level with calcium replacement as prescribed. d.Provide the parents a specific dietary plan for high-phosphorus foods to be eaten.
Maintain the child's calcium level at a normal level with calcium replacement as prescribed. Rational:Hypoparathyroidism will manifest as a low calcium level, so the nurse would expect the provider to provide a prescription to maintain the calcium level within normal range. Glucose is not a concern with parathyroid function. A referral would be made to a pediatric endocrinologist, not a gastrointestinal specialist. Phosphorus and calcium have an inverse proportion, so the nurse would recommend a low-phosphorus diet.
A 13-year-old adolescent with hyperthyroidism who takes antithyroid medication has a sore throat and a fever. The parent calls the nurse and asks what to do. Which is the best response from the nurse? a. "Fever and sore throat may be side effects of the medication." b. "Offer your child at least 8 ounces of clear fluids and call back tomorrow." c."Please take your child straight to the emergency department." d."Give your child ibuprofen according to the instructions on the box."
Please take your child straight to the emergency department." Rational:A side effect of antithyroid medications is leukopenia. Signs and symptoms that include fever and sore throat need to be seen immediately. These instructions should be reviewed with parents upon discharge. The question includes information about Graves disease, so ibuprofen would not be the treatment. The question centers around drug therapy, not the child's fluid status.
Insulin deficiency, in association with increased levels of counter-regulatory hormones and dehydration, is the primary cause of: a. ketonuria. b.diabetic ketoacidosis. c.ketone bodies. d.glucosuria.
diabetic ketoacidosis. Rationale: Insulin deficiency, in association with increased levels of counter-regulatory hormones (glucagon, growth hormone, cortisol, catecholamines) and dehydration, is the primary cause of diabetic ketoacidosis (DKA), a life-threatening form of metabolic acidosis that is a frequent complication of diabetes. Liver converts triglycerides (lipolysis) to fatty acids, which in turn change to ketone bodies. The accumulation and excretion of ketone bodies by the kidneys is called ketonuria. Glucosuria is glucose that is spilled into the urine.
The nurse is teaching a child with type 1 diabetes mellitus to administer insulin. The child is receiving a combination of short-acting and long-acting insulin. The nurse knows that the child has appropriately learned the technique when the child: a.wipes off the needle with an alcohol swab. b.administers the insulin intramuscularly into rotating sites. c.administers the insulin into a doll at a 30-degree angle. d.draws up the short-acting insulin into the syringe first.
draws up the short-acting insulin into the syringe first. Rational:Drawing up the short-acting insulin first prevents mixing a long-acting form into the vial of short-acting insulin. This maintains the short-acting insulin for an emergency. Insulin is given subcutaneously not intramuscularly. A SQ injection is administered at a 90-degree angle if the person can grasp 2 in (5 cm) of skin. If only 1 in (2.5 cm) of skin can be grasped, then the injection should be given at a 45 degree angle. The needle is sterile. It should not be wiped with an alcohol swab. Only the top of the insulin vial should be wiped with an alcohol swab.
A 6-week-old infant has been diagnosed with congenital hypothyroidism. Once the level of medication has been determined, in order to maintain the proper dosing of thyroid hormone, the nurse instructs the parents to have the baby's levels tested how often during the first year? a. every 1 to 3 days b.every 1 to 3 months c.every 1 to 3 weeks d.every 3 to 6 months
every 1 to 3 months Rational: Thyroid levels are measured at recommended intervals, such as every 2 weeks until the target range is reached on a stabilized dose of medication, then every 1 to 3 months until the child is 1 year old, every 2 to 3 months until the child is 3 years old, and becoming less frequent as the child gets older.
The nurse caring for a child who has issues with the anterior pituitary and expects the child to have issues with which hormone? a.growth hormone b.oxytocin c. Antidiuretic hormone d. Vasopressin
growth hormone Rational:Disorders of the pituitary gland depend on the location of the physiologic abnormality. The anterior pituitary, or adenohypophysis, is made up of endocrine glandular tissue and secretes growth hormone (GH), adrenocorticotropic hormone (ACTH), thyroid-stimulating hormone (TSH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin. The posterior lobe is called the neurohypophysis because it is formed of neural tissue. It secretes antidiuretic hormone (ADH; vasopressin) and oxytocin. Usually, several target organs are affected when there is a disorder of the pituitary gland, especially the adenohypophysis.
The nurse is assessing a 16-year-old boy who has had long-term corticosteroid therapy. Which finding, along with the use of the corticosteroids, indicates Cushing disease? a.high weight-to-height ratio b.history of rapid weight gain c.delayed dentition d.round, moon-shaped face
history of rapid weight gain Rationale:A history of rapid weight gain and long-term corticosteroid therapy suggests this child may have Cushing disease, which could be confirmed using an adrenal suppression test. A round, moon-shaped face is common to both Cushing disease and growth hormone deficiency. A high weight-to-height ratio and delayed dentition are findings with growth hormone deficiency.
The nurse is teaching a group of caregivers of children diagnosed with diabetes. The nurse is explaining insulin shock and the caregivers make the following statements. Which statement indicates the best understanding of a reason an insulin reaction might occur? a."On the weekends we encourage our child to participate in lots of sports activities and stay busy so they don't have an insulin reaction." b.My child monitors their glucose levels to keep them from going too high." c."My child measures their own medication but sometimes doesn't administer the correct amount." d."If my child eats as much as their older brother eats they could have an insulin reaction."
"My child measures their own medication but sometimes doesn't administer the correct amount." Rational:Insulin reaction (insulin shock, hypoglycemia) is caused by insulin overload, resulting in too-rapid metabolism of the body's glucose. This may be attributable to a change in the body's requirement, carelessness in diet (such as failure to eat proper amounts of food), an error in insulin measurement, or excessive exercise.
The nurse is educating the parents of a client newly diagnosed with type 1 diabetes. Which statement by the parents indicates additional teaching is needed? a."Our child should not participate in sports or physical activity." b."Our child should eat three meals and mid afternoon and bedtime snacks each day. c.."We and our child need to learn to identify carbohydrate, protein, and fat foods. d."We and our child need to learn to identify carbohydrate, protein, and fat foods."
"Our child should not participate in sports or physical activity." Rationale: The nurse would provide additional education if the parents state the child should not participate in sports or physical activity. The child with diabetes can, and should, be physically active to maintain proper health and facilitate efficient insulin usage by the body. Glucose levels should be checked more frequently during times of sickness, as well as assessing the urine for ketones. Consistency of intake can help prevent complications and maintain near-normal blood glucose levels. The parents and child should know how to identify foods to adequately monitor the child's nutritional intake. A dietitian with expertise in diabetes education should be consulted for referral as needed.
A nurse who is caring for a 7-year-old is providing client education to the child and caregiver. Which response by the caregiver demonstrates to the nurse that the caregiver understands the diagnosis of type 1 diabetes mellitus? a."Her body doesn't have any insulin. b."I will just feed my child healthy foods and sign her up for more sports." c."We will just have our child exercise and take medicine to cure this." d."Her body fights against the insulin."
."Her body doesn't have any insulin. Rationale:Type 1 diabetes mellitus (DM) is a disorder in which the child's body has a deficiency of insulin; children with type 1 DM cannot produce insulin. Type 2 DM is controlled through diet, medicine, and exercise. Type 2 DM can be prevented through diet and exercise, but type 1 DM cannot. Resistance to insulin is not the primary factor in type 1 DM.
A nurse is to see a child. Assessment reveals the chief complaints of urinating "a lot" and being "really thirsty." The nurse interprets these symptoms as being associated with which condition? a. precocious puberty b.syndrome of inappropriate antidiuretic hormone secretion c. diabetes insipidus d. hypopituitarism
Diabetes Insipidus Rational: The most common symptoms of central diabetes insipidus are polyuria (excessive urination) and polydipsia (excessive thirst). Children with diabetes insipidus typically excrete 4 to 15 L/day of urine despite the fluid intake. The onset of these symptoms is usually sudden and abrupt. Ask about repeated trips to the bathroom, nocturia, and enuresis. Other symptoms may include dehydration, fever, weight loss, increased irritability, vomiting, constipation, and, potentially, hypovolemic shock.
A nurse caring for a child with Graves disease is administering propylthiouracil (PTU). The child has been on this drug for a few weeks and now has sudden symptoms of a sore throat. What is the priority intervention for the nurse? a.Offer throat lozenges to soothe the throat. b.Hold the dose and call the health care provider. c.Continue medication to relieve the signs of Graves disease. d.Ask the child if there is a reason he or she does not want to go back to school.
Hold the dose and call the health care provider. Rational: The severe sore throat could be a sign of leukopenia, which is a side effect of PTU. The medication should be held and the health care provider called. The medication dose may need to be adjusted. Lozenges will not help this side effect. It is not appropriate to imply that a child may be making up symptoms to avoid school.
The nurse is obtaining a health history from parents whose 4-month-old boy has congenital hypothyroidism. What would the nurse most likely assess? a. The skin is pink and healthy looking. b.The child is active and playful. c.It is difficult to keep the child awake. d.The child has above-normal growth for his age.
It is difficult to keep the child awake. Rationale: During the health history, the parents may state that it is difficult to keep the child awake. Physical examination would reveal that the child is below weight and height, that his skin is pale and mottled, and that he is lethargic and irritable.
The nurse is assessing a child diagnosed with Cushing syndrome. Which statement by the parents demonstrates a need for further teaching? a,"My child's round, full face appearance is reversible with appropriate treatment." b."My child may experience excessive weight gain." c. "We need to pay close attention to any wounds our child gets to monitor for adequate healing." d."This disorder is most likely due to an infection my child had recently."
This disorder is most likely due to an infection my child had recently." Rationale: A round, full face (moon face), rapid weight gain, and poor wound healing are all seen in Cushing syndrome. Cushingoid appearance is reversible with appropriate treatment. The most common cause of Cushing syndrome is long-term corticosteroid therapy or a pituitary adenoma, not an infection.
The nurse is speaking with the parents of a child recently diagnosed with hypothyroidism. Which statement by a parent indicates an understanding of symptoms of this disorder? a. "Heat intolerance is a caused by low thyroid levels." B.When they get my son's thyroid levels normal, he won't be so tired."
When they get my son's thyroid levels normal, he won't be so tired." Rationale: Tiredness, fatigue, constipation, cold intolerance and weight gain are all symptoms of hypothyroidism. Nervousness, anxiety, heat intolerance, weight loss and smooth velvety skin are all symptoms of hyperthyroidism.
The nurse knows that disorders of the pituitary gland depend on the location of the physiologic abnormality. In caring for a child that has issues with the anterior pituitary, the nurse knows that this child has issues with which hormone? a.antidiuretic hormone b.growth hormone c.oxytocin d.vasopressin
growth hormone Rational:Disorders of the pituitary gland depend on the location of the physiologic abnormality. The anterior pituitary, or adenohypophysis, is made up of endocrine glandular tissue and secretes growth hormone (GH), adrenocorticotropic hormone (ACTH), TSH, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin. The posterior lobe is called the neurohypophysis because it is formed of neural tissue. It secretes antidiuretic hormone (ADH; vasopressin) and oxytocin. Usually, several target organs are affected when there is a disorder of the pituitary gland, especially the adenohypophysis.
The nurse is assessing a 4-year-old girl with ambiguous genitalia. Which finding suggests congenital adrenal hyperplasia? a.irregular heartbeat on auscultation b. pain from constipation on palpation c.hyperpigmentation of the skin d.pubic hair and hirsutism
pubic hair and hirsutism Rationale:Pubic hair and hirsutism in a preschooler indicate congenital adrenal hyperplasia. Irregular heartbeat on auscultation and pain due to constipation on palpation may be signs of hyperparathyroidism. Hyperpigmentation of the skin suggests Addison disease.
The nurse is teaching glucose monitoring and insulin administration to a child with type 1 diabetes and the parents. Which comment by a parent demonstrates a need for additional teaching? a. "Blood glucose level, food intake, and activity need to all be considered when calculating insulin dosage." b."During exercise we should wait to check blood sugars until after our child completes the activity." c."If our child is sick we should check blood glucose levels more often." d."We should check our child's blood glucose levels before meals."
"During exercise we should wait to check blood sugars until after our child completes the activity." Rational: Blood glucose monitoring needs to be performed more often during prolonged exercise. Frequent glucose monitoring before, during, and after exercise is important to recognize hypoglycemia or hyperglycemia. Frequent glucose monitoring if the child is sick is also important to recognize changes in glucose levels and prevent hypoglycemia or hyperglycemia. The parents are correct that they will check their child's glucose before meals; they should also check it before bedtime snacks. Blood glucose level should never be the only factor considered when calculating insulin dosing. Food intake and recent or expected activity/exercise must be factored in.
A 10-year-old child has been diagnosed with type 1 diabetes. The child is curious about the cause of the disease and asks the nurse to explain it. Which explanation will the nurse provide? a."The part of your body called the pancreas is broken and produces too much chemical called glucagon, which makes you really thirsty and have to go to the bathroom a lot." b."The alpha and beta cells in your pancreas are fighting against each other; that is why your blood sugar stays high and you need insulin injection." c."Special cells in a part of your body called the pancreas cannot make a chemical called insulin, which helps control the sugar level in your blood." d."The pancreas inside your belly makes enough chemical called insulin, but your body does not want to use it to keep your blood sugar level normal."
"Special cells in a part of your body called the pancreas cannot make a chemical called insulin, which helps control the sugar level in your blood." Rationale:When providing instruction to a child, the nurse must consider the developmental age. Type 1 diabetes is a disorder that involves an absolute or relative deficiency of insulin, thus the blood glucose level remains high if an appropriate amount of insulin is not administered to the client. With type 2 diabetes, the body produces an adequate amount of insulin; however, the body is resistant to using the insulin properly to keep circulating blood glucose levels at a normal level. The rest of the statements provide incorrect information regarding the pathophysiology of type 1 diabetes.
A 10-year-old child is newly diagnosed with type 1 diabetes. The child's hemoglobin A1C level is being monitored. The nurse determines that additional intervention is needed with the child based on which result? a.7.0% b.7.5 % c.6.5% d.8.5%
8.5% Rationale: The goal for hemoglobin A1C in children between the ages of 6 and 12 years is less than 8%. Therefore, a result of 8.5% would indicate that additional intervention is needed to achieve the recommended goal.
A nurse is taking care of an infant with diabetes insipidus. Which assessment data are most important for the nurse to monitor while the infant has a prescription for fluid restriction? a.Urine output b.Vital signs c.Oral mucosa d.Oral intake
Urine Output Rational: An infant with the diagnosis of diabetes insipidus has decreased secretion of antidiuretic hormone (ADH). The infant is at risk for dehydration so monitoring urinary output is the most important intervention. The child's oral intake has been ordered. Monitoring a child who is under fluid restriction includes assessing the oral mucosa; however, urine output is the most important assessment for this patient. Vital signs are part of a basic assessment.
An 8-year-old girl presents to the clinic for moodiness and irritability. The child has begun to develop breasts and pubic hair and the parents are concerned that the child is at too early an age for this to begin. The nurse knows that these symptoms may be indicative of what disorder? a.precocious puberty b.adrenal hyperplasia c.pseudopuberty d.neurofibromatosis
precocious puberty Rationale:Precocious puberty occurs when the child's sexual characteristics begin to develop before the normal age of puberty. Appropriate treatment can halt, and sometimes even reverse, sexual development and can stop the rapid growth that results in severe short adult stature caused by premature closure of the epiphysis. Treatment for precocious puberty allows the child to achieve the maximum growth potential possible. Mental development in children with precocious puberty is normal, and developmental milestones are not affected. The behavior may change to that of a typical adolescent. Girls may have episodes of moodiness and irritability, whereas boys may become more aggressive. Pseudopuberty occurs when there is only partial development after testosterone is secreted. It occurs in males. Adrenal hyperplasia is an inherited disorder and it affects the production of androgen. Neurofibromatosis is a genetic disorder of the nervous system where tumors grow on the nerves.
A 12-year-old is being seen in the office and has hyperthyroidism; the nurse knows that the most common cause of hyperthyroidism is: a.Cushing disease b.Plummer disease c.Graves disease d.Addison disease
.Graves disease Rational: Hyperthyroidism occurs less often in children than hypothyroidism. Graves disease, the most common cause of hyperthyroidism in children, occurs in 1 in 5,000 children between 11 and 15 years of age. Hyperthyroidism occurs more often in females, and the peak incidence occurs during adolescence.
The nurse working with the child diagnosed with type 2 diabetes recognizes the disorder can be managed by: a.decreasing amounts of daily insulin. b.taking oral hypoglycemic agents. c.increasing carbohydrates in the diet, especially in the evening. d.conserving energy with rest periods during the day.
.taking oral hypoglycemic agents. Rationale:Oral hypoglycemic agents, such as metformin, are often effective for controlling blood glucose levels in children diagnosed with type 2 diabetes. Insulin may be used for a child with type 2 diabetes if oral hypoglycemic agents alone are not effective, but "decreasing" the daily insulin would not help treat this disorder. Lifestyle changes such as increased exercise (not conserving energy by resting during the day), and limiting large amounts of carbohydrates are important aspects of treatment for the child.