MOM & BABY
Children who are involved in cooperative play discuss and plan activities. Therefore, a leader-follower type of relationship will develop among the children. During solitary play, the child plays with toys alone. During parallel play, children play side by side but individually, with different toys. During associative play, the children borrow or lend play materials but do not control each other's activities and therefore do not develop a leader-follower type of relationship.
Children who are involved in cooperative play discuss and plan activities. Therefore, a leader-follower type of relationship will develop among the children. During solitary play, the child plays with toys alone. During parallel play, children play side by side but individually, with different toys. During associative play, the children borrow or lend play materials but do not control each other's activities and therefore do not develop a leader-follower type of relationship.
Contractions every 5 minutes apart for 1 hour are an indication of true labor. Because the woman is a nullipara, this is an appropriate response. Contractions coming 10 minutes apart for 1 hour in a nullipara are too far apart for true labor. This reading would be appropriate for a multiparous woman, whose labor is likely to be shorter and more intense. Contractions that ease when the client walks or are irregular and vary in intensity are signs of false labor.
Contractions every 5 minutes apart for 1 hour are an indication of true labor. Because the woman is a nullipara, this is an appropriate response. Contractions coming 10 minutes apart for 1 hour in a nullipara are too far apart for true labor. This reading would be appropriate for a multiparous woman, whose labor is likely to be shorter and more intense. Contractions that ease when the client walks or are irregular and vary in intensity are signs of false labor.
Cryptorchidism & orchiopexy
Cryptorchidism is the failure of one or more testes to descend into the scrotal sac; orchiopexy surgically pulls the testicle downward into the scrotum. Downward direction of the urine is the goal if the child has hypospadias. Removal of scrotal fluid is the goal if the child has a hydrocele. Release of fibrous tissue is the goal if the child has chordee.
Fetal heart sounds are heard through the fetus's back. When the position of the fetus is in the left occiput posterior (LOP) or left occiput anterior (LOA), fetal heart sounds are heard in the left lower quadrant of the mother. The fetus is will be in the right sacrum anterior (RSA) position if the fetal heart tones are heard in this area. The fetus is in the left sacrum anterior (LSA) position if the fetal heart tones are heard in this area. The fetus is in the right occiput posterior (ROP) position if the fetal heart tones are heard in this area.
Fetal heart sounds are heard through the fetus's back. When the position of the fetus is in the left occiput posterior (LOP) or left occiput anterior (LOA), fetal heart sounds are heard in the left lower quadrant of the mother. The fetus is will be in the right sacrum anterior (RSA) position if the fetal heart tones are heard in this area. The fetus is in the left sacrum anterior (LSA) position if the fetal heart tones are heard in this area. The fetus is in the right occiput posterior (ROP) position if the fetal heart tones are heard in this area.
To evaluate kidney function, the nurse must accurately measure the hourly urine output of a 1½-year-old toddler weighing 22 lb who has been admitted with extensive burns. What is the minimum safe output per hour for a child this age?
-10-20 ml/hr The minimum safe urine output for a 1½-year-old toddler is 1 mL/kg/hr. The 18-month-old toddler whose weight is at the 50th percentile weighs approximately 11 kg. This is approximately 11 mL/hr, which is within the minimum safe output of 10 to 20 mL/hr. Sixty-one to 80 mL/hr is more than the minimum output for any age group. Forty-one to 60 mL/hr is more than the minimum output for any age group. Twenty-one to 40 mL/hr is the minimum safe output for children who weigh 21 to 40 kg and are 5 to 11 years old.
A reactive nonstress test (NST)
A reactive nonstress test (NST) indicates that the fetus is healthy because there is an active pattern of fetal heart rate acceleration with movement. The result is positive and desired; immediate birth is not required. Further testing is needed. If the pregnancy continues, another test of fetal well-being will probably be done.
cleft lip & palate surgery
Although the palate may be repaired during the neonatal period, performing the repair so early is controversial. However, the surgical repair should be done before the child talks so that the child can learn to speak coherently. Although both cleft lip and palate may occur with other birth defects, it is not always so; most birth defects are diagnosed at the time of birth. Focusing on the disfigurement may raise anxiety and increase guilt. There is a specific reason why the two surgeries are done separately, not merely to minimize complications.
Amniotic fluid changes the color of a Nitrazine strip from yellow to deep blue if the pH of the fluid is 7.5. A pH of 4.5, 5.5 or 6.5 would result in a test strip of yellow, olive yellow, or blue green, respectively.
Amniotic fluid changes the color of a Nitrazine strip from yellow to deep blue if the pH of the fluid is 7.5. A pH of 4.5, 5.5 or 6.5 would result in a test strip of yellow, olive yellow, or blue green, respectively.
BONE MARROW IN A TODDLER
Anesthesia is used for procedures such as bone marrow aspiration in children. This is a painful procedure. The child will not have pain during the procedure because anesthesia will be used. The site may be sore afterward. The child should be placed prone with a towel roll under the hips for aspiration of marrow from the posterior iliac crest. The child may handle some of the equipment as part of the explanation of the procedure; however, the child will be sedated during the procedure.
priority of preoperative nursing care for an infant with a cleft lip
Because of the anomalous structure of the upper lip, the infant with cleft lip may have difficulty sucking on a nipple. Adaptive shields are available for breastfeeding. Haberman feeders and other modified devices are used for formula feeding. Preventing crying is not an immediate concern; after surgery it becomes necessary to help prevent tension on the suture line. Cleft palate, not cleft lip, may predispose the infant to infection. The infant should be cuddled and held.
feat heart rate
Bradycardia (baseline FHR slower than 110 beats/min) indicates that the fetus may be compromised, requiring medical intervention. Resuming continuous fetal heart monitoring may be dangerous; the fetus may be compromised, and time should not be spent on monitoring. Continuing to monitor the maternal vital signs is not the priority at this time. The expected FHR is 110 to 160 beats/min between contractions.
resp. illness on babies. What major indication of illness in an infant should the nurse explain to the parent?
Grunting and rapid respirations are signs of respiratory distress in an infant. Grunting is a compensatory mechanism by which the infant attempts to keep air in the alveoli to increase arterial oxygenation; increased respirations increase oxygen and carbon dioxide exchange. Sweating in infants usually is scant because of immature function of the exocrine glands; profuse sweating is rarely seen in a sick infant. Longer periods of sleep are not necessarily a sign of illness, nor is crying immediately after feedings.
temper tantrum (toddlers)
Ignoring the temper tantrum as long as the child is not causing self-harm avoids reinforcement of the behavior. The parents should remain nearby to provide a sense of security. Restraining the child will probably worsen the behavior associated with the tantrum. Moving the child to a quiet area may be impossible; tantrums often involve lying on the floor, kicking, and screaming loudly. Medication is not the treatment of choice.
In the most common position:
In the most common position, left occiput anterior, the fetus's back is on the left side of the mother, in the left occiput anterior position. Position a is correct when the fetus is in the right sacrum anterior position. Position b is correct when the fetus is in the left sacrum anterior position. Position c is correct when the fetus is in the right occiput posterior position.
An infant is found to have hydrocephalus. Which assessment finding alerts the nurse to suspect increasing intracranial pressure?
Increased intracranial pressure exerts pressure on the vomiting center in the brain, resulting in projectile vomiting unrelated to feeding. The eyeballs will show signs of increased fluid volume in the skull and will be pushed forward, pulling the lids taut. The fontanels will show signs of increased fluid volume in the skull and therefore will bulge. With increased intracranial pressure the systolic pressure is increased and the diastolic pressure is the same or decreased, creating a widening, not narrowing, of pulse pressure.
patent ductus arteriosus (PDA)
It is a connection between the pulmonary artery and the aorta. Before birth, oxygenated fetal blood is shunted directly into the systemic circulation by way of the ductus arteriosus, a connection between the pulmonary artery and the aorta. After birth, the increased oxygen tension causes a functional closure of the ductus arteriosus. Occasionally, particularly in preterm infants, this vessel remains open, a condition known as patent ductus arteriosus. Enlargement of the diameter of the aorta is not the problem in patent ductus arteriosus. A defective wall between the right and left ventricles is a description of ventricular septal defect. A narrowing of the entrance to the pulmonary artery is a description of pulmonic stenosis.
KAWASAKI DZ
Kawasaki disease is a rare condition that mainly affects children under the age of five. It's also known as mucocutaneous lymph node syndromeThe characteristic "strawberry tongue" is a result of sloughing of the normal coating of the tongue that leaves the papillae exposed. There is bilateral congestion of the ocular conjunctiva without an exudate. The fever associated with Kawasaki disease is high and is abrupt in onset; it is unresponsive to antibiotics and antipyretics. A maculopapular rash on the extremities does not occur; peripheral edema and erythema occur with desquamation of the palms and soles. Kawasaki disease is treated with high-dose IVIG in combination with aspirin to lower the risk of coronary artery abnormalities. A clinical manifestation of bilateral nonpurulent conjunctivitis occurs with Kawasaki disease, so the nurse should avoid bright overhead lights. Nursing care is focused on adequate hydration, so fluids should not be restricted and fruit juices are not contraindicated. Kawasaki disease is an acute febrile exanthematous illness of children with a generalized vasculitis of unknown origin. It is not an infectious disease, so antibiotics (penicillin) are not administered.
Maternal hypotension is a common complication of epidural anesthesia during labor, and nausea is one of the first clues that it has occurred. Turning the client on her side will keep the uterus from putting pressure on the inferior vena cava, which causes a decrease in blood flow. If signs and symptoms do not abate after the client is turned on her side, the health care provider should be notified. Checking the vaginal area for bleeding is not an assessment specific to epidural anesthesia; it is part of the general nursing care during labor. Fetal heart rate monitoring is a continuous process, and the rate should be recorded every 15 minutes; if this monitoring is not being performed, the rate should be checked and recorded every 15 minutes.
Maternal hypotension is a common complication of epidural anesthesia during labor, and nausea is one of the first clues that it has occurred. Turning the client on her side will keep the uterus from putting pressure on the inferior vena cava, which causes a decrease in blood flow. If signs and symptoms do not abate after the client is turned on her side, the health care provider should be notified. Checking the vaginal area for bleeding is not an assessment specific to epidural anesthesia; it is part of the general nursing care during labor. Fetal heart rate monitoring is a continuous process, and the rate should be recorded every 15 minutes; if this monitoring is not being performed, the rate should be checked and recorded every 15 minutes.
What information concerning the childbearing process should the nurse teach a client during the first trimester of pregnancy?
Physical and emotional changes resulting from pregnancy. Increasing the client's knowledge of physical and psychological changes resulting from pregnancy prepares the client for expected changes as pregnancy continues; it is most effective when taught during the first trimester. It is too early to teach about labor and birth; this should be done in the last trimester. The client should be alerted to danger signs and symptoms; however, primary teaching is directed toward increasing her knowledge of expected physiological changes. Concerns about role transition to parenthood should be addressed in the third trimester.
nursing action is the priority for a client in the second stage of labor
Promote effective pushing Effective pushing will hasten the passage of the fetus's presenting part through the birth canal. The fetal position is established before the second stage. Birth is imminent, and medication given at this time will depress the newborn's respirations. Although the mother may breastfeed after the birth, during the second stage of labor she should be concentrating on the birth process, not feeding the infant.
Which item should a nurse use to feed an infant born with a unilateral cleft lip and palate
Rubber-tipped syringe Because the infant with a cleft lip and palate is unable to form the vacuum needed for sucking, a rubber-tipped syringe or dropper is used. This allows formula to flow along the sides to the back of the mouth, minimizing the danger of aspiration. A spoon is ineffective because the infant's extrusion reflex will prevent fluid from entering the mouth. A cross-cut nipple may be used with some infants, but rapid flow is dangerous because it can cause aspiration. Feeding can be accomplished with the use of special equipment; intravenous fluids are not necessary.
Squatting is
Squatting is a physiologic adaptation for children with tetralogy of Fallot. By squatting, the child decreases the amount of arterial blood that is flowing to the extremities, which in turn decreases venous return to the heart and reduces preload. Oxygen is not indicated. The child has a heart, not a respiratory, problem, so a nebulizer treatment is not indicated. The child's condition has not deteriorated; squatting is a physiologic adaptation.
Which stage of Freud's psychosexual development theory does the nurse observe in a 3-year-old child?
The anal stage of development is seen in a child at 1 to 3 years of age, during the time the child is being toilet trained. The period from birth to 1 year of age, when the child likes sucking, biting, and chewing, is said to be the oral stage. A child is in the phallic stage of development from 3 to 6 years of age. During the phallic stage, the child develops interest in sensitive areas of the body like the genitals. The latency stage of development is seen from 6 to 12 years of age, when the child channels all energy to gain knowledge and play.
HYPOSPADIAS . The critical period of organogenesis occurs during the first trimester, when fetal development is most likely to be adversely affected. The fetus is less vulnerable after the first trimester because organ development is complete. The fetus is less vulnerable to major anomalies during the second 16 weeks because all major organ systems already are formed. At the time of implantation cellular differentiation has not occurred; the genital bud appears in the seventh week.
The critical period of organogenesis occurs during the first trimester, when fetal development is most likely to be adversely affected. The fetus is less vulnerable after the first trimester because organ development is complete. The fetus is less vulnerable to major anomalies during the second 16 weeks because all major organ systems already are formed. At the time of implantation cellular differentiation has not occurred; the genital bud appears in the seventh week.
The first stage of labor lasts
The first stage of labor lasts from its onset until the cervix is fully dilated at 10 cm. The client is in the early phase of the first stage of labor. * transition is the last phase of the first stage of labor.
Which behavior is seen in children at the undifferentiated stage of spiritual development, as propounded by Fowler?
The first stage of spiritual development, as described by Fowler, is the undifferentiated stage. During this stage the children have no concept of right or wrong to guide their behaviors. The beginnings of faith are established as they develop trust in their parents or primary caregivers. Imitation of religious behavior without comprehending any meaning takes place in the intuitive-projective stage during toddlerhood. As children grow older and approach adolescence, they reason and question some of the established parental religious standards. They realize that prayers are not always answered and so they abandon some practices. A reverence for religious matters and articulation of faith takes place in the mythical-literal stage during the school-age years.
baby has occasional bouts of diarrhea. What is the best response by the nurse?
The immaturity of the immune system makes young infants vulnerable to common infections; however, if bouts of diarrhea are self-limiting and the infant continues to feed and shows no signs of illness, medical management is not required. Many, but not all, infants respond this way early in an infectious process. Occasional bouts of diarrhea do not require the intervention of a gastroenterologist. Even if medical management were required, the pediatric practitioner, not the pediatric gastroenterologist, should be notified. It is unlikely that the infant is eating ground meat at this age.
A nurse is assessing an infant with talipes equinovarus (clubfoot) who has had a corrective boot cast applied. Which peripheral vascular assessment cannot be performed while the cast is in place?
The pedal pulse cannot be palpated under a boot cast. Assessments of the color, warmth, and blanching of the toes are all appropriate neurovascular checks.
The second stage of labor lasts
The second stage of labor lasts from complete dilation to birth.
postpartum unit asks the nurse why the nurses are always encouraging her to walk
There is extensive activation of the blood clotting factors after a birth; this, together with immobility, trauma, or sepsis, encourages thromboembolization, which can be limited through activity. Respirations are enhanced by encouraging the client to turn from side to side and to deep-breathe and cough. Bladder tone is improved by the regular emptying and filling of the bladder. Exercise during the next 6 weeks can strengthen the abdominal muscles.
Weaning
Weaning is a critical developmental task, especially for the toddler, who cannot withstand frustration; weaning should be a gradual process with as little stress as possible. Telling the mother that she may start whenever she likes is too vague and does not give the mother specific instructions. Judgmental responses such as "It's already a little late" can cause guilt and diminish the mother's self-esteem. Toddlers have difficulty tolerating weaning in conjunction with other stressful situations such as changes in their lives
Mom trying to lose weight during pregnancy
Weight reduction is not advised during pregnancy; an additional 340 calories a day during the second trimester is recommended. When the client reaches the third trimester another 120 calories should be added to her diet. A pregnant woman should not diet during pregnancy. Advising the client to eat a variety of foods provides insufficient information. The client should increase her protein and calorie intake during pregnancy. Dieting during pregnancy is harmful; the fetus may be deprived of essential nutrients. The client should not be limited to a specific weight gain. There is no specific recommendation for the amount of weight a pregnant woman should gain. However, 25 to 30 lb is the average generally suggested; this figure is based on the recommended caloric intake during pregnancy and the client's prepregnancy weight and metabolic rate.
PURPOSE OF SQUATTING
When the child squats, blood pools in the lower extremities because of flexion of the hips and knees; less blood returns to the heart, decreasing the cardiac workload. Squatting does not relieve muscle aches. Squatting is not related to the pull of gravity. Squatting decreases blood return to the heart.
mother asking about the fetus rapid respiration rate
With spontaneous or stimulated activity, the fetal heart rate (FHR) is usually between 110 and 160 beats/min. This is to be expected, and the client should be made aware of this. The normal heart rate for a fetus is not twice the mother's heart rate. Stating that the FHR is rapid implies that this one is too rapid; this misinformation may cause more concerns. The FHR is rapid to accommodate the metabolic, not nutritional, needs of the fetus.
when is time for measles vaccination
between 12-15 mons.
