PEDS Ch 37 Principles and Procedures for Nursing Care of Children

1. The nurse has just assessed a toddler's temperature to be 101.5° F axillary. The physician has ordered acetaminophen 10 mg/kg every 4 to 6 hours. The child weighs 22 lb. The bottle of acetaminophen available is a suspension (160 mg/5 mL). How much should the nurse administer? Round to the nearest milliliter.

ANS: 3 mL The first thing the nurse should do is convert the 22 lb into kilograms (10 kg). Next multiply the number of kilograms the child weighs by the dose ordered by the physician (10 mg ´ 10 kg = 100). Next, use the medication that is available (160 mg/5 mL) and calculate the amount for 100 mg. The answer is 3.125. The last step is to round to the nearest milliliter = 3 mL.

6. What is the best response for a nurse to make to a parent who has asked, "When should I start dental care for my child?" a. "The recommendation is for children to have a dental examination no later than 2.5 years." b. "Children should see a dentist at least one time before kindergarten." c. "The recommendation is for children to have a dental examination before first grade." d. "A dental examination by 1 year of age is the current recommendation."

ANS: A Feedback A Children should be examined by a dentist between the time the first teeth erupt and primary dentition is complete at 2.5 years of age. B Children require regular dental examinations well before kindergarten. C Six years of age is too late to begin regular dental examinations. D Children should be examined by a dentist between the time the first teeth erupt and the time primary dentition is complete at 2.5 years of age.

8. The nurse knows that measuring temperature is an integral part of assessment. Which concept is important for the nurse to know when taking a child's temperature? a. The method used should be consistent. b. Rectal temperatures should always be taken on infants. c. Oral temperatures can be taken on all children older than 5 years of age. d. Axillary temperatures should be taken at night.

ANS: A Feedback A The method that is determined most appropriate for the child should be used consistently—the same site and device to maintain consistency and allow reliable comparison and tracking of temperatures over time. B Because of the risk of rectal perforation and the intrusive nature of the procedure, rectal temperatures are measured only when no other route can be used or when it is necessary to obtain a core body temperature. C Oral temperatures can be used on most children older than 6 years of age but may be inaccurate because of oral intake, oral surgery, oxygen therapy, nebulizer treatments, or crying. D The method of measuring temperature should be consistent, including at night.

16. The nurse is preparing a 12-year-old girl for a bone marrow aspiration. She tells the nurse she wants her mother with her "like before." The most appropriate nursing action is to a. Grant her request. b. Explain why this is not possible. c. Identify an appropriate substitute for her mother. d. Offer to provide support to her during the procedure.

ANS: A Feedback A The parents' preferences for assisting, observing, or waiting outside the room should be assessed as well as the child's preference for parental presence. The child's choice should be respected. B If the mother and child are agreeable, then the mother is welcome to stay. C An appropriate substitute for the mother is necessary only if the mother does not wish to stay. D Support is offered to the child regardless of parental presence.

13. What is appropriate to include in the care plan for a family of a child with a tracheostomy? a. Suction of the tracheostomy every 2 to 4 hours or as needed b. Application of powder around the stoma to decrease irritation c. Suction catheter insertion limited to less than 30 seconds d. Hygiene that includes showers, not baths

ANS: A Feedback A To maintain a patent airway in a child with a tracheostomy, assessing respiratory status and suctioning every 2 to 4 hours or as needed using Standard Precautions is an important intervention to teach families. B Talc powder should be avoided because of the risk of inhalation injury from breathing the powder particles. C Catheter insertion for suctioning should be less than 5 seconds to prevent hypoxia. D The family should be taught to avoid getting water in the tracheostomy during bath time. Showers should be discouraged.

19. What is critical for the nurse to know when using restraints on a child? a. Use the least restrictive type of restraint. b. Tie knots securely so they cannot be untied easily. c. Secure the ties to the mattress or side rails. d. Remove restraints every 4 hours to assess skin.

ANS: A Feedback A When restraints are necessary, the nurse should institute the least restrictive type of restraint. B Knots must be tied so that they can be easily undone for quick access to the child. C The ties are never tied to the mattress or side rails. They should be secured to a stable device, such as the bed frame. D Restraints are removed every 2 hours to allow for range of motion, position changes, and assessment of skin integrity.

14. Which action by the nurse indicates that the correct procedure has been used to measure vital signs in a toddler? a. Measuring oral temperature for 5 minutes b. Counting apical heart rate for 60 seconds c. Observing chest movement for respiratory rate d. Recording blood pressure as P/80

ANS: B Feedback A A child younger than 6 years may not be able to hold a thermometer under the tongue. B Apical pulse measurement when the child is quiet for 1 full minute is the preferred method for measuring vital signs in infants and children ages 2 years and younger. C The respiratory rate in infants and young children can be measured by watching abdominal movement. D It may be difficult to auscultate blood pressure in infants and toddlers. Systolic pressure can be palpated and should be recorded as systolic pressure over pulse (e.g., 80/P).

18. An important nursing consideration when performing a bladder catheterization on a young boy is to a. Use clean technique, not Standard Precautions. b. Insert 2% lidocaine lubricant into the urethra. c. Lubricate catheter with water-soluble lubricant such as K-Y Jelly. d. Delay catheterization for 20 minutes while anesthetic lubricant is absorbed.

ANS: B Feedback A Catheterization is a sterile procedure, and Standard Precautions for body-substance protection should be followed. B The anxiety, fear, and discomfort experienced during catheterization can be significantly decreased by preparation of the child and parents, by selection of the correct catheter, and by appropriate technique of insertion. Generous lubrication of the urethra before catheterization and use of lubricant containing 2% lidocaine may reduce or eliminate the burning and discomfort associated with this procedure. C Water-soluble lubricants do not provide appropriate local anesthesia. D Catheterization should be delayed only 2 to 3 minutes. This provides sufficient local anesthesia for the procedure.

9. A parent calls the pediatrician's office because her 1-year-old child has a 100° F temperature. What is the most appropriate initial nursing response to make to the parent? a. "Did you feel your child's forehead?" b. "Tell me about the child's behavior." c. "Has anyone in your home been sick lately?" d. "There is no need for concern if the child's temperature is less than 101° F."

ANS: B Feedback A Feeling a child's forehead can give clues related to whether the child's temperature should be measured; if it has already been measured, this is unnecessary because it does not give accurate information about the child's body temperature. B In general, the height of the fever is not an indication of the seriousness of the illness. It is more important to note changes in the child's behavior. If a child has a low-grade temperature and acts sick, he or she should be assessed further. C This question will yield relevant information for the nurse to use in advising the parent, but it is not the best initial response. D Although the height of the temperature is not an indication of the seriousness of the child's illness, it is incorrect to tell a parent to be unconcerned about temperatures less than 101° F.

1. What is the most appropriate statement for the nurse to make to a 5-year-old child who is undergoing a venipuncture? a. "You must hold still or I'll have someone hold you down. This is not going to hurt." b. "This will hurt like a pinch. I'll get someone to help hold your arm still so it will be over fast and hurt less." c. "Be a big boy and hold still. This will be over in just a second." d. "I'm sending your mother out so she won't be scared. You are big, so hold still and this will be over soon."

ANS: B Feedback A Honesty is always best and a venipuncture may hurt. B Honesty is the best approach. Children should be told what sensation they will feel during a procedure. A 5-year-old child should not be expected to hold still, and assistance ensures safety to everyone. C This statement is not supportive or honest. D Parents should be encouraged to remain with the child unless they are extremely uncomfortable doing so.

21. In preparing to give "enemas until clear" to a young child, the nurse should select a. Tap water b. Normal saline c. Oil retention d. Fleet solution

ANS: B Feedback A Plain water is not used. This is a hypotonic solution and can cause rapid fluid shift, resulting in fluid overload. B Isotonic solutions should be used in children. Saline is the solution of choice. C Oil-retention enemas will not achieve the "until clear" result. D Fleet enemas are not advised for children because of the harsh action of the ingredients. The osmotic effects of the Fleet enema can result in diarrhea, which can lead to metabolic acidosis.

4. The nurse is planning how to prepare a 4-year-old child for some diagnostic procedures. Guidelines for preparing this preschooler should include a. Planning for a short teaching session of about 30 minutes b. Telling the child that procedures are never a form of punishment c. Keeping equipment out of the child's view d. Using correct scientific and medical terminology in explanations

ANS: B Feedback A Teaching sessions for this age-group should be 10 to 15 minutes in length. B Illness and hospitalization may be viewed as punishment in preschoolers. Always state directly that procedures are never a form of punishment. C Demonstrate the use of equipment, and allow the child to play with miniature or actual equipment. D Explain the procedure in simple terms and how it affects the child.

11. What information should the nurse include in teaching parents how to care for a child's gastrostomy tube at home? a. Never turn the gastrostomy button. b. Clean around the insertion site daily with soap and water. c. Expect some leakage around the button. d. Remove the tube for cleaning once a week.

ANS: B Feedback A The gastrostomy button should be rotated in a full circle during cleaning. B The skin around the tube insertion site should be cleaned with soap and water once or twice daily. C Leakage around the tube should be reported to the physician. D A gastrostomy tube is placed surgically. It is not removed for cleaning.

12. Which nursing action is the most appropriate when applying a face mask to a child for oxygen therapy? a. The oxygen flow rate should be less than 6 L/min. b. Make sure the mask fits properly. c. Keep the child warm. d. Remove the mask for 5 minutes every hour.

ANS: B Feedback A The oxygen flow rate should be greater than 6 L/min to prevent rebreathing of exhaled carbon dioxide. B A properly fitting face mask is essential for adequate oxygen delivery. C Oxygen delivery through a face mask does not affect body temperature. D A face mask used for oxygen therapy is not routinely removed.

2. Which nursing diagnosis is appropriate for the 5-year-old child in isolation because of immunosuppression? a. Spiritual distress b. Social isolation c. Deficient diversional activity d. Sleep deprivation

ANS: C Feedback A A 5-year-old child is not developmentally advanced enough to feel spiritual distress. B The main social system for a 5-year-old child is the family, who should be allowed liberal visitation. C Children in isolation need extra attention to avoid boredom. D Sleep deprivation may occur during hospitalization but is not specific to isolation.

15. Which action by the nurse is appropriate when preparing a child for a procedure? a. Discourage the child from crying during the procedure. b. Use professional terms so the child will understand what is happening. c. Give the child choices whenever possible. d. Discourage the parents from staying in the room during the procedure.

ANS: C Feedback A Children (and adults) should be given permission to cry. B Age-appropriate language should always be used. C Allowing children to make choices gives them a sense of control. D Parents should be encouraged to stay in the room and give support to the child.

5. Which nursing action is most appropriate when treating a child who has a fever of 102.5° F? a. Restrict fluid intake. b. Administer an aspirin. c. Administer an antipyretic such as acetaminophen. d. Bathe the child in tepid water.

ANS: C Feedback A Dehydration can occur from insensible water loss. Offer the child fluids frequently and evaluate the need for IV therapy. B Aspirin is avoided because of the potential association with Reye's syndrome. C Treatment of a fever can include administration of an antipyretic. D A sponge or tub bath with tepid water to reduce fever can cause shivering and ultimately increase the child's temperature.

7. Which action is appropriate to promote a toddler's nutrition during hospitalization? a. Allow the child to walk around during meals. b. Require the child to empty his or her plate. c. Ask the child's parents to bring a cup and utensils from home. d. Select new foods for the child from the menu.

ANS: C Feedback A For safety reasons, "roaming" while eating should not be permitted. The child should be seated during meals. B Toddlers often use food as a source of control. Forcing a toddler to eat only increases the child's sense of powerlessness. Toddlers also experience food jags, a normal phenomenon when they will only eat certain foods. C Using familiar items during mealtimes increases the toddler's sense of security and control. D Hospitalization is a stressful experience for the toddler. It is not the time to introduce the child to new foods.

3. What should the nurse consider when having consent forms signed for surgery and procedures on children? a. Only a parent or legal guardian can give consent. b. The person giving consent must be at least 18 years old. c. The risks and benefits of a procedure are part of the consent process. d. A mental age of 7 years or older is required for a consent to be considered "informed."

ANS: C Feedback A In special circumstances, such as emancipated minors, the consent can be given by someone younger than 18 years without the parent or legal guardian. B In special circumstances, such as emancipated minors, the consent can be given by someone younger than 18 years without the parent or legal guardian. C The informed consent must include the nature of the procedure, benefits and risks, and alternatives to the procedure. D A mental age of 7 years is too young for consent to be informed.

10. What nursing action is appropriate for specimen collection? a. Follow sterile technique for specimen collection. b. Sterile gloves are worn if the nurse plans to touch the specimen. c. Use Standard Precautions when handling body fluids. d. Avoid wearing gloves in front of the child and family.

ANS: C Feedback A Specimen collection is not always a sterile procedure. B Gloves should be worn if there is a chance the nurse will be contaminated. The choice of sterile or clean gloves will vary according to the procedure or specimen. C Standard Precautions should always be used when handling body fluids. D The child and family should be educated in the purpose of glove use, including the fact that gloves are used with every patient, so that they will not be offended or frightened.

20. A nurse must do a venipuncture on a 6-year-old child. An important consideration in providing atraumatic care is to a. Use an 18-gauge needle if possible. b. Have another nurse try if not successful after four attempts. c. Restrain child only as needed to perform venipuncture safely. d. Show the child the equipment to be used before the procedure.

ANS: C Feedback A Use the smallest gauge needle that permits free flow of blood. B A two-try-only policy is desirable, in which two operators each have only two attempts. If insertion is not successful after four punctures, alternative venous access should be considered. C Restrain child only as needed to perform the procedure safely; use therapeutic hugging. D Keep all equipment out of sight until used.

17. The nurse wore gloves during a dressing change. When the gloves are removed, the nurse should a. Wash hands thoroughly. b. Check the gloves for leaks. c. Use an alcohol-based hand rub. d. Apply new gloves before touching the next patient.

ANS: C Feedback A When gloves are worn, the hands can be cleaned using an alcohol-based hand rub. If hands are visibly soiled they should be washed with soap and water. B Gloves should be disposed of after use. C Evidence-based research has demonstrated that alcohol-based rubs are more effective for eliminating organisms. D Hands should be thoroughly cleaned before new gloves are applied.

1. The nurse is preparing for the admission of an infant who will have several procedures performed. In which situation is informed consent required? Select all that apply. a. Catheterized urine collection b. IV line insertion c. Oxygen administration d. Lumbar puncture e. CT scan with contrast

ANS: D, E Feedback Correct Informed consent is required for invasive procedures that involve risk to a child, such as a lumbar puncture, chest tube insertion, and bone marrow aspirations. A consent is also required for a CT scan with contrast. Incorrect Informed consent is not required for procedures that are covered under the general consent to treat that is signed at admission by a parent or a guardian. These procedures all fall under this category.

2. The nurse is caring for a 2-year-old patient admitted with suspected respiratory syncytial virus (RSV). The nurse anticipates that the provider will order a throat culture to confirm the diagnosis. Is this statement true or false?

ANS: F A sputum specimen is necessary to rule out other diagnoses such as influenza or pneumonia. Because younger children can seldom produce a deep cough on command and often swallow secretions, obtaining specimens often requires nasal washing. Throat cultures are used to identify the causative agents for either a sore throat or tonsillitis.

1. The nurse is admitting a preschooler to the hospital for a scheduled minor surgical procedure requiring an overnight stay. Since the patient is under the age of 12 years, a fall risk assessment is unnecessary. Is this statement true or false?

ANS: F Most hospitalized children are physically active and may be at risk for injury from falls. Factors that contribute to falls include an altered mental status, the need for mobility assistance, and lack of attentiveness on the part of the parent. It is recommended that all children undergo a fall risk screening when admitted to a hospital and again if motor or sensory changes occur.