Peds Chapter 30: PrepU
A 6-year-old client is scheduled for removal of her tonsils and adenoids. She appears anxious and is tearful. Which statement by the nurse would best alleviate her fears?
"A special doctor will give you some medicine to make you sleep so you will not know anything that is happening."
The nurse instructs the mother of a preschool-aged child on the use of ibuprofen prescribed for a temperature. Which statement indicates that the teaching has been effective?
"I should give this medication with food."
A nurse is teaching a parent ways to reduce fever in a child. What statement made by the parent would require further education?
"I will give my child a tepid sponge bath to reduce the fever."
A parent calls the nurse in the emergency department and reports giving a tepid bath to decrease temperature in a feverish child. The parent states the child is shivering and wants to know if this means the bath was effective. What is the best response by the nurse?
"Shivering means the child is chilling, which will cause the body temperature to increase."
The nurse needs to obtain a blood sample from a 7-year-old child. How should the nurse explain this procedure to the client?
"The doctor needs to look at your blood to see why you are sick; it will hurt for a second."
A 4-year-old child is being prepared to undergo a bronchoscopy to remove an aspirated pea. The nurse knows that the parents need additional teaching based on which statement?
"We will be able to take our child home immediately after the procedure is completed."
A nurse has just received an order to apply an ice bag to a client's groin. Which of the following intervals for placement of the ice bag does the nurse plan to use?
20 minutes
While teaching parents how to effectively reduce the child's fever, the nurse should emphasize avoiding which intervention?
Acetylsalicylic acid
The nurse is caring for a minor who wishes to sign the informed consent instead of the parents. In which situations would the nurse allow the adolescent to sign the consent? Select all that apply.
Adolescent is married. Adolescent is serving in the armed forces. There is an emergent or life-threatening situation. Legal emancipation has been documented. Minor is sexually active and seeking prenatal care
An infant is scheduled to have a painful procedure performed. Which nursing action provides the best support for the parents and infant?
Allow the parents to hold the infant during the procedure.
The nurse has just inserted a nasogastric tube for an enteral feeding in a 6-month-old infant. The best way to assess whether the tube has reached her stomach is to:
Aspirate the tube for stomach contents.
A nursing student is learning how to insert and administer enteral feedings through a nasogastric (NG) tube. The student identifies the best way to check placement before each feeding as which of the following?
Aspirating stomach contents and checking pH
A preschool-aged child has not been able to eat for several days until all diagnostic tests are complete to determine the cause of chronic diarrhea. Which nursing diagnosis should the nurse identify as being appropriate for the patient at this time?
Imbalanced nutrition, less than body requirements, related to food restriction for procedures
A nurse is preparing to apply heat therapy to a client who has a back abscess. Heat has which of the following benefits? Select all that apply.
Increases circulation Causes vasodilation Promotes muscle relaxation
A pediatric nurse is teaching a class about SIDS to new mothers. Which of the following positions for sleep would the nurse emphasize for parents to use?
Back or side
After a gavage feeding has been completed for a young infant, the nurse will encourage the parent to take what action?
Burp the infant
The nurse will apply which type of restraint for the infant recovering from cleft lip repair?
Elbow
An infant is admitted to the hospital for cleft palate surgery. The type of restraint you would use with the infant postoperatively would be:
Elbow restraints
How will the nurse properly collect and care for the child's 24-hour urine specimen?
Empty each void into a designated container that keeps the urine cool
The nurse is reinforcing teaching with a group of caregivers regarding steps that can be taken to lower a child's elevated temperature. Which action would the nurse include in the discussion? Select all that apply.
Encourage fluids. Administer acetaminophen. Lower the room temperature.
A 6-year-old has just returned to his room after a spinal tap. What could the nurse do to make this unpleasant procedure less memorable for the child?
Give him a little toy that he has been wanting.
When an infant is scheduled for a painful procedure, what is the most important action by the nurse?
Help to soothe and comfort the baby before and after the procedure.
A child is reporting pain where an IV infiltrated his hand earlier in the shift. The doctor orders warm compresses to the right hand every 4 hours. What precautions would the nurse implement for this client?
Limit treatments to 20 minutes at a time.
A nurse is preparing to insert a nasogastric (NG) tube in an infant. How will the nurse determine the appropriate length of tubing to use for the infant?
Measure from the tip of the child's nose to the earlobe down to the tip of the sternum.
The floor nurse is making rounds on her clients and discovers that an 8-month-old admitted with pneumonia has an oxygen saturation of 91% on room air. The physician has standing orders to keep saturations at 96% or above. Which oxygen delivery system would the nurse choose for this client?
Nasal cannula
Parents asks the nurse why their premature infant is receiving a feeding through the mouth rather than the nose. What is the best explanation by the nurse?
Newborns are obligate nose breathers so nasogastric may obstruct their breathing.
The doctor orders a urinalysis on a 15-month-old toddler. The mother states that the child is not potty trained. What is the best way for the nurse to collect the specimen?
Place a urine collection bag on the child after cleaning off the perineum.
If a urine specimen for analysis is ordered for an 8-month-old girl, which intervention would you use?
Place a urine collector on her just prior to feeding.
Which intervention should the nurse use when collecting a urine specimen from an 8-month-old client?
Place a urine collector on the baby just prior to feeding.
The nurse obtains a stool specimen for ova and parasites. It would be important for the nurse to:
See that it arrives at the laboratory promptly.
The nurse should consider which stool sample collected from a child as contaminated and not acceptable for analysis?
Stool removed from surrounding urine
A nurse is administering a bolus nasogastric (NG) feeding to a child who begins gasping, coughing, and developing cyanosis. What is the first action that the nurse should take after this observation?
Stop the feeding and withdraw the tube.
A nurse working with a patient who has an elevated temperature notices that the child is beginning to shiver. Which of the following should the nurse do immediately?
Stop whatever intervention is being done to lower the temperature.
A preschool child has been admitted to the hospital. Which prescription should the nurse question?
Tap water enema 500 ml
A child has returned to the unit after having a lumbar puncture. Which instructions are important for the nurse to provide the parents and child?
The child will need to remain flat to prevent a headache.
The nurse has assisted the provider in performing a spinal tap on a 6-month-old infant. Which of the following should the nurse include in documenting the procedure?
The nurse documents the child's response to the procedure.
The nurse has delegated the task of obtaining vital signs on a school-aged child to the nursing assistant. Which action by the nursing assistant is correct when obtaining a pulse?
The radial pulse was counted for one full minute.
The nurse finds an elevated temperature in a blanket-wrapped infant a mother is holding and rocking. What first temperature reduction measure will the nurse take?
Unwrap the infant and place the child in the crib.
A young preschooler who has been playing in the hospital playroom needs transportation to the imaging department. What conveyance will the nurse choose?
Wagon
A nurse is caring for a hospitalized infant being treated for dehydration. What does the nurse need to do to measure the output when the child is wearing a diaper?
Weigh the wet diaper and subtract the weight of a dry diaper; the difference is the amount to record.
