Ch. 13 Key Pediatric Nursing Interventions

The nurse is calculating the urinary output for the infant. The infant's diaper weighed 40 g prior to placing the diaper on the infant. After removal of the wet diaper, the diaper weighed 75 g. How many milliliters of urine can the nurse document as urinary output? Record your answer using a whole number.

Answer: 35 The diaper must be weighed before being placed on the infant and after removal to determine urinary output. For each 1 g of increased weight, this is the equivalent of 1 mL of fluid. 75 g − 40 g = 35 g = 35 mL

The adolescent weighs 113 lb (51.36 kg). The nurse closely monitors the child's urine output. How many milliliters of urine is the least amount that the adolescent should make during an 8-hour shift? Record your answer using a whole number.

Answer: 411 The child weighs 113 lb (51.36 kg). 51.36 kg × 1 mL/1 kg = 51.36 mL/hour; 51.36 × 8 hours = 410.90; Rounded to the nearest whole number = 411 mL

The child weighs 27 kg. Using the following formula, calculate how many milliliters of intravenous fluids should be administered to the child in a 24 hour period. Record your answer using a whole number Formula: 100 mL/kg of body weight for the first 10 kg 50 mL/kg of body weight for the next 10 kg 20 mL/kg of body weight for the remainder of body weight in kilograms

Answer: 1640 (First 10 kg) 10 kg × 100 mL/kg = 1,000 mL (Second 10 kg) 10 kg × 50 mL/kg = 500 mL (remaining kilograms of body weight) 7 kg × 20 mL/kg = 140 mL 1,000 + 500 + 140 = 1,640 mL

The child weighs 47 lb (21.31 kg). How many kilograms does the child weigh? Record your answer using one decimal place.

Answer: 21.4 There are 2.2 lb per kg. 47 lb × 1 kg/2.2 lb = 21.363636 kg. When rounded to the tenth place, the answer is 21.4 kg.

The nurse is educating the parents of a 5-month old how to administer an oral antibiotic. Which response indicates a need for further teaching? a. "We can mix the antibiotics into his formula or food." b. "We can follow his medicine with some applesauce or yogurt." c. "We can place the medicine along the inside of his cheek." d. "We should not forcibly squirt the medication in the back of his throat."

Answer: a Never mix a medication with formula or food. The child may associate the bitter taste with the food and later refuse to eat it.

The nurse is caring for a 4-year old who requires a venipuncture. To prepare the child for the procedure, which explanation is most appropriate? a. "The doctor will look at your blood to see why you are sick." b. "The doctor wants to see if you have strep throat." c. "The doctor needs to take your blood to see why you are sick." d. "The doctor needs to culture your blood to see if you have strep."

Answer: a The nurse should provide a description of and reason for the procedure in age-appropriate language. The nurse should avoid the use of terms such as culture or strep throat as it is not age appropriate for a 4-year old. The nurse should also avoid confusing terms like "take your blood" that might be interpreted literally.

The nurse is preparing to administer medication to a 10-year old who weighs 70 lb (32 kg). The prescribed single dose is 3 to 4 mg/kg/day. Which dose range is appropriate for this child? a. 96 to 128 mg b. 105 to 140 mg c. 210 to 280 mg d. 420 to 560 mg

Answer: a The nurse should use the child's weight in kilograms. The nurse would then multiply the child's weight in kilograms by 3 mg (32 kg × 3 mg = 96 mg) for the low end and then by 4 mg for the high end (32 lb × 4 mg = 128 mg).

Age affects how the medication is distributed throughout the body. Which factors affect how medication distribution is altered in infants and young children? Select all that apply. a. Infants and young children have an increased percentage of water in their bodies. b. Infants and young children have an increased percentage of body fat. c. Infants and young children have an increased number of plasma proteins available for binding to drugs. d. The blood-brain barrier in infants and young children does not easily allow permeation by many medications. e. The livers of infants and young children are immature.

Answer: a, e It is true that infants and young children have an increased percentage of water in their bodies. Infants and young children have immature livers.

The nurse is caring for a child with an intravenous device in his hand. Which sign would alert the nurse that infiltration is occurring? a. Warmth, redness b. Cool, puffy skin c. Induration d. Tender skin

Answer: b Signs of infiltration included cool, puffy, or blanched skin. Warmth, redness, induration, and tender skin are signs of inflammation.

The nurse is preparing to remove an IV device from the arm of a 6-year-old girl. Which approach is best for minimizing fear and anxiety? a. "This won't be painful; you'll just feel a tug and a pinch." b. "The first step is for you to help me remove this dressing from your IV." c. "Be sure to keep your hands clear of the scissors so I don't cut you." d. "Please be a big girl and don't cry when I remove this."

Answer: b The nurse should explain what is to occur and enlist the child's help in the removal of the tape or dressing. This provides the child with a sense of control over the situation and also encourages his or her cooperation. The nurse should avoid using scissors to remove the tape or dressing and the comment regarding cutting may be perceived as threatening and/or frightening. Telling the child to be a big girl is inappropriate and does not teach. Telling the child the procedure will not hurt and using the terms tug and pinch could increase the child's fear and lead to misunderstanding.

The nurse is preparing to administer a medication via a syringe pump as ordered for a 2-month-old girl. Which is the priority nursing action? a. Gather the medication b. Verify the medication order c. Gather the necessary equipment and supplies d. Wash hands and put on gloves

Answer: b The priority nursing action is to verify the medication ordered. The first step in the eight rights of pediatric medication administration is to ensure that the child is receiving the right medication. After verifying the order, the nurse would then gather the medication, the necessary equipment and supplies, wash hands, and put on gloves.

The nurse is assessing the aspirate of a gavage feeding tube to confirm placement. Which assessment finding indicates intestinal placement? a. Clear aspirate b. Yellow aspirate c. Tan aspirate d. Green aspirate

Answer: b Yellow or bile-stained aspirate indicates intestinal placement. Clean, tan, or green aspirate indicates gastric placement.

A nurse is caring for a child who requires intravenous maintenance fluid. The child weighs 30 kg. Which is the child's daily maintenance fluid requirement? a. 1,500 mL b. 1,600 mL c. 1,700 mL d. 1,800 mL

Answer: c The child's daily intravenous fluid maintenance is 1,700 mL. The child requires 100 mL/kg for the first 10 kg, plus 50 mL/kg for the next 10 kg, plus 20 mL/kg for each kg more than 20 kg. This equals the number of kg required for 24 hours. (10 × 100) + (10 × 50) + (10 × 20) = 1,700.

A nurse is educating the parents how to administer daily oral medication to their 5-year-old boy. Which response indicates a need for further teaching? a. "I should never refer to the medicine as candy." b. "We should never bribe our child to take the medicine." c. "He needs to take his medicine or he will lose a privilege." d. "We checked that the medicine can be mixed with yogurt or applesauce."

Answer: c The nurse should emphasize that the parents should never threaten the child in order to make him take his medication. It is more appropriate to develop a cooperative approach that will elicit the child's cooperation since he needs ongoing, daily medication. The other statements are correct.

A nurse is preparing to administer an ordered IM injection to an infant. The nurse knows that the most appropriate injection site for this child is which muscle? a. Deltoid b. Ventrogluteal c. Dorsogluteal d. Vastus lateralis

Answer: d The preferred injection site for infants is the vastus lateralis muscle. An alternative site is the rectus femoris muscle. The dorsogluteal is not a recommended site for the infant. The deltoid muscle, which is a small muscle mass, is used as an IM injection site in children after the age of 4 to 5 years of age due to the small muscle mass.