Chapt 22 Pediatric MSK

The nurse is providing postoperative care for a 14-month-old girl who has undergone a myelomeningocele repair. The girl's mother is extremely anxious and tells the nurse she is afraid she will never learn how to care for her daughter at home. Which response by the nurse would be most appropriate?

A) "I will help you become comfortable in caring for your daughter." The nurse needs to empower families to become the experts on their child's needs and conditions via education and participation in care. The most positive approach is to let the mother know the nurse will support her and help her become an expert on her daughter's care. Telling the mother that she must learn how to care for her daughter or that she must have a positive attitude is not helpful. Telling her that she needs to collaborate with the caregivers is true, but does not address her fears.

The nurse is caring for a 14-month-old boy with rickets who was recently adopted from overseas. His condition was likely a result of a diet very low in milk products. The nurse is providing teaching regarding treatment. Which response by the parents indicates a need for further teaching?

A) "We must give him calcium and phosphorus with food every morning." The nurse should emphasize that the calcium and phosphorus supplements should be administered at alternate times to promote proper absorption of both of these supplements. Taking vitamin D, spending time in the sun, and encouraging intake of fish, dairy, and liver are appropriate responses.

A child with Duchenne muscular dystrophy is to receive prednisone as part of his treatment plan. After teaching the child's parents about this drug, which statement by the parents indicates the need for additional teaching?

A) "We should give this drug before he eats anything." Corticosteroids such as prednisone can cause gastric upset, so the medication should be given with food to reduce this risk. The drug may mask the signs of infection, so the parents need to monitor the child closely for any changes. Treatment with this drug should not be stopped abruptly due to the risk for acute adrenal insufficiency. Common side effects of this drug include weight gain, osteoporosis, and mood changes.

An 8-year-old girl was diagnosed with a closed fracture of the radius at approximately 2 p.m. The fracture was reduced in the emergency department and her arm placed in a cast. At 11 p.m. her mother brings her back to the emergency department due to unrelenting pain that has not been relieved by the prescribed narcotics. Which action would be the priority?

A) Notifying the doctor immediately The nurse should notify the doctor immediately because the girl's symptoms are the classic sign of compartment syndrome. Immediate treatment is required to prevent excessive swelling and to detect neurovascular compromise as quickly as possible. The ice should be removed and the arm brought below the level of the heart to facilitate whatever circulation is present. Giving additional pain medication will not help in this situation.

The nurse is caring for a 10-year-old in traction. While performing a skin assessment, the nurse notices that the skin over the calcaneus appears slightly red and irritated. Which action would the nurse take first?

A) Reposition the child's foot on a pressure-reducing device. The nurse's first action is to remove continuous pressure from this area. The other actions can help decrease the potential for skin breakdown, but the pressure must be relieved first.

When developing the plan of care for a child with cerebral palsy, which treatment would the nurse expect as least likely?

A) Skeletal traction Skeletal traction would be the least likely treatment for a child with cerebral palsy. Physical therapy, orthotics and braces, and occupational therapy are all common treatments used for cerebral palsy.

The nurse is assessing the neuromusculoskeletal system of a newborn. What is an abnormal assessment finding?

A) Sluggish deep tendon reflexes Deep tendon reflexes are present at birth and are initially brisk in the newborn and progress to average over the first few months. Sluggish deep tendon reflexes indicate an abnormality. The newborn is capable of spontaneous movement but lacks purposeful control. Full range of motion is present at birth. Healthy infants and children demonstrate normal muscle tone; hypertonia or hypotonia is an abnormal finding.

The nurse is caring for an infant with osteogenesis imperfecta and is providing instruction on how to reduce the risk of injury. Which response from the mother indicates a need for further teaching?

B) "I must carefully lift the baby from under the armpits." The nurse needs to emphasize that the mother must not lift a baby or young child with osteogenesis imperfecta from under the armpits as it may cause harm. Avoiding pushing or pulling, not bending an arm or leg into an awkward position, and avoiding lifting the legs by the ankles are appropriate responses.

The nurse is conducting a physical examination of a child with suspected developmental dysplasia of the hip. Which finding would help confirm this diagnosis?

B) A distinct "clunk" is heard with Barlow and Ortolani maneuvers. A distinct "clunk" while performing Barlow and Ortolani maneuvers is caused as the femoral head dislocates or reduces back in to the acetabulum. A higher-pitched "click" may occur with flexion or extension of the hip. This is a benign, adventitious sound that should not be confused with a true "clunk" when assessing for developmental dysplasia of the hip. Abduction to 75 degrees, adduction within 30 degrees, and symmetric thigh and gluteal folds are normal findings.

The nurse is caring for a 2-month-old with cerebral palsy. The infant is limp and flaccid with uncontrolled, slow, worm-like, writhing, and twisting movements. What word would the nurse use when documenting these observations?

B) Athetoid Athetoid cerebral palsy is characterized by abnormal, involuntary movement. It affects all four extremities with possible involvement of the face, neck, and tongue. The movements increase in periods of stress. Dysarthria and drooling may be present as well. Spastic cerebral palsy is characterized by poor control of posture, balance, and movement; exaggeration of deep tendon reflexes; and hypertonicity of affected extremities. Ataxic is characterized by poor coordination, unsteady gait, and wide-based gait.

What information would the nurse include in the preoperative plan of care for an infant with myelomeningocele?

B) Covering the sac with saline-soaked nonadhesive gauze For the infant with a myelomeningocele, saline-soaked nonadhesive gauze or antibiotic-soaked gauze is used to keep the sac moist. The infant is positioned prone, with a folded towel under the abdomen, so that the urine and feces flow away from the sac. A warmer or isolette is used to keep the infant warm. Blankets are avoided because they could place excess pressure on the sac. Diapering may be contraindicated to avoid placing pressure on the sac.

The nurse is assessing a newborn who was delivered after a prolonged labor due to an abnormal presentation. The newborn sustained a cranial nerve injury. The nurse would most likely expect to assess deficits related to which cranial nerve?

B) Facial The most common cranial nerve injury occurring during birth trauma involves facial nerve palsy. The optic, acoustic, and trigeminal nerves are not typically injured during birth trauma.

A nurse is caring for a 14-year-old girl following myelography. What is the priority nursing action?

B) Observing for signs of meningeal irritation Following myelography, the nurse should carefully observe for signs of meningeal irritation because of what is involved in this procedure. Monitoring for a decrease in muscle spasticity, assessing motor function, and observing for mental confusion or hallucinations is appropriate following an intrathecal test dose of baclofen.

The nurse is conducting a physical examination of a child with a brachial plexus injury. Which finding would lead the nurse to be highly suspicious of Erb palsy?

B) The involved extremity is adducted, prone, and internally rotated. Erb palsy is an upper brachial plexus injury and the involved extremity usually presents as adducted, prone, and internally rotated. Inability to close one eye, facial asymmetry, or drawing of the mouth to the noninvolved side are associated with facial nerve palsy as a result of cranial nerve injuries.

The nurse is teaching a group of students about myelinization in a child. Which statement by the students indicates that the teaching was successful?

B) The process occurs in a head-to-toe fashion. Myelinization occurs in a cephalocaudal, proximodistal manner and is completed by 2 years of age. As myelinization proceeds, nerve impulses become faster and more accurate.

The nurse is caring for a 10-year-old with Duchenne muscular dystrophy. As part of the plan of care, the nurse focuses on maintaining his cardiopulmonary function. Which intervention would the nurse implement to best promote maximum chest expansion?

B) Upright positioning The nurse should emphasize that the child's position should be arranged to promote maximum chest expansion. This is usually in the upright position. Deep-breathing exercises are for strengthening/maintaining respiratory muscles. Coughing helps clear the airways. Chest percussion helps loosen secretions in lungs.

A nursing instructor is preparing for a class discussion on spinal muscular atrophy (SMA). When describing type 2 SMA, which information would the instructor include? Select all answers that apply.

B) Weakness most severe in shoulders and hips D) Slowly progressing condition E) Genetic disease with autosomal recessive inheritance Any type of spinal muscular atrophy is a genetic motor neuron disease due to autosomal recessive inheritance. Type 2 SMA usually occurs between 6 and 18 months of age, with weakness that is most severe in the shoulders, hips, thighs, and upper back. It is slower in progression than type 1. Survival into adulthood is common if respiratory status is maintained appropriately. Type 1 SMA occurs before birth to 6 months of age and the child usually has difficulty swallowing, sucking, and breathing.

The nurse is teaching the mother of a 5-year-old boy with a myelomeningocele who has developed a sensitivity to latex. Which response from his mother indicates a need for further teaching?

C) "A product's label indicates whether it is latex-free." The Food and Drug Administration (FDA) requires that all medical supplies be labeled if they contain latex, but this is not the case with consumer products. The mother must be familiar with products that contain latex. The Spina Bifida Association of America maintains an updated list of latex-containing products. Getting a medical alert identification, talking with his caregivers, and avoiding all contact with latex are correct.

A 6-year-old boy with cerebral palsy has been admitted to the hospital for some tests. His condition is stable. The boy's mother remains with her son, but she is obviously exhausted and stressed. Which response by the nurse would be most appropriate?

C) "He's in good hands; consider going home to get some sleep." Providing daily, intense care can be quite demanding and tiring. When a child with cerebral palsy is admitted to the hospital, this may serve as a time of respite for family and primary caregivers. The nurse should remind the mother that her son is in good hands and urge her to go home. Asking her whether she is planning to stay might make the mother feel obligated to stay. Asking if she wants a blanket or pillow does not encourage the mother to leave the hospital. Telling the mother she is doing a good job is nice, but does not encourage her to take a break.

The nurse is caring for a 13-year-old boy in traction prior to surgery for slipped capital femoral epiphysis. He has been in an acute care setting for 2 weeks and will require an additional 10 days in the hospital. He is complaining that he feels isolated and is resisting further treatment. Which response by the nurse would be most appropriate?

C) "Let's come up with things to do like books, movies, games, and friends to visit." After 2 weeks in traction, a teenager can become easily bored and isolated from usual peer interaction. The most helpful intervention would be to engage the help of the child to develop a list of books, games, movies, and other activities that he would enjoy. The nurse should also encourage visitation and phone calls from friends. Telling the adolescent that he needs to remain immobile or telling him that he has only 2 more weeks do not address the adolescent's issue. Telling the adolescent that his condition will worsen if he resists is threatening and inappropriate.

The nurse is caring for an active 14-year-old boy who has recently been diagnosed with scoliosis. He is dismayed that a "jock" like himself could have this condition, and is afraid it will impact his spot on the water polo team. Which response by the nurse would best address the boy's concerns?

C) "Let's talk to another boy with scoliosis, who is winning trophies for his swim team." Because this boy is concerned about limiting his participation in water polo and perceives scoliosis as a disease that does not affect "jocks," putting the child in contact with someone with the same problem would be helpful. Telling the adolescent about not needing surgery if he wears his brace or that his curvature is minimal may or may not be true in his case and thus would be false reassurance. Although these suggestions and also the suggestion about talking to the doctor about treatment options could be helpful by engaging his input in the treatment, these do not address his specific concerns about his body image.

The nurse is caring for a female infant with torticollis and is providing instructions to the parents about how to help their daughter. Which statement by the parents indicates a need for further teaching?

C) "We must apply firm pressure and stretching every other day." The nurse needs to remind the parents that the stretching exercises should be done several times a day. The stretching is applied with gentle, not firm, pressure and should be done every day for multiple sessions. The statements about turning the head both ways, flatness on one side as common, and daily stretching with multiple sessions are correct.

The nurse is caring for a 2-year-old girl in a bilateral brace with tibia vara. Her parents are upset by their toddler's limited mobility. Which response by the nurse would be most appropriate?

C) "You are doing a great job. Let's put our heads together on how to keep her busy." The nurse should support the parents by encouraging and praising their compliance with bracing. It is also important to work with the parents to help develop age-appropriate diversions to promote normal growth and development. Telling the parents that they must be compliant or their daughter could develop severe bowing does not teach, does not offer solutions, and does not address the parents' concerns. Telling the parents that they must simply accept this and that the treatment could take years is likely to upset them and does not teach. It also does not address their concerns.

A nurse is preparing a program for a group of parents about injury prevention. What would the nurse include as an important contributing factor for cervical spine injury in a child?

C) Increased mobility of the spine Compared to the adult, a child's spine is very mobile, especially in the cervical spine region, resulting in a higher risk for cervical spine injury. Exposure to teratogens in utero may lead to altered growth and development of the brain or spinal cord. Immaturity of the central nervous system places the infant at risk for insults that may result in delayed motor skill attainment or cerebral palsy. Incomplete myelinization reflects the lack of motor control.

A child with spastic cerebral palsy is to receive botulin toxin. The nurse prepares the child for administration of this drug by which route?

C) Intramuscular injection Botulin toxin is administered by injection into the muscle. It may cause dry mouth. It is not administered orally, by subcutaneous injection, or by intravenous infusion.

The nurse is developing a teaching plan for a child who is to have his cast removed. What instruction would the nurse most likely include?

C) Soaking the area in warm water every day After a cast is removed, the child and family should be instructed to soak the area in warm water every day to help soften and remove the dry flaky skin. Moisturizing lotion, not petroleum jelly, should be applied to the skin. Vigorous rubbing would traumatize the skin and should be avoided. Warm soapy water, not dilute peroxide and water, should be used to wash the area.

A child with cerebral palsy has undergone surgery for placement of a baclofen pump. Which instruction would the nurse include when teaching the parents about caring for their child?

D) Discouraging the child from stretching or bending forward for 4 weeks After insertion of a baclofen pump, the parents should discourage any twisting at the waist, reaching high overhead, stretching, or bending forward or backward for 4 weeks. The child would avoid tub baths for about 2 weeks and avoid sleeping on his stomach for 4 weeks. The parents should notify the physician or nurse practitioner if the child's temperature is greater than 101.5°F.

After teaching a class of nursing students about muscular dystrophy, the instructor determines that the teaching was successful when the students identify which type of muscular dystrophy as demonstrating an X-linked recessive pattern of inheritance?

D) Duchenne Duchenne muscular dystrophy follows an X-linked recessive inheritance pattern. Limb-girdle muscular dystrophy is believed to be autosomal or X-linked inherited. Myotonic and distal muscular dystrophy follow an autosomal dominant inheritance pattern.

The nurse has developed a plan of care for a 6-year-old with muscular dystrophy. He was recently injured when he fell out of bed at home. Which intervention would the nurse suggest to prevent further injury?

D) Recommend raising the bed's side rails when a caregiver is not present. The nurse should recommend that side rails on the bed be elevated when a caregiver is not present. The use of restraints should be avoided if at all possible. Suggesting that a caregiver be present at all times places undue stress on the family. Close observation is more appropriate. Recommending side rails be elevated at all times may be upsetting to the child and make him feel like a "baby."

The nurse is developing a teaching plan for the parents of a child with a myelomeningocele who will require clean intermittent catheterization. What information would the nurse include?

D) Soaking the catheter in a vinegar and water solution to sterilize When teaching parents how to perform clean intermittent catheterization, the nurse would instruct the parents to apply a water-based lubricant to the catheter, clean the reusable catheter with soap and water after each use, store the reusable clean catheter in a zip-top bag or other clean storage container, and soak the catheter in a 1:1 vinegar and water solution for about 30 minutes weekly, rinsing well before the next use or placing the catheter in boiling water for 10 minutes.