Chapter 30: Procedures and Treatments Maternal Prep - U

A nurse is teaching the parents of a preschool-aged child how to collect a stool specimen at home for ova and parasites? The nurse determines that the teaching was successful based on which statement?

"We will take the specimen to the laboratory immediately."

Following the repair of a cleft palate, the nurse places an 18-month-old child in restraints. The caregivers are with the child and will stay in the room at all times. Which type of restraints would the nurse most likely use for this child?

elbow restraint

The nurse is caring for an infant recovering from surgery for a cleft palate. Which type of restraint would the nurse anticipate using for this infant post-operatively?

elbow

The nurse will apply which type of restraint for the infant recovering from cleft lip repair?

elbow

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." Explanation:

A 7-year-old boy has been admitted to the hospital with a diagnosis of fever of unknown origin. He has numerous tests ordered for diagnosis. When preparing him for the blood tests ordered, the best explanation would be:

"The doctor needs to look at your blood to see why you are sick; it will hurt for a second."

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."

The nurse is preparing to assist with a procedure on a child. The nurse states the child can pick a toy from the prize box after the procedure. The parent asks the nurse, "Are you trying to bribe my child?" Which response by the nurse is appropriate?

"We give rewards to help children remember the experience as not all bad."

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

A nasogastric tube for enteral feedings has just been inserted in a 6-month-old infant. Which method would the nurse anticipate being used to confirm placement?

Have an abdominal X-ray completed

The nurse needs to provide instructions to a school-age girl about how to obtain a clean catch midstream urine specimen. Which instructions are best?

Clean the labia from front to back, then void a small amount into the toilet before collecting in the cup.

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.

After a gavage feeding has been completed for a young infant, the nurse will encourage the parent to take what action?

Burp the infant.

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.

A toddler has a peripheral IV and has pulled it out twice on one shift. The nurse decides to apply an elbow restraint on the right arm to prevent the client from pulling the IV out again. What interventions would the nurse implement in caring for a client in elbow restraints? Select all that apply.

Ensure that the restraint does not go too high under the axillae. Check the skin under the restraint every 1 to 2 hours. Pin the restraint to the child's shirt for stability. Tongue depressors can be used to construct the restraint.

The nurse is preparing a school-age child for a diagnostic procedure. What is an important nursing role in relation to obtaining informed consent for this procedure for this client?

Ensure the child understands and assents to the test.

When performing a procedure on a child in the health care setting, what should the priority intervention by the nurse be?

Ensuring the child's safety

The nurse is attempting to insert an intravenous (IV) line in a child. The child will not remain still, moving constantly. The caregiver asks, "Can you use a restraint? The IV has to be in for my child to get the medicine needed to get better." Which action will the nurse take?

Explain that restraints are used only as a last resort.

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 nurse is caring for a 14-year-old with a gastrostomy tube. The girl has skin breakdown and irritation at the insertion site. What would be the most appropriate method to clean and secure the gastrostomy tube?

If any drainage is present, use a presplit 2 × 2 and place it loosely around the site.

A nurse will explain to a child's caregiver any procedure that is to be done. What is the primary reason for this explanation?

It helps to reduce anxiety.

An adolescent is scheduled to have the present gastrostomy tube replaced with a gastrostomy button. What advantage of the button over the tube will the nurse emphasize?

The button will be smaller and less visible when not in use.

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.

How will the nurse determine the length of orogastric tubing needed to gavage the 14-month-old infant?

Measure from nose tip to earlobe to end of sternum.

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.

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.

A nurse receives a physician's order to collect a specimen for the diagnosis of respiratory syncytial virus. How should the nurse collect this specimen?

Obtain a nasal washing.

A nurse inserts a nasogastric (NG) tube into a child for enteral feeding. How will the nurse ensure appropriate placement of the tube after insertion?

Obtain radiologic confirmation.

The health care provider 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.

The nurse is caring for a 2-year-old child in the pediatric unit. The child was being fed by unlicensed assistive personnel and had a temper tantrum and spit out the food. The child now needs to be taken for a diagnostic procedure. Which nursing action would be the best method of transporting this child?

Place the child in a crib with high side rails or in a crib with a bubble top.

A pediatric client is having difficulty breathing. Which nursing intervention is appropriate for this client?

Provide oxygen as needed to maintain oxygen saturation above 93%.

The nurse is caring for a comatose school-age child receiving gastrostomy tube feedings. The nurse aspirates 15 ml of stomach contents prior to administering a feeding. What is the appropriate action by the nurse?

Replace the stomach contents and continue with the feedings as prescribed.

Colin, age 1, has been admitted for an injury on his head that requires sutures to be placed. He is crying and trying to sit up when he is placed on the examining table. To keep him safe during the procedure, the nurse would choose which method to restrain him?

Restrain him with a mummy restraint and release it as soon as the procedure is completed.

The nurse aspirates stomach contents before administering a nasogastric (NG) tube feeding. How will the nurse manage the aspirate? Select all that apply.

Return the aspirate to the stomach. Determine the pH of the aspirate. Record the amount of the aspirate.

A 6-month-old infant requires a routine urine specimen for analysis. Which action by the nurse would be appropriate?

Squeezing the diaper to obtain the urine sample. urine Place a urine collector on the baby just prior to feeding.

The nurse is caring for a child receiving oxygen. The nurse observes the caregiver remove petroleum-based cream from a bag and prepare to apply the cream to the child. The caregiver states the child has dry skin and this cream is applied daily at home. Which action will the nurse take?

Stop the caregiver from applying the cream.

A nurse working with a client 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 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 is preparing a 7-year-old child for surgery. Which nursing action is the highest priority?

The nurse should follow the facility's policies.

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 nurse is preparing to insert a feeding tube into a child and lubricates the tube with water or a water-soluble jelly first. Why does the nurse avoid the use of an oil-based lubricant?

There is a danger of oil aspiration into the lungs.

A child has been admitted to the pediatric unit with diarrhea. The nurse must collect a stool specimen for ova and parasites. The nurse knows that the proper procedure must be followed for detection of the ova and parasites. The proper procedure includes:

Transport the stool specimen to the laboratory promptly.

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.

The nurse is administering a prescribed bolus gavage feeding. Which action would be incorrect in performing this procedure?

Verify placement by auscultating for sounds in the stomach when air is inserted.

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 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.

For which client would the nurse question the doctor's orders for a throat culture swab?

a toddler suspected to have epiglottitis

While teaching parents how to effectively reduce the child's fever, the nurse should emphasize avoiding which intervention?

acetylsalicylic acid

A child has been admitted to the pediatric unit with an oral temperature of 102°F (38.9°C). Acetaminophen has failed to control the fever. The nurse knows that she may utilize which therapeutic modalities? Select all that apply.

cooling blanket hydration lightweight clothes cool room

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 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

The nurse is caring for an 11-year-old admitted with a respiratory condition. The child requires occasional administration of low-flow oxygen. Which of the following methods of oxygen administration would likely be used for this child?

nasal prongs

A preschool child has been admitted to the hospital. Which prescription should the nurse question?

tap water enema 500 ml

Which of the following are situations that might warrant a restraint of a pediatric client? Select all that apply.

to protect the child from injury during a procedure or examination to ensure the child's safety

A young preschooler who has been playing in the hospital playroom needs transportation to the imaging department. What conveyance will the nurse choose?

wagon

The nurse is about to place a gastrostomy tube in an infant. After gathering the supplies, which is the first step in the procedure?

Explain the procedure to the parents.

An older school-aged child is taught to apply warm, nonsterile compresses to an inflamed area on one leg. Which suggestion by the nurse will increase the effectiveness and safety of the child's self-care?

Set a timer for not longer than 20 minutes as a removal reminder.

The nurse is caring for a child who has a gastrostomy tube in place. The nurse is about to give a feeding when it becomes evident that the tube is filled with dark brown fluid. The nurse's best action would be to:

report to the health care provider that a complication may be occurring.

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

The nurse needs to transport her preschool client to radiology for a chest X-Ray. Which transportation device would be most appropriate?

wagon