Chapter 32

A child with chronic immune thrombocytopenia presents to the emergency department, where the parents report a 3-day history of severe headache and recent change in mental status. What diagnostic test does the nurse prepare to facilitate as the priority? A. CT of the head B. Lumbar puncture C. Platelet count D. White blood cell count

ANS: A A child with ITP is at risk for intracerebral hemorrhage, manifested by changes in level of consciousness, headaches, visual changes, ataxia, and/or slurred speech. The diagnostic test of choice is a CT scan of the head. A lumbar puncture is often used to diagnose meningitis; because this child does not have a fever, meningitis is a low probability. Platelet count and complete blood count (including WBCs) will be done, but the priority is to obtain a head CT.

A child with sickle cell disease is receiving hypertransfusion therapy, and the current serum ferritin level is 1,035 µg/L. What medication does the nurse prepare to administer? A. Deferoxamine (Desferal) B. Elemental iron C. Furosemide (Lasix) D. Morphine sulfate (Duramorph)

ANS: A A complication of hypertransfusion is iron overload, diagnosed with a serum ferritin level of greater than 1,000 µg/L. The treatment is chelation therapy with an agent such as deferoxamine. Iron would be contraindicated. Lasix is given for fluid overload. Morphine is given for pain.

A child presents to the emergency department with sickle cell crisis. Which intervention does the nurse perform first? A. Administer oxygen. B. Assess and treat pain. C. Provide warm blankets. D. Start IV fluids.

ANS: A All interventions are appropriate for this child. However, airway and breathing come first, so the nurse administers oxygen then starts an IV.

A nursing student asks the instructor why he was marked off on his care plan when explaining a low hemoglobin level as being caused by "anemia." What response by the instructor is best? A. Anemia is a symptom, not a disease. B. Anemia only refers to a low red blood cell count. C. Hemoglobin and anemia are unrelated. D. The hemoglobin must not be too low.

ANS: A Anemia is a symptom that can be caused by many disease states. It is not a disease that explains low hemoglobin. The other answers are incorrect.

The nurse has educated parents on administration of iron to their child. What statement by the parents indicates a need for further instruction? A. "I will call the doctor right away if my child has black, tarry stools." B. "It is best if the iron is taken on an empty stomach or with orange juice." C. "Rinsing the mouth after taking iron will prevent staining the teeth." D. "We will have our child drink the iron preparation through a straw."

ANS: A Black, tarry stools are a common side effect of iron and the parents need not call the provider. The other statements show good understanding of iron and its administration.

A child is suspected of having aplastic anemia. What physical assessment should the nurse perform to correlate with this condition? A. Abdominal palpation B. Lung auscultation C. Oral assessment D. Skin inspection

ANS: A Children with aplastic anemia do not have hepatosplenomegaly, so when palpating the abdomen, it feels normal. The other assessments are not as specific for findings in this disease.

The parents of an 8-year-old child with sickle cell anemia call the clinic to report that the child developed chest pain after playing soccer. What advice from the nurse is most appropriate? A. "Go to the nearest emergency department." B. "Have him rest and take Tylenol (acetaminophen)." C. "If he doesn't improve, bring him in to the clinic." D. "Try a warm pack on his chest for 10 minutes."

ANS: A In sickle cell disease, the abnormally shaped RBCs are sticky and adhere to the blood vessel walls, creating obstructions to circulation. This creates the potential for tissue ischemia and death. The child could be having a heart attack and needs immediate evaluation.

A nurse is assessing an infant for the most common type of anemia worldwide. What action by the nurse is most helpful? A. Assess if formula is iron-fortified. B. Determine family history of anemia. C. Look at mucous membranes for pallor. D. Perform range of motion on the hips.

ANS: A The most common type of anemia worldwide is iron-deficiency anemia, which can be caused by ingesting non-iron-fortified formula if the child is not breastfed. This type of anemia is not genetic. Pallor, either of the skin or mucous membranes, would be seen in any type of anemia. Range of motion of the hips or shoulders is an important assessment in sickle cell disease, in which avascular necrosis can occur.

A 2-year-old child's hemoglobin is 8.2 g/dL. What action by the nurse is best? A. Ask the parents about activity level. B. Document findings in the chart. C. Notify the provider immediately. D. Schedule a re-draw of blood in 6 months.

ANS: A The normal hemoglobin for a child this age is 10.55-12.7 g/dL, so this child is somewhat anemic. The nurse should assess for other manifestations of anemia, including normal activity level. The findings should be documented, but this is not the only action that the nurse should take. The provider needs to be notified, but it does not have to be done immediately, as this is not an emergency. After a full evaluation, the provider may or may not want to repeat the laboratory work in 6 months.

A school-age child is scheduled to have a bone marrow biopsy. What action by the nurse takes priority? A. Ensure informed consent is on the chart. B. Help position the child to facilitate the sample. C. Provide developmentally appropriate teaching. D. Use distraction techniques during the procedure.

ANS: A This invasive procedure requires informed consent. The nurse will also provide developmentally appropriate teaching and help position the child during the procedure, but these do not take priority over this legal requirement. For young children, sedation, not distraction, is used.

A faculty member is reviewing guidelines for blood transfusions with a student whose patient is to receive 2 units of packed red blood cells. Which of the following does the student know about transfusions? (Select all that apply.) A. Do not obtain the unit of blood more than 30 minutes before starting it. B. Obtain a baseline set of vital signs prior to starting the transfusion. C. Run the blood transfusion at a slow rate for the first 15 minutes. D. The transfusion of 1 unit of blood must be completed within 6 hours. E. Two appropriate health-care providers must check the blood at the bedside.

ANS: A, B, C, D Always check institutional policies before transfusing any type of blood product. These options are from the American Association of Blood Banks. Transfusions must be completed within 4 hours.

A child is hospitalized with immune thrombocytopenia (ITP). What treatment options does the nurse prepare to answer questions about? (Select all that apply.) A. Anti-D antibody (WinRho) B. IV immune gamma globulin C. Platelet transfusions D. Steroid administration E. Whole blood transfusion

ANS: A, B, C, D Treatment options for ITP include WinRho, IV immune gamma globulin (IVIG), platelet transfusion in case of a life-threatening condition, and steroids. Whole blood is not transfused. If the child experiences a severe hemolytic anemia secondary to the WinRho, packed red blood cells might be considered, but usually this is a rapidly improving condition.

A child has mild anemia. Parents learn to assess for signs of worsening anemia, including which of the following? (Select all that apply.) A. Decreased activity B. Irritability C. Listlessness D. Pale skin E. Rapid heart rate

ANS: A, B, C, E Signs of moderate anemia include decreased activity, irritability or listlessness, tachycardia, systolic heart murmur, irritability, fatigue, delayed motor development, hepatomegaly, and congestive heart failure. Pale skin can be seen in both mild and moderate anemia.

A child is in the pediatric intensive care unit with disseminated intravascular coagulation (DIC). What laboratory findings correlate with this condition? (Select all that apply.) A. Decreased PTT B. Increased D-dimer C. Increased fibrinogen D. Low platelet count E. Normal white blood cell count

ANS: B, D Laboratory findings consistent with DIC include prolonged PT and PTT, elevated D-dimer, low fibrinogen, and low platelet count. The WBCs are not diagnostic for DIC.

The pediatric nurse knows that which of the following might be included in the collaborative care of children with mild to moderate anemia? (Select all that apply.) A. Administration of epopoietin alfa (Epogen) B. Blood product transfusions C. Bone marrow transplantation D. Routine laboratory analysis E. Supplements and iron-rich diet

ANS: A, B, D, E Collaborative care for the anemic child depends on the nature of the anemia, but includes colony-stimulating factors such as Epogen, transfusions, routine laboratory draws, iron supplements, and a nutritious diet rich in iron. Bone marrow transplantation is an option only for severe cases, such as aplastic anemia.

A pediatric intensive care nurse understands that which of the following are complications of apheresis procedures? (Select all that apply.) A. Air embolism B. Bleeding C. Hypercalcemia D. Hyperthermia E. Hypotension

ANS: A, B, E Complications of apheresis procedures include air embolism, bleeding, hypocalcemia, hypothermia, hypotension, transfusion reaction, thrombosis, and infection.

The student studying pediatric hematological disorders learns that anemia can occur in several ways, including which of the following? (Select all that apply.) A. Acute or chronic blood loss B. Altered shape of RBCs C. Decreased RBC production D. Increased RBC destruction E. Lack of functional RBCs

ANS: A, C, D The three major causes of anemia include increased destruction of RBCs, decreased production of RBCs, and blood loss. Altered shape and function do not cause anemia.

The pediatric nurse understands blood types. Which of the following donor/recipient matches are suitable? (Select all that apply.) A. Donor: A+ Recipient: A+ B. Donor: B+ Recipient: B- C. Donor: AB+ Recipient: Anyone D. Donor: O- Recipient: Anyone E. Donor: A- Recipient: A-, A+

ANS: A, D, E See Box 32-3 for compatibilities between blood donors and recipients.

A hospitalized child is receiving antithymocyte globulin (ATG) for aplastic anemia. What action by the nurse is most important? A. Assess the IV site for good blood return. B. Ensure emergency equipment is nearby. C. Obtain informed consent for each dose. D. Pad side rails and institute seizure precautions.

ANS: B ATG is made from horse or rabbit serum and can cause anaphylaxis, even after test dosing. The nurse ensures that appropriate emergency equipment is available in case of such an emergency. Assessing the IV site is also an important action, but does not take priority over being prepared for an emergency. Informed consent is not required for each dose. Seizure precautions are not needed.

An 8-year-old child had a hematopoietic stem cell transplant 10 months ago. The father brings her to the clinic, where the child reports "I just don't feel well." Dad relates that the child has been lethargic and sleeping a lot. The child's vital signs are within normal range for age. What action by the nurse is best? A. Explain that growth spurts can cause fatigue. B. Prepare the family for a "fever" workup. C. Provide reassurance to the father and child. D. Review side effects of immunosuppressants.

ANS: B After a stem cell transplant, patients are on lifelong immunosuppressant therapy. These patients may contract illnesses, especially infections, without showing the classic signs and symptoms. The nurse should assume the child has an infection and prepare the child and father for a full workup to determine the origins of the infection. Reassurance is always an important nursing intervention, but does not take priority over the child's physical health. At each clinic visit, the nurse should review the treatment regimen, including side effects of medications, but again this is not the priority. Until proven otherwise, this child is ill, and not just having a growth spurt.

The nurse administering a blood transfusion is aware that which of the following is the most important nursing action to prevent a transfusion reaction? A. Checking the provider's orders for transfusion B. Identifying the patient with two unique identifiers C. Monitoring vital signs per protocol D. Staying with patient for the first 15 minutes

ANS: B All actions are important when administering blood products. However, to prevent a transfusion reaction, accurate patient identification using two unique identifiers (and two nurses) is critical. The nurse should check the orders prior to proceeding. Staying with the patient and monitoring vital signs will not help prevent a reaction but will help identify one quickly.

A couple who recently married and want to have children ask the nurse what the chances are that their children will inherit thalassemia from them, as they both are carriers. What information from the nurse is most accurate? A. All of your children will inherit it. B. Each child has a 25% chance of inheriting it. C. None of your children will inherit it. D. Only the boys will inherit it.

ANS: B Thalassemia is an autosomal recessive disorder. Each of their children has a 25% chance of having only normal genes, a 25% chance of inheriting both defective genes from the parents and expressing the disease, and a 50% chance of being a carrier.

A toddler had a minor fall and now has a swollen, bruised, painful knee. What diagnostic test is most important for the nurse to educate the parents about? A. Complete blood count B. Plasma factor assay C. Plasma ferritin level D. Platelet count

ANS: B The child has manifestations consistent with hemophilia. The most important diagnostic testing for this disease is a direct assay of plasma factor activity level for hemophilia A and B. A CBC will also most certainly be done, as will a platelet count. Plasma ferritin measures iron and is not warranted.

A nurse working in pediatrics learns that the normal hemoglobin value for an infant is high at birth, then decreases by 2 months of age before increasing again as the child grows. The nurse knows the reason for this shift is which of the following? A. Hemodilution from starting oral nutrition B. Lower available oxygen while in utero C. Rapid hemoglobin destruction at birth D. Slower hemoglobin production after birth

ANS: B The fetus needs a higher hemoglobin level to compensate for the relatively low-oxygen environment of the uterus. The other answers are incorrect.

A child is receiving a blood transfusion. On assessment, the nurse finds the child short of breath, febrile, and hypotensive. After stopping the transfusion, what action by the nurse takes priority? A. Document the findings. B. Obtain oxygen saturation. C. Prepare fluid resuscitation. D. Sit the child upright in bed.

ANS: B The manifestations can be related to several different types of transfusion reactions, but hypoxia is most closely associated with transfusion-related lung injury (TRALI). The nurse obtains an oxygen saturation. Documentation must be completed, but this is not the priority. It is unknown at this time if the child needs aggressive fluid resuscitation or blood pressure support. Sitting the child upright may help breathing, but will worsen the hypotension.

A child is taking desmopressin acetate (DDAVP) for von Willebrand's disease. What teaching about this medication does the nurse provide? A. Avoid products with aspirin (salicylate) in them. B. Get a new needle for each injection. C. Monitor your child's weight and report a gain. D. Use ice packs and pressure for epistaxis.

ANS: C DDAVP can cause hypervolemia and hyponatremia. The child may show a rapid weight gain, which should be reported. Avoiding aspirin and using ice packs for nosebleeds are care measures for the disease, not the medication. DDAVP is given intranasally for this condition.

In preparing a patient to receive an autologous bone marrow transplantation, which action by the nurse is best? A. Ensure HLA typing has been done. B. Limit visitors to one per shift. C. Place the child in protective isolation. D. Teach about long-term complications.

ANS: C In preparation for a bone marrow transplant, patients are given "near lethal" doses of chemotherapy and/or radiation in order to completely destroy their own bone marrow. This child will need protective isolation. HLA typing does not need to be done, as the source of the bone marrow is the child herself. Visitors do not need to be limited so severely. Teaching about complications is important, but does not take priority over protecting the child.

An adolescent has been taught to administer replacement factors for bleeding episodes related to hemophilia. What action by the teen indicates that further instruction is needed? A. Disposes of sharps in an approved container B. Reconstitutes the medication with sterile water C. Selects the appropriate needle for an IM injection D. Washes hands prior to working with the drug

ANS: C Replacement factors are given intravenously. The other actions are appropriate.

A child is on IV heparin. Which laboratory value does the nurse analyze to determine if the dose is therapeutic? A. Platelet count B. PT C. PTT D. Red blood cell count

ANS: C The PTT (or sometimes factor anti-Xa) is used to monitor heparin therapy for therapeutic benefit. The platelet count is also monitored to detect thrombocytopenia, a side effect of heparin. The PT is used to monitor warfarin (Coumadin) therapy. The RBC count is not used to determine anticoagulation benefit.

An acutely ill, anemic child's peripheral blood smear shows small, dense, spherical RBCs. What action by the nurse takes priority? A. Assess and treat the child's pain adequately. B. Discuss the option of a bone marrow transplant. C. Obtain informed consent for blood transfusions. D. Prepare the family for chelation therapy.

ANS: C The peripheral blood smear indicates spherocytosis, which, when acute, is treated with transfusions. The nurse ensures informed consent is obtained and present on the chart. Assessing and treating pain is important but does not take priority. Chelation therapy is not indicated in the question. A bone marrow transplant may or may not be considered, but is not the primary need of this child.

A nurse is assessing a child who presents to the pediatric clinic, where the parent reports new bruising and petechiae. What question asked by the nurse would elicit the most helpful information? A. "Do bleeding disorders run in your family?" B. "Does your child have arthritis symptoms?" C. "Has your child had a recent viral infection?" D. "Has your child been exposed to heavy metals?"

ANS: C These manifestations may be those of acute immune thrombocytopenia (ITP). This often follows a viral infection, so asking about recent infections is most appropriate. The other questions are not related to this disease.

A child with pancytopenia is getting a blood transfusion and it is time to administer her IV antibiotic. The child has only one IV line. What action by the nurse is most appropriate? A. Administer the antibiotic with the blood. B. Obtain an order for an oral antibiotic. C. Start a new peripheral IV in another site. D. Stop the blood to give the antibiotic.

ANS: C This child needs two IV sites or a multi-lumen IV catheter. Ideally this would have been done prior to starting the transfusion, but at this point the best option is to start another IV to administer the antibiotic. Other than normal saline, nothing can be run with blood. If there is no way to obtain another IV site, the nurse and provider would determine which was the priority. Blood transfusions should not be interrupted due to the chance of contamination and the need for strict adherence to the timeframe in which it is administered.

A child is hospitalized with the following laboratory values: WBCs, 2,100 mm3; segs, 48%; and bands, 2%. What action by the nurse is best? A. Move the child to a laminar airflow room. B. Place the child on strict protective isolation. C. Use good hand hygiene measures consistently. D. Wear a mask when entering the child's room.

ANS: C This child's absolute neutrophil count (ANC) is 1,050 mm3, which is classified as minimal, or class 2, neutropenia. Good hand hygiene and keeping sick visitors away from the child should be sufficient. Protective isolation is usually not used until the ANC falls below 500 mm3. Laminar airflow may or may not be used; this modality is often used for patients with tuberculosis. A mask is not needed.

A child has been hospitalized with a sickle cell crisis and given morphine sulfate (Duramorph) for severe pain. On assessment 45 minutes later, the child appears to be sleeping quietly with a respiratory rate of 6 breaths/minute. What action by the nurse is most appropriate? A. Document findings and let the child sleep. B. Plan to hold the next dose of morphine. C. Prepare to administer naloxone (Narcan). D. Wake the child up to take deep breaths.

ANS: C This child's respiratory rate is dangerously low, brought on by the narcotic analgesic. The nurse should prepare to administer Narcan per protocol. Letting the child sleep could lead to respiratory arrest, although the findings and subsequent actions should be documented. The provider should be notified afterward to adjust the next dose of pain medication. The child may or may not be able to cooperate with deep breathing instructions.

A teenager is hospitalized with sickle cell disease and vaso-occlusive crisis. What pain medication regimen does the nurse assist the patient with? A. Acetaminophen (children's Tylenol) B. Ketorolac (Toradol) orally C. Meperidine (Demerol), given intravenously D. PCA pump with morphine (Duramorph)

ANS: D A teenager is able to manage his or her own pain control, so a PCA pump is ideal. Morphine is often considered the drug of choice in sickle cell crises. Tylenol would be ineffective for pain this severe. Demerol is avoided due to its side effects. Toradol is a good choice; however, it is given parenterally for severe, acute pain.

Which health promotion measure does the nurse teach as being most important for the child with sickle cell disease? A. Adequate nutrition B. Ensured rest periods C. Plenty of fluids D. Routine vaccinations

ANS: D All options are appropriate for the child with sickle cell disease; however, vaccinations are vital to prevent sepsis and death from preventable diseases.

A child has mild anemia and the parent asks why this makes the child have difficulty concentrating. What response by the nurse is best? A. "All sick children have trouble concentrating." B. "Her anemia makes her too tired to think." C. "She may have another problem with her brain." D. "The brain isn't getting enough oxygen."

ANS: D Anemia leads to decreased oxygenation of body tissues, including the brain. A lowered cerebral oxygen concentration can lead to dizziness and difficulty concentrating. Stating that all sick children have this problem is inaccurate and vague. The child may be tired, but this answer is also vague and does not really address the question. Describing the possibility of another medical problem is not warranted at this time.

A child is receiving a dose of filgrastim (Neupogen). The parent asks the nurse what this medication is for. What response by the nurse is best? A. Causes bones that don't usually make blood cells to create them B. Results in white blood cells being able to live longer C. Stimulates bone marrow to make more red blood cells D. Stimulates bone marrow to make more white blood cells

ANS: D Neupogen is a colony-stimulating factor that stimulates the bone marrow to make more white blood cells. The other answers are incorrect.

A child has a disease involving an antigen-antibody complex disorder. What treatment regimen does the nurse prepare the family for? A. Apheresis B. Erythrocytaphoresis C. Leukapheresis D. Plasmapheresis

ANS: D Plasmapheresis is used to remove plasma containing harmful substances such as cholesterol, antigen-antibody complexes, and toxins. Erythrocytaphoresis removes red blood cells. Leukapheresis removes white blood cells. Apheresis is a generic term that encompasses all types of these procedures.

The pediatric nurse is aware that the most common type of transfusion reaction is which of the following? A. Acute hemolytic reaction B. Allergic reaction C. Circulatory overload D. Febrile reaction

ANS: D The febrile reaction is the most common type of transfusion reaction and can occur up to 12 hours post-transfusion.

The nurse working in the pediatric intensive care unit understands that the priority for treating disseminated intravascular coagulation (DIC) is to do which of the following? A. Administer antibiotics. B. Discuss organ donation. C. Provide massive transfusions. D. Treat the underlying cause.

ANS: D There are several treatment modalities to support the patient in DIC, but because this disorder is always secondary to another problem, treating the primary medical condition is the priority. Antibiotics alone are not used in DIC. Organ donation requests are premature when looking at treatment options. Transfusions may be required.