Chapter 39: Pediatric Variations of Nursing Interventions Perry: Maternal Child Nursing Care, 6th Edition

3. The most appropriate nursing action to implement when a preschooler being prepped for outpatient surgery refused to allow the parent to remove his/her underwear? a. Allow the child to wear their underpants. b. Discuss to the mother why this is important. c. Ask the mother to explain to her child why he/she must remove the underwear. d. Explain in a kind, matter-of-fact manner that this is hospital policy.

ANS: A It is appropriate for the child to leave his/her underpants on. This allows his/her some measure of control during the foot surgery. The mother should not be required to make the child more upset. The child is too young to understand what hospital policy means.

31. A 6-year-old child is hospitalized for intravenous (IV) antibiotic therapy. He eats little on his "regular diet" trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. Which is the best nursing action? a. Request these favorite foods for him. b. Identify healthier food choices that he likes. c. Explain that he needs fruits and vegetables. d. Reward him with ice cream at the end of every meal that he eats.

ANS: A Loss of appetite is a symptom common to most childhood illnesses. To encourage adequate nutrition, favorite foods should be requested for the child. Even though these substances are not nutritious, they can provide necessary fluid and calories and can be supplemented with additional fruits and vegetables. Ice cream and other desserts should not be used as rewards or punishment.

9. A 3 year old has a 102° F fever associated with a viral illness that has not responded to acetaminophen. The nurse's action should be based on what knowledge about fevers in children? a. Fevers such as this are common with viral illnesses. b. Seizures are common in children when antipyretics are ineffective. c. Fever over 102° F indicates greater severity of illness. d. Fever over 102° F indicates a probable bacterial infection.

ANS: A Most fevers are of brief duration, have limited consequences, and are viral. Little evidence supports the use of antipyretic drugs to prevent febrile seizures. Neither the increase in temperature nor its response to antipyretics indicates the severity or etiology of infection.

20. When teaching a mother how to administer eyedrops, where should the nurse instruct to place them? a. In the conjunctival sac that is formed when the lower lid is pulled down. b. Carefully under the upper eyelid while it is gently pulled upward. c. On the sclera while the child looks to the side. d. Anywhere as long as drops contact the eye's surface.

ANS: A The lower lid is pulled down, forming a small conjunctival sac. The solution or ointment is applied to this area. The medication should not be administered directly on the eyeball.

11. The nurse wore gloves during a dressing change. When the gloves are removed, the nurse should perform which initial action? a. Wash hands thoroughly. b. Check the gloves for leaks. c. Rinse gloves in disinfectant solution. d. Apply new gloves before touching the next patient.

ANS: A When gloves are worn, the hands are washed thoroughly after removing the gloves because both latex and vinyl gloves fail to provide complete protection. Gloves should be disposed of after use and hands should be thoroughly washed again before new gloves are applied.

30. What critical information should the nurse incorporate into care when using restraints on a child? a. Use the least restrictive type of restraint. b. Tie knots securely so they cannot be untied easily. c. Secure the ties to the mattress or side rails. d. Remove restraints every 4 hours to assess skin.

ANS: A When restraints are necessary, the nurse should institute the least restrictive type of restraint. Knots must be tied so that they can be easily undone for quick access to the child. The ties are never tied to the mattress or side rails. They should be secured to a stable device, such as the bed frame. Restraints are removed every 2 hours to allow for range of motion, position changes, and assessment of skin integrity.

2. The advantages of the ventrogluteal muscle as an injection site in young children include which of the following? (Select all that apply.) a. Less painful than vastus lateralis b. Free of important nerves and vascular structures c. Cannot be used when child reaches a weight of 20 lbs d. Increased subcutaneous fat, which increases drug absorption e. Easily identified by major landmarks

ANS: A, B, E Less painful, free of important nerves and vascular structures, and easily identifiable are advantages of the ventrogluteal muscle. The major disadvantage is lack of familiarity by health professionals and controversy over whether the site can be used before weight bearing. Cannot be used when a child is 20 lbs or more and increased subcutaneous fat are not advantages of the ventrogluteal muscle as an injection site in young children.

29. Which nursing action is the most appropriate when applying a face mask to a child prescribed oxygen therapy? a. Set the oxygen flow rate at less than 6 L/min. b. Make sure the mask fits properly. c. Keep the child warm. d. Remove the mask for 5 minutes every hour.

ANS: B A properly fitting face mask is essential for adequate oxygen delivery. The oxygen flow rate should be greater than 6 L/min to prevent rebreathing of exhaled carbon dioxide. Oxygen delivery through a face mask does not affect body temperature. A face mask used for oxygen therapy is not routinely removed.

21. A 2-year-old child comes to the emergency department demonstrating signs of dehydration and hypovolemic shock. Which best explains why an intraosseous infusion is started? a. It is less painful for small children. b. Rapid venous access is not possible. c. Antibiotics must be started immediately. d. Long-term central venous access is not possible.

ANS: B In situations in which rapid establishment of systemic access is vital and venous access is hampered, such as peripheral circulatory collapse and hypovolemic shock, intraosseous infusion provides a rapid, safe lifesaving alternative. The procedure is painful, and local anesthesia and systemic analgesia are given. Antibiotics could be given when vascular access is obtained. Long-term central venous access is time-consuming, and intraosseous infusion is used in an emergency situation.

26. In preparing to give "enemas until clear" to a young child, the nurse should select which solution? a. Tap water b. Normal saline c. Oil retention d. Fleet solution

ANS: B Isotonic solutions should be used in children. Saline is the solution of choice. Plain water is not used. This is a hypotonic solution and can cause rapid fluid shift, resulting in fluid overload. Oil-retention enemas will not achieve the "until clear" result. Fleet enemas are not advised for children because of the harsh action of the ingredients. The osmotic effects of the Fleet enema can result in diarrhea, which can lead to metabolic acidosis.

4. Using knowledge of child development, what is the best approach when preparing a toddler for a procedure? a. Avoid asking the child to make choices. b. Demonstrate the procedure on a doll. c. Plan for the teaching session to last about 20 minutes. d. Show necessary equipment without allowing child to handle it.

ANS: B Prepare toddlers for procedures by using play. Demonstrate on a doll, but avoid the child's favorite doll because the toddler may think the doll is really "feeling" the procedure. In preparing a toddler for a procedure, the child is allowed to participate in care and help whenever possible. Teaching sessions for toddlers should be about 5 to 10 minutes. Use a small replica of the equipment and allow the child to handle it.

25. A child is receiving total parenteral nutrition (TPN; hyperalimentation). At the end of 8 hours, the nurse observes the solution and notes that 200 mL/8 hr is being infused rather than the ordered amount of 300 mL/8 hr. The nurse should adjust the rate so that how much will infuse during the next 8 hours? a. 200 mL b. 300 mL c. 350 mL d. 400 mL

ANS: B The TPN infusion rate should not be increased or decreased without the practitioner being informed because alterations in rate can cause hyperglycemia or hypoglycemia. Knowing this will result in the infusion rate being set to the original prescribed flow rate.

14. What is an important nursing consideration when performing a bladder catheterization on a young boy? a. Use clean technique, not Standard Precautions. b. Insert 2% lidocaine lubricant into the urethra. c. Lubricate catheter with water-soluble lubricant such as K-Y Jelly. d. Delay catheterization for 20 minutes while anesthetic lubricant is absorbed.

ANS: B The anxiety, fear, and discomfort experienced during catheterization can be significantly decreased by preparing the child and parents, selecting the correct catheter, and using appropriate insertion technique. Generous lubrication of the urethra before catheterization and use of lubricant containing 2% lidocaine may reduce or eliminate the burning and discomfort associated with this procedure. Catheterization is a sterile procedure, and Standard Precautions for body-substance protection should be followed. Water-soluble lubricants do not provide appropriate local anesthesia. Catheterization should be delayed only 2 to 3 minutes. This provides sufficient local anesthesia for the procedure.

7. The nurse is caring. What skin care interventions for an unconscious child should be included in the plan of care? a. Avoiding use of pressure reduction on the bed. b. Massaging reddened bony prominences to prevent deep tissue damage. c. Using drawsheet to move child in bed to reduce friction and shearing injuries. d. Avoiding rinsing skin after cleansing with mild antibacterial soap to provide a protective barrier.

ANS: C A drawsheet should be used to move the child in the bed or onto a gurney to reduce friction and shearing injuries. Do not drag the child from under the arms. Bony prominences should not be massaged if reddened. Deep tissue damage can occur. Pressure-reduction devices should be used to redistribute weight instead. The skin should be cleansed with mild nonalkaline soap or soap-free cleaning agents for routine bathing.

17. The nurse administering a bitter oral medication to an infant or small child should mix the medication with what substance? a. A bottle of formula or milk. b. Any food the child is going to eat. c. A teaspoon of jam or ice cream. d. Large amounts of water to dilute medication sufficiently.

ANS: C Mix the drug with a small amount (about 1 teaspoon) of sweet-tasting substance. This will make the medication more palatable to the child. The medication should be mixed with only a small amount of food or liquid. If the child does not finish drinking/eating, it is difficult to determine how much medication was consumed. Medication should not be mixed with essential foods and milk. The child may associate the altered taste with the food and refuse to eat in future.

5. The nurse is cleaning multiple facial abrasions on a 9-year-old who was brought to the emergency department by his/her mother. When the child begins crying and screaming loudly, what intervention should the nurse implement to best manage this situation? a. Calmly ask the child to be quieter. b. Suggest that his/her mother help the child to relax. c. Tell the child it is okay to cry and scream. d. Suggest that he/she talk to his/her mother as a form of distraction.

ANS: C The child should be allowed to express feelings of anger, anxiety, fear, frustration, or any other emotion. The child needs to know that it is all right to cry. There is no reason for him to be quieter. He is too upset and needs to be able to express his feelings.

32. What procedure is recommended to facilitate a heelstick on an ill neonate to obtain a blood sample? a. Apply cool, moist compresses. b. Apply a tourniquet to the ankle. c. Elevate the foot for 5 minutes. d. Wrap foot in a warm washcloth.

ANS: D Before the blood sample is taken, the heel is heated with warm moist compresses for 5 to 10 minutes to dilate the blood vessels in the area. Cooling causes vasoconstriction, making blood collection more difficult. A tourniquet is used to constrict superficial veins. It will have an insignificant effect on capillaries. Elevating the foot will decrease the blood in the foot available for collection.

23. It is important to make certain that sensory connectors and oximeters are compatible since wiring that is incompatible increases the risk of which injury? a. Hyperthermia b. Electrocution c. Pressure necrosis d. Burns under sensors

ANS: D It is important to make certain that sensor connectors and oximeters are compatible. Wiring that is incompatible can generate considerable heat at the tip of the sensor, causing second- and third-degree burns under the sensor. Incompatibility would cause a local irritation or burn, not hyperthermia. A low voltage is used, which should not present risk of electrocution. Pressure necrosis can occur from the sensor being attached too tightly, but this is not a problem of incompatibility.

36. When administering a gavage feeding to a school-age child, the nurse should implement what intervention to assure safety? a. Lubricate the tip of the feeding tube with Vaseline to facilitate passage. b. Check the placement of the tube by inserting 20 mL of sterile water. c. Administer feedings over 5 to 10 minutes. d. Position the child on the right side after administering the feeding.

ANS: D Position the child with the head elevated about 30 degrees and on the right side or abdomen for at least 1 hour. This is in the same manner as after any infant feeding to minimize the possibility of regurgitation and aspiration. Insert a tube that has been lubricated with sterile water or water-soluble lubricant. With a syringe, inject a small amount of air into the tube, while simultaneously listening with a stethoscope over the stomach area. Feedings should be administered via gravity flow and take from 15 to 30 minutes to complete.

8. What is an appropriate intervention to encourage food and fluid intake in a hospitalized child? a. Force child to eat and drink to combat caloric losses. b. Discourage participation in noneating activities until caloric intake is sufficient. c. Administer large quantities of flavored fluids at frequent intervals and during meals. d. Give high-quality foods and snacks whenever child expresses hunger.

ANS: D Small, frequent meals and nutritious snacks should be provided for the child. Favorite foods such as peanut butter and jelly sandwiches, fruit yogurt, cheese, pizza, macaroni, and cheese should be available. Forcing a child to eat only meets with rebellion and reinforces the behavior as a control mechanism. Large quantities of fluid may decrease the child's hunger and further inhibit food intake.

22. When caring for a child with an intravenous infusion, the nurse should include which intervention in the plan of care? a. Using a macrodropper to facilitate reaching the prescribed flow rate. b. Avoid restraining the child to prevent undue emotional stress. c. Changing the insertion site every 24 hours. d. Observing the insertion site frequently for signs of infiltration.

ANS: D The nursing responsibility for intravenous therapy is to calculate the amount to be infused in a given length of time, set the infusion rate, and monitor the apparatus frequently, at least every 1 to 2 hours, to make certain that the desired rate is maintained, the integrity of the system remains intact, the site remains intact (free of redness, edema, infiltration, or irritation), and the infusion does not stop. A minidropper (60 drops/mL) is the recommended intravenous tubing in pediatrics. The intravenous site should be protected. This may require soft restraints on the child. Insertion sites do not need to be changed every 24 hours unless a problem is found with the site. Frequent change exposes the child to significant trauma.

18. When liquid medication is given to a crying 10-month-old infant, which approach minimizes the possibility of aspiration? a. Administering the medication with a syringe (without needle) placed along the side of the infant's tongue. b. Administering the medication as rapidly as possible with the infant securely restrained. c. Mixing the medication with the infant's regular formula or juice and administering by bottle. d. Keeping the child upright with the nasal passages blocked for a minute after administration.

ANS: A Administer the medication with a syringe without needle placed alongside of the infant's tongue. The contents are administered slowly in small amounts, allowing the child to swallow between deposits. Medications should be given slowly to avoid aspiration. The medication should be mixed with only a small amount of food or liquid. If the child does not finish drinking/eating, it is difficult to determine how much medication was consumed. Essential foods also should not be used. The child may associate the altered taste with the food and refuse to eat in future. Holding the child's nasal passages increases the risk of aspiration.

12. The nurse gives an injection in a patient's room. Which method should the nurse use to dispose of the needle? a. Dispose of syringe and needle in a rigid, puncture-resistant container in patient's room. b. Dispose of syringe and needle in a rigid, puncture-resistant container in an area outside of patient's room. c. Cap needle immediately after giving injection and dispose of in proper container. d. Cap needle, break from syringe, and dispose of in proper container.

ANS: A All needles (uncapped and unbroken) are disposed of in a rigid, puncture-resistant container located near the site of use. Consequently, these containers should be installed in the patient's room. The uncapped needle should not be transported to an area distant from use.

33. After collecting blood by venipuncture in the antecubital fossa, what intervention should the nurse implement in order to assure control of any bleeding? a. Keep arm extended while applying a bandage to the site. b. Keep arm extended, and apply pressure to the site for a few minutes. c. Apply a bandage to the site, and keep the arm flexed for 10 minutes. d. Apply a gauze pad or cotton ball to the site, and keep the arm flexed for several minutes.

ANS: B Applying pressure to the site of venipuncture stops the bleeding and aids in coagulation. Pressure should be applied before a bandage is applied.

15. What is the most appropriate statement for the nurse to make to a 5-year-old child who is undergoing a venipuncture? a. "You must hold still or I'll have someone hold you down. This is not going to hurt." b. "This will hurt like a pinch. I'll get someone to help hold your arm still so it will be over fast and hurt less." c. "Be a big boy and hold still. This will be over in just a second." d. "I'm sending your mother out so she won't be scared. You are big, so hold still and this will be over soon."

ANS: B Honesty is the best approach. Children should be told what sensation they will feel during a procedure. A 5-year-old child should not be expected to hold still, and assistance ensures safety to everyone. Telling the child that "This will be over in just a second" is not supportive or honest. Parents should be encouraged to remain with the child unless they are extremely uncomfortable doing so.

2. The nurse is planning how to best prepare a 4-year-old child for some diagnostic procedures. What guideline should the nurse consider when preparing a preschooler for a diagnostic procedure? a. Planning for a short teaching session of about 30 minutes. b. Telling the child that procedures are never a form of punishment. c. Keeping equipment out of the child's view. d. Using correct scientific and medical terminology in explanations.

ANS: B Illness and hospitalization may be viewed as punishment in preschoolers. Always state directly that procedures are never a form of punishment. Teaching sessions for this age-group should be 10 to 15 minutes in length. Demonstrate the use of equipment and allow the child to play with miniature or actual equipment. Explain the procedure and how it affects the child in simple terms.

19. Guidelines for intramuscular administration of medication in school-age children include what instruction? a. Inject medication as rapidly as possible. b. Insert the needle quickly, using a dart-like motion. c. Penetrate the skin immediately after cleansing the site, before skin has dried. d. Have the child stand, if possible, and if he or she is cooperative.

ANS: B The needle should be inserted quickly in a dart-like motion at a 90-degree angle unless contraindicated. Inject medications slowly. Allow skin preparation to dry completely before skin is penetrated. Place the child in a lying or sitting position.

28. What information should the nurse include when teaching parents how to care for a child's gastrostomy tube at home? a. Never turn the gastrostomy button. b. Clean around the insertion site daily with soap and water. c. Expect some leakage around the button. d. Remove the tube for cleaning once a week.

ANS: B The skin around the tube insertion site should be cleaned with soap and water once or twice daily. The gastrostomy button should be rotated in a full circle during cleaning. Leakage around the tube should be reported to the physician. A gastrostomy tube is placed surgically. It is not removed for cleaning.

6. The nurse monitoring a child for signs and symptoms of malignant hyperthermia should be alert for which early sign of this disorder? a. Apnea b. Bradycardia c. Muscle rigidity d. Decreased blood pressure

ANS: C Early signs of malignant hyperthermia include tachycardia, increasing blood pressure, tachypnea, mottled skin, and muscle rigidity. Apnea is not a sign of malignant hyperthermia. Tachycardia, not bradycardia, is an early sign of malignant hyperthermia. Increased, not decreased, blood pressure is characteristic of malignant hyperthermia.

10. What intervention is appropriate when administering tepid water or sponge baths prescribed for hyperthermia in children? a. Add isopropyl alcohol to the water. b. Direct a fan on the child in the bath. c. Stop the bath if the child begins to chill. d. Continue the bath for 5 minutes.

ANS: C Environmental measures such as sponge baths can be used to reduce temperature if tolerated by the child and if they do not induce shivering. Shivering is the body's way of maintaining the elevated set point. Compensatory shivering increases metabolic requirements above those already caused by the fever. Ice water and isopropyl alcohol are inappropriate, potentially dangerous solutions. Fans should not be used because of the risk of the child developing vasoconstriction, which defeats the purpose of the cooling measures. Little blood is carried to the skin surface, and the blood remains primarily in the viscera to become heated. The child is placed in a tub of tepid water for 20 to 30 minutes.

35. What nursing consideration is related to the administration of oxygen (O2) in an infant? a. Humidify the oxygen if the infant can tolerate it. b. Assess the infant to determine how much oxygen should be given. c. Arterial oxygen saturation (SaO2) readings are used to guide O2 therapy. d. Direct the oxygen flow so that it blows directly into the infant's face in a hood.

ANS: C Pulse oximetry is a continuous, noninvasive method of determining arterial oxygen saturation (SaO2) to guide oxygen therapy. Oxygen is drying to the tissues. Oxygen should always be humidified when delivered to a patient. A child receiving oxygen therapy should have the oxygen saturation monitored at least as frequently as vital signs. Oxygen is a medication, and it is the responsibility of the practitioner to modify dosage as indicated. Humidified oxygen should not be blown directly into an infant's face.

16. What important consideration in providing atraumatic care should the nurse consider when preforming a venipuncture on a 6-year-old child? a. Use an 18-gauge needle if possible. b. If not successful after four attempts, have another nurse try. c. Restrain the child only as needed to perform venipuncture safely. d. Show the child equipment to be used before procedure.

ANS: C Restrain the child only as needed to perform the procedure safely; an alternative would be the use of therapeutic hugging. Use the smallest gauge needle that permits free flow of blood. A two-try-only policy is desirable, in which two operators each have only two attempts. If insertion is not successful after four punctures, alternative venous access should be considered. Keep all equipment out of sight until used.

27. What nursing action is appropriate for specimen collection? a. Follow sterile technique for specimen collection. b. Sterile gloves are worn if the nurse plans to touch the specimen. c. Use Standard Precautions when handling body fluids. d. Avoid wearing gloves in front of the child and family.

ANS: C Standard Precautions should always be used when handling body fluids. Specimen collection is not always a sterile procedure. Gloves should be worn if there is a chance the nurse will be contaminated. The choice of sterile or clean gloves will vary according to the procedure or specimen. The child and family should be educated in the purpose of glove use, including the fact that gloves are used with every patient, so that they will not be offended or frightened.

24. What intervention should the nurse implement when suctioning a child with a tracheostomy? a. Encouraging the child to cough to raise the secretions before suctioning. b. Selecting a catheter with a diameter three-fourths as large as the diameter of the tracheostomy tube. c. Ensuring that each pass of the suction catheter take no longer than 10 seconds. d. Allowing the child to rest after every 5 times the suction catheter is passed.

ANS: C Suctioning should require no longer than 10 seconds per pass. Otherwise the airway may be occluded for too long. If the child is able to cough up secretions, suctioning may not be indicated. The catheter should have a diameter one-half the size of the tracheostomy tube. If it is too large, it might block the child's airway. The child is allowed to rest for 30 to 60 seconds after each aspiration to allow oxygen tension to return to normal. Then the process is repeated until the trachea is clear.

1. What should the nurse consider when having consent forms signed for surgery and procedures on children? a. Only a parent or legal guardian can give consent. b. The person giving consent must be at least 18 years old. c. The risks and benefits of a procedure are part of the consent process. d. A mental age of 7 years or older is required for a consent to be considered "informed." \

ANS: C The informed consent must include the nature of the procedure, benefits and risks, and alternatives to the procedure. In special circumstances such as emancipated minors, the consent can be given by someone younger than 18 years without the parent or legal guardian. A mental age of 7 years is too young for consent to be informed.

13. Frequent urine testing for specific gravity and glucose are required on a 6-month-old infant. How should the nurse collect small amounts of urine for these tests? a. Apply a urine-collection bag to the perineal area. b. Tape a small medicine cup to the inside of the diaper. c. Aspirate urine from cotton balls inside the diaper with a syringe. d. Aspirate urine from a superabsorbent disposable diaper with a syringe.

ANS: C To obtain small amounts of urine, use a syringe without a needle to aspirate urine directly from the diaper. If diapers with absorbent material are used, place a small gauze dressing or cotton balls inside the diaper to collect the urine, and aspirate the urine with a syringe. For frequent urine sampling, the collection bag would be too irritating to the child's skin. Taping a small medicine cup to the inside of the diaper is not feasible; the urine will spill from the cup. Diapers with superabsorbent gels absorb the urine, so there is nothing to aspirate.

34. Which is the preferred site for intramuscular injections in infants? a. Deltoid b. Dorsogluteal c. Rectus femoris d. Vastus lateralis

ANS: D The preferred site for infants is the vastus lateralis. The deltoid and dorsogluteal sites are used for older children and adults. The rectus femoris is not a recommended site.

1. The nurse is preparing for the admission of an infant who will have several procedures performed. In which situation is informed consent required? (Select all that apply.) a. Catheterized urine collection b. Intravenous (IV) line insertion c. Oxygen administration d. Lumbar puncture e. Bone marrow aspiration

ANS: D, E Informed consent is required for invasive procedures that involve risk to a child, such as a lumbar puncture, chest tube insertion, and bone marrow aspirations. Catheterized urine collection, IV line insertion, and oxygen administration all fall under this category.