Essentials of Pediatric Nursing - Chapter 21

The nurse is caring for a pediatric client who is scheduled for the surgical removal of a Wilms tumor. Which is contraindicated in the client's care?

Abdominal palpation Explanation: Abdominal palpation is contraindicated preoperatively in a client with a Wilms tumor. Cells may break loose and spread the tumor. Intravenous fluids and supine positioning are appropriate in the client's care. A Foley catheter is typically not placed.

The nurse is caring for a child who receives dialysis via an AV fistula. Which finding indicates an immediate need to notify the physician?

Absence of a thrill Explanation: The nurse should always auscultate the site for presence of a bruit and palpate for presence of a thrill. The nurse should immediately notify the physician if there is an absence of a thrill. Dialysate without fibrin or cloudiness is normal and is used with peritoneal dialysis, not hemodialysis.

The nurse is reinforcing teaching with the caregiver of 5-year-old twins regarding urinary tract infections (UTIs). The caregiver is puzzled about why her daughter has had three urinary tract infections but her son has had none. She reports that their diets and fluid intake is similar. Which statement would be accurate for the nurse to tell this mother?

"A girl's urethra is much shorter and straighter than a boy's, so it can be contaminated fairly easily." Explanation: Many different bacteria may infect the urinary tract, and intestinal bacteria, particularly Escherichia coli, account for about 80% of acute episodes. The female urethra is shorter and straighter than the male urethra, so it is more easily contaminated with feces.

The nurse is preparing a 7-year-old girl for discharge after treatment for nephrotic syndrome. Which instructions would the nurse include in the discharge teaching plan for the parents?

"Let's meet with the dietitian and plan some meals." Explanation: Consultation with a dietitian would be most helpful for meal planning because so many of children's favorite foods are high in sodium. Restricting sodium may not be necessary if the child is not edematous; in addition, the statement does not teach. Protein-rich snacks should be encouraged. The nurse needs to provide the parents with specific instructions, assistance, and resources in addition to simple written instructions.

The nurse is caring for the parents of a newborn who has an undescended testicle. Which comment by the parents indicates understanding of the condition?

"Our son's condition may resolve on its own." Explanation: Normally both testes will descend prior to birth. In the event this does not happen the child will be observed for the first 6 months of life. If the testicle descends without intervention further treatment will not be needed. Surgical intervention is not needed until after 6 months if the testicle has not descended.

The caregiver of a 1-year-old boy calls the nurse, upset that his wife has just told him that their son is being given a hormone. His wife says that the pediatrician called it human chorionic gonadotropic hormone but that is all she understood. The nurse most accurately clarifies the caregiver's question by making which statement regarding the son's treatment?

"The doctor is hoping that the hormone will cause your son's undropped testes to move into their proper place." Explanation: Shortly before or soon after birth, the male gonads (testes) descend from the abdominal cavity into their normal position in the scrotum. Occasionally one or both of the testes do not descend, which is a condition called cryptorchidism. The testes are usually normal in size; the cause for failure to descend is not clearly understood. A surgical procedure called orchiopexy is used to bring the testes down into the scrotum and anchor them there. Some physicians prefer to try medical treatment such as injections of human chorionic gonadotropic hormone before doing surgery. If this is unsuccessful in bringing down the testes, orchiopexy is performed. If both testes remain undescended, the male will be sterile. If the processus does not close, fluid from the peritoneal cavity passes through, causing hydrocele. If the hydrocele remains by the end of the first year, corrective surgery is performed.

The nurse is caring for a 10-year-old child experiencing nocturnal enuresis with no physiologic cause. The child states, "I am embarrassed and I wish I could stop this right now!" How will the nurse respond?

"There are several things we can do to help you achieve this goal." Explanation: The child wants to stop this problem immediately, so the nurse's most therapeutic response is to assure the child that enuresis is indeed solvable. For some children, learning about the high prevalence of the problem may provide consolation. However, this may not alleviate the child's embarrassment and it does not address the desire for solutions. Telling the child that he or she will "grow out of this" downplays the embarrassment and does not address the desire to solve the problem. Pull-ups conceal the consequences of enuresis but do not provide a solution.

The nurse is collecting data on a 6-year-old child admitted with acute glomerulonephritis. Which vital sign would the nurse anticipate with this child's diagnosis?

Blood pressure 136/84 Explanation: Hypertension appears in 60% to 70% of clients during the first 4 or 5 days with a diagnosis of acute glomerulonephritis. The pulse of 112 would be a little high for a child this age, but not a concern with this diagnosis. The other vital signs are within normal limits for this age child.

A child is being evaluated for renal and urinary tract disease. What would the nurse expect to be ordered to evaluate the child's glomerular filtration rate?

Creatinine clearance rate Explanation: The glomerular filtration rate is measured by creatinine clearance rate, or the amount of creatinine excreted in 24 hours as determined by a 24-hour urine sample along with a venous blood sample and compared with the urine findings. Urinalysis provides general information about kidney function. A kidneys, ureters, and bladder x-ray provides information about the size and contour of the kidneys. A computed tomography reveals the size and density of kidney structures and adequacy of urine flow.

A nurse is developing a teaching plan for the parents of an 8-year-old experiencing nocturnal enuresis. The nurse determines that additional teaching is needed when the parents identify what as an appropriate measure?

Encouraging fluid intake after dinner Explanation: In many children, limiting fluids after dinner can be helpful for nocturnal enuresis. Bladder-stretching exercises also can be helpful. If these measures are ineffective, desmopressin may be prescribed. Stress factors may be contributing to the child's problem. Therefore, measures to address stress and promote coping would be appropriate.

A parent is asking how to help the child deal with the peer ridicule at school in regards to enuresis. What is the best response by the nurse?

Demonstrate love and acceptance at home. Explanation: Enuresis is the contined incontinence of urine past the age of toliet training. It is a source of shame and embarrassment. It affects the child's life emotionally, behaviorally and socially. It causes the child to have a low self-esteem. Demonstrating love and acceptance at home will help counteract the ridicule the child is getting at school.The child should not be punished for a behavior he or she cannot control. Demonstrating how to use the toliet and going to the bathroom to void are good subjects but they do not help a child who has no control of the enuresis. Testing may need to be done to see if there are anatomical reasons and medications may be needed to correct the problem.

A 16-year-old girl visits her gynecologist with a complaint of metrorrhagia, or bleeding between menstrual periods, since her last visit 3 months ago. On consulting the client's chart, the nurse learns that she was prescribed an oral contraceptive at her last visit. Which intervention should the nurse implement in this situation?

Explain that breakthrough bleeding is normal during the first 3 or 4 months of oral contraceptive use but that it should go away after that. Explanation: Metrorrhagia is bleeding between menstrual periods. This may occur in teenagers taking oral contraceptives (breakthrough bleeding) during the first 3 or 4 months of use. If metrorrhagia occurs for more than one menstrual cycle in a teenager who is not taking oral contraceptives (which is not the case here), she be referred to her primary care provider for examination, because abnormal vaginal bleeding is an early sign of uterine or cervical carcinoma or an ovarian cyst. Endometrium ablation, used with premenopausal women to halt metrorrhagia, is not recommended for adolescents. There is no need at this point for the client to change prescriptions, as the bleeding will likely go away in the next month or so as the client's body adapts to the current contraceptive.

The nurse is caring for a child diagnosed with hydronephrosis. Which manifestation is consistent with complications of the disorder?

Hypertension Explanation: Complications of hydronephrosis include renal insufficiency, hypertension, and eventually renal failure. Hypotension, hypothermia, and tachycardia are not associated with hydronephrosis.

The nurse is assessing a male neonate and notes that the urethral opening is on the ventral aspect of the penis. Which finding is documented?

Hypospadias Explanation: Hypospadias is a condition in which the urethral opening in on the ventral surface of the penis. Epispadias is present when the urethral opening is on the dorsal surface of the penis. Patent urachus refers to a fistula between the bladder and umbilicus. Bladder exstrophy involves the bladder lying open and exposed on the abdomen.

The nurse is caring for an 8-year-old child hospitalized with nephrotic syndrome. Which nursing intervention would be appropriate for this child?

Measure the abdominal girth daily. Explanation: Measure the child's abdomen daily at the level of the umbilicus, and make certain that all staff personnel measure at the same level. Weigh the child at the same time every day on the same scale in the same clothing. Test the urine regularly for albumin and specific gravity. Elevated temperature is not an issue with nephrotic syndrome.

Which nursing diagnosis would be the priority when caring for a child in renal failure following a kidney transplant?

Risk for infection related to immunocompromised state Explanation: Children are administered immunosupressants following a transplant. These drugs lower the immune system response and help prevent rejection following the transplant. As a result, this leaves them susceptible to infection. The child may have pain from the surgical procedure but it does not occur from the rejection of the organ. Constipation may occur from the opioids used for pain management but it is not the priority nursing diagnosis. The fluid volume should return to normal once the transplanted kidney is functioning properly.

The nurse recognizes that what would be a likely physiologic cause for a child to have enuresis?

Sleeping too soundly Explanation: Physiologic causes may include a small bladder capacity, urinary tract infection, and lack of awareness of the signal to empty the bladder because of sleeping too soundly. Psychological causes might include rigorous toilet training, resentment toward family caregivers, a desire to regress to an earlier level of development to receive more care and attention, or emotional stress and stressful situations. Enuresis can be a symptom of sexual abuse.

The nurse is caring for a 10-year-old boy with end-stage renal disease (ESRD) with metabolic acidosis. What would the nurse expect to administer if ordered?

Sodium bicarbonate tablets Explanation: Bicitra or sodium bicarbonate tablets are used for the correction of acidosis. Ferrous sulfate is used for the treatment of anemia. Vitamin D and calcium are used for the correction of hypocalcemia and hyperphosphatemia. Erythropoietin stimulates red blood cell growth.

The nurse is taking a health history of a 12-year-old boy presenting with scrotal pain. Which assessment finding would indicate testicular torsion?

Sudden onset of severe scrotal pain with significant hemorrhagic swelling Explanation: Testicular torsion is characterized by a testicle that is abnormally attached to the scrotum and twisted. Signs and symptoms include sudden onset of severe scrotal pain with significant hemorrhagic swelling. Enlarged glands and fever point to infection. A hardened and tender epididymitis points to epididymitis. Fever and urethral discharge suggest infection. Scrotal swelling is associated with testicular torsion, epididymitis, and hydrocele.

A 16-year-old adolescent tells the nurse about having severe dysmenorrhea. Which action would be the best health teaching measure?

Take over-the-counter ibuprofen for its prostaglandin action. Explanation: Dysmenorrhea is pain associated with menstruation. A prostaglandin release is responsible for the smooth muscle contraction of the uterus during menstruation. The nonsteroidal anti-inflammatory drug Ibuprofen has an antiprostaglandin mechanisim that will block the prostaglandin release. It is the best choice for dysmenorrhea. Acetominophen has no antiprostaglandin properties, so it is not the drug of choice. Ice will only work on localized areas so it has limitied, if any, effect on the uterus. Ice also is a vasoconstrictor and reduced blood flow could intensify the pain. Fluid intake has no effect on uterine pain.

The nurse is caring for a child admitted with acute glomerulonephritis. Which clinical manifestation would likely have been noted in the child with this diagnosis?

Tea-colored urine Explanation: The presenting symptom in acute glomerulonephritis is grossly bloody urine. The caregiver may describe the urine as tea or cola colored. Periorbital edema may accompany or precede hematuria. Loose stools are seen in diarrhea. A strawberry-colored tongue is a symptom seen in the child with Kawasaki disease. Jaundiced skin is noted in hepatitis.

The nurse is caring for a 5-month-old boy with an undescended left testis. What would the nurse identify as indicative of true cryptorchidism?

Testis cannot be "milked" down inguinal canal Explanation: With true cryptorchidism, the retractile testis cannot be "milked" down the inguinal canal. Fluid in the scrotal sac is a hydrocele. A venous varicosity along the spermatic cord is a varicocele. Testis that can be brought into the scrotum refers to a retractile testis.

The nurse is caring for a 2-year-old girl with suspected vulvovaginitis. The nurse suspects the cause as Candida albicans based on which finding?

White cottage cheese-like discharge Explanation: White cottage cheese-like discharge indicates C. albicans. Thin gray discharge with a fishy odor points to Bordetella or Gardnerella. Foul yellow-gray discharge indicates Trichomonas vaginalis. Irritation of the labia and vaginal opening is commonly found with poor hygiene.

A voiding cystourethrogram (VCUG) is prescribed for a child. What education should be provided to the parents?

The VCUG will rule out vesicoureteral reflux. Explanation: A voiding cystogram (VCUG) is performed by having the bladder filled with a contrast medium via catheterization. Under fluorscopy the bladder is visualized filling and emptying. A VCUG is used to rule out reflux in the urinary tract, causes of hematuria, UTI, and structural anomalies. Reflux may cause frequent infections and scarring in the urinary tract if not diagnosed and treated. A VCUG will not diagnose renal stones. Renal stones would be detected by a CT scan. A VCUG would not be performed to detect if infections of the UTI have cleared. This would be done by assessing a urinalysis.

The nurse knows this is a description of peritoneal dialysis when compared to hemodialysis:

The child can live a more normal lifestyle. Explanation: The child can live a more normal lifestyle with peritoneal dialysis. This is a 7-day-a-week procedure, but there are less diet restrictions and more freedom with this type of procedure. Peritoneal dialysis can be performed at home.

A caregiver brings her 7-year-old son to the pediatrician's office, concerned about the child's bedwetting after being completely toilet trained even at night for over 2 years. The caregiver further reports that the child has wet the bed every night since returning home from a 1-week fishing trip. The child refuses to talk about the bedwetting. The nurse notes the child is shy, skittish, and will not make eye contact. Further evaluation needs to be done to rule out what possible explanation for the bedwetting?

The child has been sexually abused, maybe on the fishing trip. Explanation: Enuresis may have a physiologic or psychological cause and may indicate a need for further exploration and treatment. Enuresis in the older child may be an expression of resentment toward family caregivers or of a desire to regress to an earlier level of development to receive more care and attention. Emotional stress can be a precipitating factor. The health care team also needs to consider the possibility that enuresis can be a symptom of sexual abuse. Bruising, bleeding, or lacerations on the external genitalia, especially in the child who is extremely shy and frightened, may be a sign of child abuse and should be further explored.

The nurse is collecting data for a child diagnosed with acute glomerulonephritis. What would the nurse likely find in this child's history?

The child recently had an ear infection. Explanation: In the child with acute glomerulonephritis, presenting symptoms appear 1 to 3 weeks after the onset of a streptococcal infection, such as strep throat, otitis media, tonsillitis, or impetigo. There is not a family history of the disorder, a history of congenital concerns or defects, nor asthma in children with acute glomerulonephritis.

Which goal of therapy would be appropriate for a nurse to establish with a client's family and a client who has a diagnosis of enuresis?

The client remains continent throughout the night. Explanation: The goal of therapy is for the client to be continent of urine throughout the night. The nurse should encourage the child to awaken and void and not have any fluids before bedtime. During an activity, the child should be encouraged to void before and after the activity to prevent incontinence.

A nurse is discussing with a family the various causes of their child's vulvovaginitis. What would be included in the education?

The use of cleansing towelettes may have caused the vulvovaginitis. Explanation: Vulvovaginitis can result from an overgrowth of bacteria or yeast or from chemical factors. Chemical factors include bubble baths, and soaps or perfumes in personal care items like cleasnisng towelletes. This is a common childhood problem in girls. It is not necessarily a sign of abuse so child protective services would not need to be involved. Constipation and fevers are usually associated with this disorder but are not the cause.

The nurse is reviewing the causative organisms noted on laboratory reports. Which organism is transmitted solely by sexual contact?

Trichomonas Explanation: The organism transmitted solely by sexual contact is Trichomonas. The other organisms are causes of various infections and acquired in various ways.

Which instruction should a nurse give to a client who has a history of urinary tract infection to prevent recurrence?

Wipe from front to back. Encourage fluids throughout the day. Finish all antibiotic prescribed. Explanation: Teaching caregivers to wipe from front to back, encouraging fluids, and finishing all prescribed medications are vital principles in the prevention of recurring UTIs. The use of bubble bath is contraindicated because it can be a source of infection.

The caregiver of a child with a history of ear infections calls the nurse and reports that her son has just told her his urine "looks funny." He also has a headache, and his mother reports that his eyes are puffy. Although he had a fever 2 days ago, his temperature is now down to 100℉ (37.8℃). The nurse encourages the mother to have the child seen by the care provider because the nurse suspects the child may have:

acute glomerulonephritis. Explanation: Acute glomerulonephritis is a condition that appears to be an allergic reaction to specific infections, most often group A beta-hemolytic streptococcal infections such as rheumatic fever. Presenting symptoms appear 1 to 3 weeks after the onset of a streptococcal infection such as strep throat, otitis media, tonsillitis, or impetigo. Usually the presenting symptom is grossly bloody urine. Periorbital edema may accompany or precede hematuria. Fever may be 103℉ to 104℉ (39.4℃ to 40℃) at the onset, but decreases in a few days to about 100℉ (37.8℃). Slight headache and malaise are usual, and vomiting may occur.

The condition in which one or both of the testes does not descend in the male infant is referred to as:

cryptorchidism. Explanation: When one or both of the testes do not descend, the condition is called cryptorchidism. An orchiopexy is the surgical procedure to pull the testes down into the scrotal sac. If the undescended testicle is left untreated it can can sterility in the adult male. A hydrocele is fluid in the scrotal sac. It generally resolves without surgery. Enuresis is nighttime bed wetting.

Most urinary tract infections seen in children are caused by:

intestinal bacteria. Explanation: Although many different bacteria may infect the urinary tract, intestinal bacteria, particularly Escherichia coli, account for about 80% of acute episodes. Hereditary and dietary concerns are not causes of urinary tract infections.

The nurse is concerned about the pediatric client's immune system after taking corticosteroids. Which laboratory study is the nurse most correct to assess?

leukocyte count Explanation: Since the nurse is concerned about the client's immune system, it is most correct to assess the client's white blood cells or cells of the immune system called leukocytes. Red blood cells are in a complete blood count, and low red blood cells result in anemia. Eosinophils and basophils are components of the white blood cells. They can indicate allergies.

Which condition is a risk factor for the development of pelvic inflammatory disease?

multiple sexual partners Explanation: Clients who have had multiple sexual partners have a higher incidence of developing pelvic inflammatory disease. Oral contraceptive use, history of UTI, and dysmmeorrhea are not risk factors for developing pelvic inflammatory disease.

Which is a priority for the nurse caring for a client with bladder exstrophy?

preventing skin breakdown Explanation: Prevention of skin breakdown is the priority to prevent infection and the surface from drying out. Encouraging fluids and voiding are not the priority for this client. Prone position is not recommended; the correct position is supine so urine drains freely.

A 3-year-old child is scheduled for a surgery to correct undescended testes. For what postoperative consideration would the nurse want to prepare the parents?

some discomfort at the surgery site Explanation: A orchiopexy is the surgical procedure to release the spermatic cord and pull the testes into the scrotum. After the testes are in the scrotum, they are sutured into place to prevent them from returning to the abdominal cavity. This produces a "tugging" or painful sensation. Complete bed rest, a liquid diet, and remaining in a semi-Fowler position are not required as part of the post

A 4-year-old child with a urinary tract infection is scheduled to have a voiding cystourethrogram. When preparing the child for this procedure, the nurse would want to prepare the child to:

void during the procedure. Explanation: At the start of the voiding cystourethrogram, a catheter is inserted into the bladder. The contrast medium is inserted through the catheter into the bladder. Fluroscopy is performed to demonstarate the filling of the bladder and the collapsing of the bladder upon emptying. The assessment of emptying requires the child to void during the procedure so that bladder emptying and urethra flow can be assessed. No anesthetic is required for this procedure. The fluid filling the bladder is inserted via the catheter so no drinking of water is required. A headache following the procedure would not be expected.

A nurse has just admitted a client with symptoms of vulva inflammation, pain, odor, and pruritus. Based on these findings, the nurse could conclude that this client will be diagnosed with which condition?

vulvovaginitis Explanation: Vulvovaginitis is diagnosed with clients experiencing vaginal or vulval inflammation, pain odor, and purititis. Pelvic inflammatory disease and urinary tract infection are not consistent with these symptoms.