M&P CH 55

A nine-month-old who is not sitting independently has been diagnosed with ataxic cerebral palsy (CP). Which clinical manifestations would the nurse expect to see in the baby? a. Hypotonia and muscle instability b. Hypertonia and persistence primitive reflexes c. Tremors and exaggerated posturing d. Hemiplegia and hypertonia

a Hypotonia in infancy and muscle instability are seen in ataxic cerebral palsy. Hypertonia and persistent primitive reflexes are seen in spastic CP. Tremors and exaggerated posturing are seen in dyskinetic cerebral palsy. Hemiplegia and hypertonia are seen in spastic cerebral palsy.

The nurse is planning care for a child with bacterial meningitis. What is the priority nursing diagnosis? a. Impaired gas exchange b. Infection, risk for c. Anxiety (parental) d. Acute pain

a Impaired gas exchange would be the priority to ensure patent airway and adequate gas exchange.

A child has been diagnosed with a basilar skull fracture. The nurse should monitor this child for: a. Periorbital ecchymosis. b. Subdural hematoma. c. Protruding bone. d. Epidural hematoma.

a Periorbital ecchymosis, also called raccoon eyes, is seen with a basilar fracture. Subdural hematoma might be seen with a linear fracture. Protruding bone might be seen with a compound fracture. Epidural hematoma is seen with linear fracture.

The nurse has received a child from the emergency department with a diagnosis of decreased level of consciousness secondary to increased intracranial pressure. Which physician's order would the nurse question? a. Passive range-of-motion exercises b. Oxygen at 2L nasal cannula to keep saturation above 95% c. Hourly vital signs and neuro checks d. Elevate head of bed 30 degrees

a Range-of-motion exercises would not be done. It is imperative to keep the child with increased intracranial pressure quiet, with as little stimulation as possible. Hourly vital signs and neuro checks are appropriate to watch for changes in this child's condition. The head is elevated 30 degrees to help decrease increased intracranial pressure.

The nurse is doing an assessment on a four-month-old infant. Which assessment finding would the nurse consider abnormal? a. The posterior fontanel is open. b. The infant has good head control when held upright. c. The infant is able to roll only from abdomen to back. d. The anterior fontanel is open and soft.

a The posterior fontanel closes between two and three months of age. Good head control is expected at four months of age. Rolling from abdomen to back is a skill the four-month-old should be learning An open anterior fontanel, which is soft, is a normal finding at four months

Following an outbreak of chicken pox in the school, the school nurse is concerned that children are at risk for Reye syndrome. The nurse sends home letters reminding the parents not to administer aspirin and describes the initial symptoms of Reye syndrome which are: a. Nausea, vomiting, and confusion. b. Headache, vomiting, and seizures. c. Sore throat, moist respirations, and cough. d. Fever, rash, and photophobia.

a These are the early symptoms of Reye syndrome. Headache, vomiting, and seizures are associated with a malfunctioning shunt. Sore throat, moist respirations, and cough indicate pneumonia. Fever, rash, and photophobia are not the early symptoms of Reye syndrome.

When the home health nurse visits the home of a 10-month-old child, she observes the environment for risks for injury to the child. Which observation will the nurse discuss with the mother? a. The mother leaves the filled mop bucket on the floor while in another room. b. This is appropriate to reduce the risk of injury. c. The mother fills the bath tub before bringing the baby into the bathroom. d. When riding in a car, the child is in a car seat in the middle of the back seat.

a Toddlers can drown in a minimum amount of water. The child may look in the bucket and fall in head first. Because of mobility limitations, the child may not be able to get out of the bucket without help.

In caring for a hospitalized eight-year-old child with myelodysplasia, the nurse should remember to: (Select all that apply.) a. Expect the child to have normal intelligence. b. Use latex precautions. c. Allow the child to do her own self-catheterization. d. Ensure that the child has a low-fiber diet e. Encourage the child to shift positions hourly when in her wheelchair.

a, b, c, e any children with myelodysplasia have normal intellect. They should be treated according to their intellectual level rather than their motor development. Children with myelodysplasia are at great risk for latex allergy. It is important to use latex-free products. Self-catheterization fosters independence in this child. It is important to maintain the same schedule as much as possible when this child is hospitalized. Due to decreased sensation in the buttocks and lower extremities, it is very important for the child to shift positions while she is in her wheelchair to prevent pressure sores. Children with myelodysplasia need a high-fiber diet to maintain adequate stool and bowel function.

The pregnant woman has had no prenatal care and arrives at the hospital fully dilated. Assessment of the newborn indicates a probable gestational age of 35 weeks combined with intrauterine growth restriction. The nurse will monitor the infant for signs of neonatal abstinence syndrome, including: (Select all that apply.) a. Poor feeding. b. Difficult to arouse. c. Constipation. d. Seizures. e. Yawning.

a, d, e These infants are usually restless, difficult to feed, and irritable, not sleepy. Seizures are common in the child with neonatal abstinence syndrome. The infant with neonatal abstinence syndrome yawns frequently. The infant is more likely to have diarrhea.

A seven-year-old with a head injury is hospitalized after losing consciousness when he was hit in the head with a bat at baseball practice. The child was not wearing a helmet. The last set of vital signs showed heart rate 48, BP 148/74, respiratory rate 28 and irregular. The nurse suspects that these vital signs are: a. A sign that this child has a spinal cord injury. b. A sign of increased intracranial pressure. c. Typical for a sleeping child at this age. d. A sign that the child's condition is improving.

b These vital signs show increased BP, with a wide pulse pressure, slow heart rate, and respirations that are irregular, all indicating possible significant increased intracranial pressure. These vital signs are a sign of increased intracranial pressure. If it were a spinal cord injury, and neurogenic shock were suspected, the child would be hypotensive. Normal sleeping pulse at this age is 60-90 bpm. Without previous vital signs, there is no way to determine the changes in the vital signs.

The nurse is teaching the kindergarten teacher about a five-year-old with cerebral palsy who will be starting school. The child has a continuous baclofen pump. The nurse informs the teacher of possible side effects of this drug, including: a. Diarrhea. b. Hypertonia. c. Hypotonia. d. Restlessness.

c Hypotonia is possible if the child is getting too much baclofen. Continuous baclofen infusion does not cause diarrhea. Hypertonia is not seen as a side effect of baclofen infusion. Restlessness is not seen with baclofen; rather, these children can be drowsy and sleepy.

The nurse is caring for a nine-month-old who just returned from the PACU after a shunt placement for hydrocephalus. Which of the physician's orders would the nurse question? a. Vital signs and neuro checks hourly b. Small, frequent formula feedings c. Elevate head of bed d. Daily head circumference

c The nine-month-old should be placed in a flat position so that CSF drainage is not too rapid. Frequent vital signs and neuro checks are needed postoperatively. Small, frequent feedings are appropriate to decrease the chance of vomiting Daily head circumferences are needed to help evaluate shunt functioning.

The teacher is speaking to the school nurse about one of the girls in the fifth grade. The girl has always been a good student but lately seems to be daydreaming a lot. The teacher says, "Sometimes when I ask her a question, she will just stare at me for 15 seconds, then blink and ask me to repeat the question. What do you think is going on with her?" Based on this data, the nurse will suspect: a. The girl has a crush on a boy in the class. b. The girl has increased intracranial pressure. c. The child may have had a head injury. d. The girl is experiencing absence seizures.

d Absence seizures may cause staring and blinking; they are more common in girls in this age group and often are first noticed by the classroom teacher. There is no data to suspect a childhood crush is creating the situation. There is no indication of increased intracranial pressure or head injury.

A child with a history of seizures arrives in the emergency department in status epilepticus. What is the nurse's initial action? a. Take vital signs. b. Establish an intravenous line. c. Perform rapid neurological assessment. d. Maintain patent airway.

d Airway is always the priority of care. Taking vital signs is important, but airway always comes first. Once the airway is secure, securing an IV is vital. A rapid neurological assessment is appropriate once the airway is secure.

A young child admitted to the pediatric unit has fever, irritability, and vomiting. The physician suspects bacterial meningitis. The nurse would expect the cerebrospinal fluid (CSF) to show: a. Decreased protein count. b. Clear, straw-colored fluid. c. Positive for RBCs. d. Decreased glucose level.

d Glucose levels are low in CSF when a child has bacterial meningitis. Bacterial meningitis causes CSF protein levels to be elevated due to swelling and obstruction of CSF flow, the fluid is often cloudy with WBCs, and Glucose levels are low in CSF.

A four-year-old with intractable seizures has been on a ketogenic diet for the last six months, with a decrease in seizure activity. This child is now admitted to the pediatric unit with left-sided pain. The nurse knows that possible complications of the ketogenic diet include: a. Appendicitis. b. Bowel obstruction. c. Urinary tract infection. d. Kidney stones.

d Kidney stones are seen in 5% of children on a ketogenic diet.

A baby just born with a meningomyelocele is to have surgery in the morning. The nurse knows the care of this newborn includes: a. Applying a diaper to prevent contamination of sac. b. Positioning the newborn in a side-lying position. c. Encouraging the mother to hold the newborn, because she will not be able to pick him up after surgery. d. Positioning the newborn in a prone position.

d The newborn should be placed in a prone position to keep pressure off the sac. The others place pressure on the sac.

The mother brings her five-month-old infant to the clinic for a well-child visit. The mother tells the nurse that the baby's father had febrile seizures when he was an infant. The mother says she is concerned her baby will have a febrile seizure and wants to know what she should do to prevent it. The nurse explains: (Select all that apply.) a. That the baby has no more risk of febrile seizures than any other baby. b. When the infant has a fever, the mother should give the baby dose-appropriate aspirin. c. That the baby should be sponged with cold water. d. The mother should increase the child's fluid intake. e. That after the tepid bath, the child should be patted dry.

d, e Fluid intake will help heat loss. A tepid bath will bring down the temperature; patting, instead of rubbing, will help keep the child's temperature down. Febrile seizures run in families and are more common in males. Aspirin should be avoided due to the risk for Reye syndrome. Cold water may cause shivering, which will increase the body temperature.