Pediatric HESI
Following the administration of immunizations to a 6-month-old girl, the nurse provides the family with home care instructions. Which statement by the mother indicates that further teaching is needed?
"I will give her a baby aspirin every 4 hours as needed for fever." Rationale: Although fever may occur, non-aspirin-containing medications should be used because of the risk of Reye's syndrome
The nurse is taking the family history of a 2-year-old child with atopic dermatitis (eczema). Which statement by the mother is most important in formulating a plan of care for this child?
"My husband and our daughter are both lactose-intolerant." Rationale: Environmental exposure to allergens (milk) and a positive family history for milk allergies are important data in planning care of the child with atopic dermatitis because milk allergies can contribute to the child's outbreaks.
A 7-month-old male infant diagnosed with spastic cerebral palsy is seen by the nurse in the clinic. Which statement by the parent warrants immediate intervention by the nurse?
"My son often chokes while I am feeding him." Rationale: Airway obstruction is always a priority when caring for any client
The nurse is assessing a male adolescent client's knowledge of contraception. The teen states, "I have all the info I need." What is the best response by the nurse?
"Tell me what you know about birth control." Rationale: Teens often obtain information from peers, which may not be accurate. Knowing the source of the information may assist the nurse in evaluating the information that the teenager has regarding contraception
A woman whose first child died at 6 weeks of age because of sudden infant death syndrome (SIDS) is being discharged following the birth of her second child. The mother tells the nurse that she is fearful that this infant will also develop SIDS. Which response is best for the nurse to provide this woman?
"The fear of losing another child to SIDS is very realistic. Have you thought about what support you may need?" Rationale: The most effective way to provide emotional support is to acknowledge what clients may be feeling, be a sounding board for them so they can listen to themselves, and allow them to discover their own solutions
The mother of a 6-month-old asks the nurse when her baby will get the first measles, mumps, and rubella (MMR) vaccine. Based on the recommended childhood immunization schedule published by the Centers for Disease Control, which response is accurate?
12 to 15 months
Ampicillin, 75 mg/kg, is prescribed for a 22-lb child. It is available in a solution that contains 250 mg/5 mL. How many milliliters should the nurse administer in one dose?
15 Rationale: Take 22lbs / 2.2 = 10kg 10kg X 75mg/kg = 750mg 750/250 mg = 3mg X 5mL = 15
A nurse who is working in the Poison Control Center receives several telephone calls from parents whose children have ingested possible poisons. The nurse should recommend inducing vomiting for which child?
16-month old who drank 2 ounces of acetaminophen (Tylenol) elixir.
A 3-month-old infant weighing 10 lb 15 oz has an axillary temperature of 98.9° F. What caloric amount does this child need?
600 calories/day Rationale:An infant requires 108 calories/kg/day. The first step is to change 10 lb 15 oz to 10.9 lb. Then convert pounds to kilograms by dividing pounds by 2.2, which is 10.9/2.2 = 4.954 kg, rounded to 5 kg. The second step is to multiply 108 calories/kg/day (108 × 5 = 540 calories/day). However, this infant requires 10% more calories because of the 1° F temperature elevation. Ten percent of 540 (calories/day) is 54 and 540 + 54 = 594. This infant will require approximately 600 calories/day
As part of the physical assessment of children, the nurse observes and palpates the fontanels. Which child's fontanel finding should be reported to the healthcare provider?
A 6-month-old with failure to thrive that has a closed anterior fontanel.
Surgery is being delayed for an infant with undescended testes. In collaboration with the healthcare provider and the family, which prescription should the nurse anticipate
A trial of human chorionic gonadotrophic hormone
Which intervention(s) should the nurse include in the teaching plan for the mother of a 6-year-old who is experiencing encopresis secondary to a fecal impaction? (Select all that apply.)
Administer mineral oil daily. Eliminate dairy products. Initiate consistent toileting routine. Rationale: Encopresis is fecal incontinence, usually as the result of recurring fecal impaction and an enlarged rectum caused by chronic constipation. Encopresis is managed through bowel retraining with mineral oil, eliminating dairy products, and initiating a regular toileting routine. A high-fiber diet and increased daily fluids are components of care for a child with encopresis.
A 16-year-old is brought to the Emergency Center with a crushed leg after falling off a horse. The adolescent's last tetanus toxoid booster was received eight years ago. What action should the nurse take?
Administer tetanus toxoid booster.
The nurse should teach the parents of a child with a cyanotic heart defect to perform which action when a hypercyanotic spell occurs?
Allow the child to assume a knee-chest position, with the head and chest slightly elevated. Rationale: Assuming a knee-chest position with the head and chest slightly elevated will help restore hemodynamic equilibrium.
Which nursing intervention(s) is (are) therapeutic when caring for a hospitalized toddler? (Select all that apply.)
Allow the toddler to choose a colored Band-Aid after an injection & Give brief but simple explanations to the child before procedures. Rationale: Giving the toddler a choice may increase autonomy in the hospitalized setting. Brief but simple explanations are beneficial with the toddler. Separation from the parent can cause emotional distress. Regression is expected, and bedwetting is not an indication for a urinary catheter. The nurse should encourage age-appropriate toys to be brought in from home.
Which nursing diagnosis has the highest priority when planning care for an infant with eczema?
Altered comfort (pruritus) related to vesicular skin eruptions Rationale: Altered comfort (pruritus) has the highest priority because itching will cause the infant to scratch, creating complications such as scarring or infection.
Which of the following should the nurse expect to note as a frequent complication for a child with congenitalheart disease? a.Susceptibility to respiratory infection b. Bleeding tendencies c. Frequent vomiting and diarrhea d. Seizure disorder
Answer A Children with congenital heart disease are more prone to respiratory infections.Bleeding tendencies, frequent vomiting, and diarrhea and seizure disorders are not associated with congenital heart disease
A newborn's failure to pass meconium within the first 24 hours after birth may indicate which of the following? a.Hirschsprung disease b. Celiac disease c. Intussusception d. Abdominal wall defect
Answer A Failure to pass meconium within the first 24 hours after birth may be an indication of Hirschsprung disease, a congenital anomaly resulting in mechanical obstruction due to inadequate motility in an intestinal segment. Failure to pass meconium is not associated with celiac disease, intussusception, or abdominal wall defect.
Which of the following should the nurse do first after noting that a child with Hirschsprung disease has a fever and watery explosive diarrhea? a. Notify the physician immediately b. Administer antidiarrheal medications c. Monitor child ever 30 minutes d. Nothing, this is characteristic of Hirschsprung disease
Answer A For the child with Hirschsprung disease, fever and explosive diarrhea indicate enterocolitis, a life-threatening situation. Therefore, the physician should be notified immediately. Generally, because of the intestinal obstruction and inadequate propulsive intestinal movement, antidiarrheals are not used to treat Hirschsprung disease. The child is acutely ill and requires intervention, with monitoring more frequently than every 30 minutes.Hirschsprung disease typically presents with chronic constipation.
Which of the following parameters would the nurse monitor to evaluate the effectiveness of thickened feedings for an infant with gastroesophageal reflux (GER)? a.Vomiting b. Stools c. Uterine d. Weight
Answer A Thickened feedings are used with GER to stopthe vomiting. Therefore, the nurse wouldmonitor the child's vomiting to evaluate theeffectiveness of using the thickened feedings.No relationship exists between feedings andcharacteristics of stools and uterine. Iffeedings are ineffective, this should be notedbefore there is any change in the child's weight.
While assessing a newborn with cleft lip,the nurse would be alert that which of the following will most likely be compromised? a.Sucking ability b. Respiratory status c. Locomotion d. GI function
Answer A. Because of the defect, the child will be unable to from the mouth adequately around nipple, there by requiring special devices to allow for feeding andsucking gratification. Respiratory status may be compromised if the child is fed improperly or during postoperative period, Locomotion would be a problem for the older infant because of the use of restraints. GI functioning is not compromised in the child with a cleft lip
A child with leukemia is being discharged after beginning chemotherapy. Which of the following instructions will the nurse include when teaching the parents of this child? a)provide a diet low in protein and high carbohydrates b) avoid fresh vegetables that are not cooked or peeled c) notify the doctor if the child's temperature exceeds 101 F (39C) d) increase the use of humidifiers throughout the house
Answer B fresh fruits and vegetables harbor microorganisms, which can cause infections in immune-compromised child. Fruits and vegetables should either be peeled or cooked. The physician should be notified of a temperature above 100F, a diet low in protein is not indicated, and humidifiers harbor fungi in the water containers.
Which of the following health teachings regarding sickle cell crisis should be included by the nurse? a) it results from altered metabolism and dehydration b) tissue hypoxia and vascular occlusion cause the primary problems c) increased bilirubin levels will cause hypertension d) there are decreased clotting factors with an increase in white blood cells
Answer B tissue hypoxia occurs as a result of the decreased oxygen-carrying capacity of the red blood cells. The sickled cells begin to clump together, which leads to vascular occlusion.
When providing postoperative care for the child with a cleft palate, the nurse should position the child in which of the following positions? a.Supine b. Prone c. In an infant seat d. On the side
Answer B. Postoperatively children with cleft palate should be placed on their abdomens to facilitate drainage.If the child is placed in the supine position, he or she may aspirate. Using an infant seat does not facilitate drainage. Side-lying does not facilitate drainage as well as the prone position
When assessing a child for possible intussusception, which of the following would be least likely to provide valuable information? a.Stool inspection b. Pain pattern c. Family history d. Abdominal palpation
Answer C Because intussusception is not believed to have a familial tendency, obtaining a family history would provide the least amount of information. Stool inspection, pain pattern, and abdominal palpation would reveal possible indicators of intussusception. Current, jelly-like stools containing blood and mucus are an indication of intussusception. Acute,episodic abdominal pain is characteristics of intussusception. A sausage-shaped mass may be palpated in the right upper quadrant.
A client and her husband are positive for the sickle cell trait. The client asks the nurse about chances of her children having sickle cell disease. Which of the following is appropriate response by the nurse? a)one of her children will have sickle cell disease b) only the male children will be affected c) each pregnancy carries a 25% chance of the child being affected d) if she had four children, one of them would have the disease
Answer C In autosomal recessive traits, both parents are carriers. There is a 25% chance with each pregnancy that a child will have the disease.
A 16 month old child diagnosed with Kawasaki Disease (KD) is very irritable,refuses to eat, and exhibits peeling skin on the hands and feet. Which of the following would the nurse interpret as the priority? a)applying lotions to the hands and feet b) offering foods the toddler likes c) placing the toddler in a quiet environment d) encouraging the parents to get some rest
Answer C One of the characteristics of children with KD is irritability. They are often inconsolable.Placing the child in a quiet environment may help quiet the child and reduce the workload of the heart. The child's irritability takes priority over peeling of the skin.
After teaching the parents of a preschooler who has undergone T and A(Tonsillectomy and Adenoidectomy) about appropriate foods to give the child afterdischarge, which of the following, if stated by the parents as appropriate foods, indicates successful teaching? a)meatloaf and uncooked carrots b) pork and noodle casserole c) cream of chicken soup and orange sherbet d) hot dog and potato chips
Answer C for the first few days after a T and A (Tonsillectomy and Adenoidectomy) , liquids and soft foods are best tolerated by the child while the throat is sore. Avoid hard and scratchy foods until throat is healed.
An 8 year old child has been diagnosed to have iron deficiency anemia. Which ofthe following activities is most appropriate for the child to decrease oxygen demands on the body? a)Dancing b) playing video games c) reading a book d) riding a bicycle
Answer C reading a book is restful activity and can keep the child from becoming bored. Choices a, b, and d require too much energy for a child with anemia and can increase oxygen demands on the body.
Which of the following nursing diagnoses would be inappropriate for the infant with gastroesophageal reflux(GER)? a.Fluid volume deficit b. Risk for aspiration c. Altered nutrition: less than body requirements d. Altered oral mucous membranes
Answer D GER is the backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the lower esophageal (cardiac)sphincter. No alteration in the oral mucous membranes occurs with this disorder. Fluid volume deficit, risk for aspiration, and altered nutrition are appropriate nursing diagnoses
A client with hemophilia has a very swollen knee after falling from bicycleriding. Which of the following is the first nursing action? a)initiate an IV site to begin administration of cryoprecipitate b) type and cross-match for possible transfusion c) monitor the client's vital signs for the first 5 minutes d) apply ice pack and compression dressings to the knee
Answer D rest, ice, compression, and elevation (RICE)are the immediate treatments to reduce the swelling and bleeding into the joint. These are the priority actions for bleeding into the joint of a client with hemophilia
A child diagnosed with tetralogy of fallot becomes upset, crying and thrashing around when a blood specimen is obtained.The child's color becomes blue and respiratory rate increases to 44 bpm.Which of the following actions would the nurse do first? a)obtain an order for sedation for the child b) assess for an irregular heart rate and rhythm c) explain to the child that it will only hurt for a short time d) place the child in knee-to-chest position
Answer D the child is experiencing a "tet spell" or hypoxic episode.Therefore the nurse should place the child in a knee-to-chest position. Flexing the legs reduces venous flow of blood from lower extremities and reduces the volume of blood being shunted through the interventricular septal defect and the overriding aorta in the child with tetralogy of fallot. As a result, the blood then entering the systemic circulation has higher oxygen content, and dyspnea is reduced. Flexing the legs also increases vascular resistance and pressure in the left ventricle. An infant often assumes a knee-to-chest position to relieve dyspnea. If this position is ineffective, then the child may need sedative. Once the child is in this position, the nurse may assess for an irregular heart rate and rhythm.Explaining to the child that it will only hurt for a short time does nothing to alleviate hypoxia.
Which of the following would the nurse perform to help alleviate a child's joint pain associated with rheumatic fever? a)maintaining the joints in an extended position b) applying gentle traction to the child's affected joints c) supporting proper alignment with rolled pillows d) using a bed cradle to avoid the weight of bed lines on the joints
Answer D for a child with arthritis associated with rheumatic fever, the joints are usually so tender that even the weight of bed linens can cause pain. Use of the bed cradle is recommended to help remove the weight of the linens on painful joints. Joints need to be maintained in good alignment, not positioned inextension, to ensure that they remain functional.Applying gentle traction to the joints is not recommended because traction is usually used to relieve muscle spasms, not typically associated with rheumatic fever. Supporting the body in good alignment and changing the client's position are recommended, but these measures are not likely to relieve pain.
A 2-year-old child recently diagnosed with hemophilia A is discharged home. What information should the nurse include in a teaching plan about home care?
Apply pressure and ice for bleeding while elevating and resting the extremity.
During routine screening at a school clinic, an otoscope examination of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. Based on these findings, what action should the nurse take?
Ask if the child has had a cold, runny nose, or any ear pain lately. Rationale: The tympanic membrane is normally pearly gray, not bulging, and moves when a client blows against resistance or when a small puff of air is blown into the ear canal. Because these findings are not completely normal, further assessment of history and related signs and symptoms are needed to interpret the findings accurately.
The nurse is conducting an initial admission assessment of a 12-month-old child in celiac crisis. Which intervention is most important for the nurse to implement?
Assess the child's mucous membranes and skin turgor Rationale: An infant having a celiac crisis has severe diarrhea and is at high risk for fluid volume deficit. The nurse should first assess for indications of fluid volume deficit
A child is rescued from a burning house and brought to the emergency room with partial-thickness burns on the face and chest. Which action should the nurse implemented first?
Assess the child's respiratory status
The nurse is preparing a teaching plan for the mother of a child who has been diagnosed with celiac disease. Choosing which lunch will be within the therapeutic management of a child with celiac disease?
Baked chicken, coleslaw, soda, and frozen fruit dessert Rationale: A child with celiac disease is managed on a gluten-free diet, which eliminates food products containing oats, wheat, rye, or barley
The nurse observes a 4-year-old boy in a day care setting. Which behavior should the nurse expect this child to exhibit?
Boasts aggressively when telling a story Rationale: Four-year-old children are aggressive in their behavior and enjoy telling tales
A child is admitted to the hospital for confirmation of a diagnosis of acute lymphoblastic leukemia. During the initial nursing assessment, which symptoms will this child most likely exhibit?
Bone pain, pallor Rationale: Leukemic cells invade the bone marrow, gradually causing a weakening of the bone and a tendency toward pathologic fractures. As leukemic cells invade the periosteum, increasing pressure causes severe pain and anemia results from decreased erythrocytes, causing pallor.
A 3-week-old infant is referred to an orthopedic clinic because the pediatrician heard a click when flexing the child's right hip during a routine physical examination. The orthopedic physician suspects that the child might have developmental dysplasia of the hip (DDH). The parents ask the nurse to identify risk factors commonly associated with DDH. Which response is accurate?
Breech presentation
A mother calls the clinic because her 6-year-old son, who has been taking prescribed antibiotics for 7 of the previous 10 days, continues to have a cough that she reports is worsening. Further questioning by the nurse reveals that the cough is nonproductive. What advice should the nurse provide to this mother?
Bring the child to the clinic today for an examination related to the cough. Rationale: The child should be evaluated as soon as possible for pneumonia. Antibiotics usually improve symptoms during the first few days of treatment but should be continued for the full prescribed course. A continued cough after 7 days of antibiotic treatment may indicate an infectious process in the lower lungs, which could cause a nonproductive cough. Children with pneumonia can deteriorate unexpectedly and rapidly and can become seriously ill, with no sputum production
A 4-year-old boy was admitted to the emergency room with a fractured right ulna and a short arm cast is applied. When preparing the parents to take the child home, which discharge instruction has the highest priority?
Call the healthcare provider immediately if his nail beds appear blue.
When taking the health history of a child, the nurse knows that which finding is an early indication of hypothyroidism in children?
Cessation of growth in a child that had been normal.
A 4-year-old girl continues to interrupt her mother during a routine clinic visit. The mother appears irritated with the child and asks the nurse, "Is this normal behavior for a child this age?" The nurse's response should be based on which information?
Children need to retain a sense of initiative without impinging on the rights and privileges of others.
A full term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that the infant may have an esophageal atresia. Which symptoms are this newborn likely to exhibit?
Choking, coughing, and cyanosis.
A nurse is preparing to end the shift and receives a lab report stating that a child with asthma has a theophylline level of 15 mcg/dL. Which action should the nurse take?
Communicate the result to the oncoming nurse and document. Rationale: The therapeutic level of theophylline is 10 to 20 mcg/dL, so the child's level is within the therapeutic range. This information evaluates the prescribed therapy and should be communicated in the nurse's report.
A 2-year-old child with Down syndrome is brought to the clinic for his regular physical examination. The nurse knows which problem is frequently associated with Down syndrome?
Congenital heart disease.
The nurse is planning postoperative care for a child who has had a cleft lip repair. What is the most important reason to minimize this child's crying during the recovery period?
Crying stresses the suture line. Rationale: Prevention of stress on the lip suture line is essential for optimum healing and the cosmetic appearance of a cleft lip repair.
A 3-year-old boy is brought to the emergency room because he swallowed an entire bottle of children's vitamin pills. Which intervention should the nurse implement first?
Determine the child's pulse and respirations.
In making the initial assessment of a 2-hour-old infant, which finding should lead the nurse to suspect a congenital heart defect?
Diminished femoral pulses Rationale: Diminished femoral pulses (D) could indicate coarctation of the aorta.
The nurse expects a 2-year-old child to exhibit which behavior?
Display possessiveness with toys. Rationale: Two-year-old children are egocentric and unable to share with other children.
The mother of a preschool-aged child asks the nurse if it is all right to administer Pepto Bismol to her son when he "has a tummy ache." After reminding the mother to check the label of all over-the-counter drugs for the presence of aspirin, which instruction should the nurse include when replying to this mother's question?
Do not give if the child has chickenpox, the flu, or any other viral illness.
The nurse is teaching the parents of a 2-year-old child with a congenital heart defect about signs and symptoms of congestive heart failure. Which information about the child is most important for the parents to report to the health care provider?
Exhibits a sudden and unexplained weight gain Rationale: Sudden and unexplained weight gain (B) can indicate fluid retention and is a sign of congestive heart failure.
A 6-year-old is admitted to the pediatric unit after falling off a bicycle. Which intervention should the nurse implement to assist the child's adjustment to hospitalization?
Explain hospital schedules to the child, such as mealtimes.
A 15-year-old girl tells the school nurse that all of her friends have started their periods and she feels abnormal because she has not. Which response is best for the nurse provide?
Explain that menarche varies and occurs between the ages of 12 and 18 years
The nurse admits a child to the intensive care unit with a diagnosis of acquired aplastic anemia. What is the most common cause of this type of anemia?
Exposure to certain drugs Rationale: Aplastic anemia often follows exposure to certain drugs such as chloramphenicol, sulfonamides, and phenylbutazone (Butazolidin), insecticides such as DDT, and chemicals, especially, benzene.
During discharge teaching of a child with juvenile rheumatoid arthritis, the nurse should stress to the parents the importance of obtaining which diagnostic testing?
Eye exams.
The nurse is developing a plan of care for a 3-year-old who is scheduled for a cardiac catheterization. To assist in decreasing anxiety for the child on the day of the procedure, which intervention is best for the nurse to implement?
Give the child a ride on a gurney to visit the cardiac catheterization lab and meet a nurse who works there.
A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He is placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this infant?
Have a bulb syringe readily available to remove secretions
A burned child is brought to the emergency department, and the nurse uses a modified rule of nines to estimate the percentage of the body burned. When calculating the percentage of burn, which parts of the child's body is proportionally larger than an adult's?
Head and neck Rationale: The standard rule of nines is inaccurate for determining burned body surface areas with children because a child's head and neck are proportionately larger than an adult's. Specially designed charts are commonly used to measure the percentage of burn in children.
A 4-year-old child has cystic fibrosis. Which stage of Erikson's theory of psychosocial development is the nurse addressing when teaching inhalation therapy?
Initiative Rationale: Children 4 to 5 years of age are in the "Initiative vs. Guilt" stage of Erikson's theory of psychosocial development
A 7-month-old infant with a rotavirus causing severe diarrhea is admitted for treatment. Which intervention should the nurse implement first?
Insert an intravenous (IV) line and begin IV fluids. Rationale: An infant with severe diarrhea is at high risk for dehydration, so the nurse's priority is to initiate IV fluids
At which point during the physical examination should a child with asthma be assessed for the presence or absence of intercostal retractions?
Inspiration Rationale: Intercostal retractions result from respiratory effort to draw air into restricted airways. The retractions will not be noticeable when air is expelled from the lungs, such as when the client is coughing or expiring
The nurse is examining a male child experiencing an exacerbation of juvenile rheumatoid arthritis (JRA) and notes that his mobility is greatly reduced. What is the most likely cause of the child's impaired mobility?
Joint inflammation Rationale: Joint inflammation and pain are the typical manifestations of an exacerbation of JRA
When caring for a child with congenital heart disease and polycythemia, which nursing intervention has the highest priority?
Maintaining adequate hydration Rationale: The key word in this question is polycythemia. Hydration decreases blood viscosity and the risk for thrombus formation, the most common complication of polycythemia.
When inserting a nasogastric tube into the stomach of a 3-month-old infant, which nursing intervention is most important to implement?
Monitor the infant's heart rate
A 3-month-old infant develops oral thrush. Which pharmacologic agent should the nurse plan to administer for treatment of this disorder?
Nystatin (Mycostatin).
Which preoperative nursing intervention should be included in the plan of care for an infant with pyloric stenosis?
Observe for projectile vomiting. Rationale: Projectile vomiting (D), the classic sign of pyloric stenosis, contributes to metabolic alkalosis.
An infant is receiving digoxin (Lanoxin) for congestive heart failure. The apical heart rate is assessed at 80 beats/min. What intervention should the nurse implement?
Obtain a therapeutic drug level. Rationale: Sinus bradycardia (heart rate < 90 to 110 beats/min in an infant) is an indication of digoxin toxicity, so assessment of the client's digoxin level has the highest priority.
The nurse is assessing the neurovascular status of a child in Russell's traction. Which finding should the nurse report to the healthcare provider?
Pale bluish coloration of the toes
A newborn female whose mother is HIV-positive is scheduled for the first follow-up assessment with the nurse. If the child is HIV-positive, which initial symptom is she most likely to exhibit?
Persistent cold Rationale: Respiratory tract infections commonly occur in the pediatric population, but the child with AIDS has a decreased ability to defend the body against these common infections. Thus, the most typical presenting symptom of a child who contracted AIDS through vertical transmission (i.e., from the mother during delivery) is a persistent cold or respiratory infection
A child with a permanent tracheostomy is confined to a wheelchair and is going to school for the first time tomorrow. During the school day, which intervention should be implemented for this child?
Place suctioning supplies on the back of the wheelchair when transporting. Rationale: Suctioning supplies should always be readily available for use with any client who has a tracheostomy.
A child breaks out with varicella infection (chickenpox) while hospitalized for a minor surgical procedure. Which intervention should the nurse implement first?
Place the child in strict isolation to prevent an outbreak on the unit. Rationale: The period of communicability of varicella is 2 days before the rash appears until all lesions are crusted; varicella is spread by direct or indirect contact of saliva or vesicles. Strict isolation is indicated to prevent further exposure to staff and others. Staff who have had varicella or the vaccine are not susceptible to contracting or spreading the virus and should be the only personnel assigned to care for this client
A 3-month-old infant returns from surgery with elbow restraints and a Logan's bow over a cleft lip suture line. Which intervention should the nurse implement to maintain suture line integrity during the initial postoperative period?
Place the infant upright in an infant seat position. Rationale: The use of an infant seat simulates a supine position with the head elevated and also prevents aspiration. Prone positioning should be avoided to prevent disruption of the protective Logan's bow and prevent the infant from rubbing the face on the bed surface. Mittens are not necessary and decrease the ability to provide sensory comfort, such as hand holding. Nasal suctioning should be avoided to prevent trauma or dislodging clots at the surgical site. Water-soluble lubricant will dry the suture line and cause crusting, which predisposes the suture line to poor healing and scarring.
A nurse provides the parents with information on health maintenance for their child with sickle cell disease. Which information reflected by the parents indicates understanding of the child's care?
Plenty of fluids should be consumed daily.
A 2-year-old child with trisomy 21 (Down syndrome) is brought to the clinic for a routine evaluation. Which assessment finding suggests the presence of a common complication often experienced by those with Down syndrome?
Presence of a systolic murmur Rationale: Congenital heart disease occurs in 40% to 50% of children with trisomy 21 (Down syndrome). Defects of the atrial or ventricular septum that create systolic murmurs are the most common heart defects associated with this congenital anomaly.
Following the reduction of an incarcerated inguinal hernia, a 4-month-old boy is scheduled for surgical repair of the inguinal hernia. Under which circumstance should the parents notify the health care provider prior to surgery?
Presence of an inguinal bulge after gentle palpation Rationale: The parents should notify the health care provider if the hernia remains irreducible after implementing simple measures, such as gentle palpation, warm bath, and comforting to reduce crying. If a loop of intestines is forced into the inguinal ring or scrotum and incarcerates, swelling can follow and possible strangulation of the bowel, intestinal obstruction, or gangrene of the bowel loop can occur, necessitating emergency surgical release.
An infant is born with a ventricular septal defect (VSD) and surgery is planned to correct the defect. The nurse recognizes that surgical correction is designed to achieve which outcome?
Prevent the return of oxygenated blood to the lungs.
When evaluating the effectiveness of interventions to improve the nutritional status of an infant with gastro-esophageal reflux, which intervention is most important for the nurse to implement?
Record weight daily.
The nurse is preparing a child with an intussusception for a prescribed barium enema. What is the main purpose of conducting this procedure prior to surgical intervention?
Reduce the invaginated bowel segment. Rationale: Intussusception, an invagination or telescoping of one portion of the intestine into another, causes intestinal obstruction in children (usually occurs between 3 months and 5 years of age). Nonsurgical treatment is attempted with hydrostatic pressure created by barium instillation, which often reduces the area of bowel intussusception, thereby negating the need for surgical intervention.
A 6-month-old male infant is admitted to the postanesthesia care unit with elbow restraints in place. He has an endotracheal tube and is ventilator-dependent but will be extubated soon following recovery from anesthesia. Which nursing intervention should be included in this child's plan of care?
Remove restraints one at a time and provide range-of-motion exercises. Rationale: Removing restraints one at a time is safer than simultaneously. The infant should have the restrained extremities assessed frequently for signs of neurologic or vascular impairment, and range-of-motion exercises should be performed with these assessments. Under no circumstances should restraints be applied to the client continuously. Documentation of assessment findings regarding the restrained extremities must occur much more frequently than every 72 hours; however, the reason for using restraints must be justified and should be stated in the medical record.
The nurse is teaching an adolescent girl with scoliosis about a Milwaukee brace that her health care provider has prescribed. Which instruction should the nurse provide to this client?
Remove the brace 1 hour each day for bathing only. Rationale: The Milwaukee brace is designed to slow the progression in spinal curvature while the adolescent is growing. The brace should be worn 23 hours a day and removed a total of 1 hour a day for hygiene. There are no specific exercises for increasing the range of motion in the back that should be performed. A T shirt should be worn next to the body and the brace put on over the T shirt to protect the skin. The brace will not cure the spinal curvature but should slow the progression of the scoliosis.
To take the vital signs of a 4-month-old child, which order provides the most accurate results?
Respiratory rate, heart rate, then rectal temperature
An 18-month-old is admitted to the hospital with possible Hirschsprung's disease. When obtaining a nursing history, the nurse asks about bowel habits. What description of the disease?
Ribbon-like and brown.
The nurse reviews the latest laboratory results for a child who received chemotherapy last week and identifies a reduced neutrophil count. Which nursing diagnosis has the highest priority for this child?
Risk for infection
A child comes to the school nurse complaining of itching. Further assessment reveals that the child has impetigo. What action should the nurse take?
Send the child home with the parents to see the health care provider before returning to school. Rationale: Impetigo is a staphylococcal infection and is transmitted by person-to-person contact. The child should be sent home with a note to the parents explaining the condition
A 5-month-old is admitted to the hospital with vomiting and diarrhea. The pediatrician prescribes dextrose 5% and 0.25% normal saline with 2 mEq KCl/100 ml to be infused at 25 ml/hour. Prior to initiating the infusion, the nurse should obtain which assessment finding?
Serum BUN and creatinine levels
An 18-month-old child returns to the unit following a cardiac catheterization with a cannulated femoral artery site. Which intervention should the nurse implement?
Show the parents how to hold the child with the extremity extended. Rationale: The extremity should be extended to prevent trauma to the femoral catheterization site
The nurse notes that a 16-year-old male client is refusing visits from his classmates. Further assessment reveals that he is concerned about his edematous facial features. Based on these assessment findings, the nurse should plan interventions related to which nursing diagnosis?
Social isolation Rationale: Peer acceptance and body image are significant issues in the growth and development of adolescents. The answer addresses the problem of a lack of contact with peers stemming from his desire to protect his ego.
Which assessment finding(s) should the nurse expect when caring for a child with cystic fibrosis? (Select all that apply.)
Steatorrhea Foul-smelling stools Delayed growth Pulmonary congestion
During administration of a blood transfusion, a child complains of chills, headache, and nausea. Which action should the nurse implement?
Stop the infusion immediately and notify the healthcare provider.
The nurse is preparing a health teaching program for parents of toddlers and preschoolers and plans to include information about the prevention of accidental poisonings. It is most important for the nurse to include which instruction?
Store all toxic agents and medicines in locked cabinets. Rationale: The only reliable way to prevent poisonings in young children is to make the items inaccessible
A father of a 5-year-old boy calls the nurse to report that his son, who has had an upper respiratory infection, is complaining of a headache, and his temperature has increased to 103° F, taken rectally. Which intervention has the highest priority?
Tell the parent to take the child to the emergency department. Rationale: The child is exhibiting symptoms that may indicate possible meningitis, and the parents should be encouraged to get immediate evaluation
A premature newborn girl, born 24 hours ago, is diagnosed with a patent ductus arteriosus (PDA) and placed under an oxygen hood at 35%. The parents visit the nursery and ask to hold her. Which response should the nurse provide to the parents?
The oxygen hood is holding the baby's oxygen level just at the point which is needed. You may stroke and talk to her.
Prophylactic antibiotics are prescribed for a child who has mitral valve damage. The nurse should advise the parents to give the antibiotics prior to which occurrence?
Urinary catheterization Rationale: Prophylactic antibiotics are usually prescribed prior to any invasive procedure for children who have valvular damage.
The nurse assigns an unlicensed assistive personnel (UAP) to provide morning care to a newly admitted child with bacterial meningitis. What is the most important instruction for the nurse to review with the UAP?
Use designated isolation precautions.
A female teenager is taking oral tetracycline HCL (Achromycin V) for acne vulgaris. What is the most important instruction for the nurse to include in this client's teaching plan?
Use sunscreen when lying by the pool.
A child falls on the playground and is brought to the school nurse with a small laceration on the forearm. Which action should the nurse implement first?
Wash the wound gently with mild soap and water.
A 2-year-old child with gastro-esophageal reflux has developed a fear of eating. What instruction should the nurse include in the parents' teaching plan?
consistently follow a set mealtime routine.
