Pediatrics: PrepU: Chapter 16
The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity?
Moving the infant's head every 2 hours
A child with a seizure disorder is being admitted to the inpatient unit. When preparing the room for the child, what should be included? Select all that apply.
Oxygen gauge and tubing Suction at bedside Padding for side rails
Moving the infant's head every 2 hours
Serum glucose level Explanation: Status epilepticus is the occurrence of repetitive seizures in an individual. This is a neurological emergency. The events of the repetitive seizures greatly expends energy. This will result in rapid drops in serum glucose level, making this the priority laboratory value to review.
Arnold-Chiari malformation
Video electroencephalogram
The nurse is assessing a toddler for motor function. Which activity will be the most valuable?
Watch the child reach for a toy. Explanation: Watching the child reach for a toy would be most valuable for assessing motor function because the infant should be able to extend extremities to a normal stretch. Catching a ball or kicking a ball forward are too advanced for a toddler to accomplish. Looking at a picture book would help assess visual acuity and eye movement
A 1-year-old infant has just undergone surgery to correct craniosynostosis. Which comment is the best psychosocial intervention for the parents?
"The surgery was successful. Do you have any questions?" Explanation: Often what parents need most is someone to listen to their concerns. Although this is a good time for education, the parents are more concerned about the success of the surgery than their infant's appearance. Watching the hemoglobin, hematocrit and swelling are important nursing functions but they do not address the parents' psychosocial needs. The parents do not need to be taught statistics about their infant's condition. They more than likely know this from health care provider visits, the Internet, and parent support groups. Following surgery, this knowledge is not what parents are concerned about. Parents want to know their infant is safe and well
The nurse is providing education to the parents of a 3-year-old girl with hydrocephalus who has just had an external ventricular drainage system placed. Which question is best to begin the teaching session?
"What questions or concerns do you have about this device?" Explanation: Always start by assessing the family's knowledge. Ask them what they need to know. Knowing when to clamp the drain is important, but they might not be listening if they have another question on their minds. Autoregulation is too technical. Teaching should be based on the parents' level of understanding. Keeping her head elevated is not part of the information which would be taught regarding the drainage system.
The nurse is assessing the neurological functioning of a preschool child. What actions will best review functioning of cranial nerve III?
A bright-colored toy is moved in the child's visual fields. Explanation: Cranial nerve III, the oculomotor nerve, is assessed by using a brightly colored object to assess the child's ability to watch its movement. Cranial nerve I (olfactory nerve) controls the sense of smell. Asking the child to smell objects would be an assessment of this cranial nerve. Cranial nerve VII (facial nerve) is assessed by monitoring symmetry of facial movements. Cranial nerve VIII (acoustic nerve) is assessed by whispering.
A child has been diagnosed with a basilar skull fracture. The nurse identifies ecchymosis behind the child's ear. This would be documented as:
Battle sign. Explanation: Two signs of basilar skull fracture include Battle sign (bruising or ecchymosis behind the ear) and "raccoon eyes" (blood leaking into the frontal sinuses causing an edematous and bruised periorbital area). Rhinorrhea is CSF leakage from the nose. Otorrhea is CSF leaking from the ear.
The nurse is observing an infant who may have acute bacterial meningitis. Which finding might the nurse look for?
Irritability, fever, and vomiting Explanation: Findings associated with acute bacterial meningitis may include irritability, fever, and vomiting along with seizure activity. Fontanels (fontanelles) would be bulging as intracranial pressure rises, and Kernig sign would be present due to meningeal irritation. Jaundice, drowsiness, and refusal to eat indicate a GI disturbance rather than meningitis.
Tonic-clonic seizures
most dramatic seizure disorder. It is characterized by a loss of consciousness, along with the entire body experiencing tonic contractions followed by rhythmic clonic contractions alternating with relaxation of all muscle groups. Cyanosis may be noted due to apnea, and saliva may collect in the mouth due to inability to swallow. All of these symptoms would make Risk for injury the highest priority.
Preterm infants have more fragile capillaries in the periventricular area than term infants. This put these infants at risk for which problem?
Intracranial hemorrhaging Explanation: Fragile capillaries in the periventricular area of the brain put preterm infants at risk for intracranial hemorrhage. Closure of the fontanels has nothing to do with fragile capillaries within the brain. Larger head size gives children a higher center of gravity which causes them to hit their head more readily. Congenital hydrocephalus may be caused by abnormal intrauterine development or infection.
Any individual taking phenobarbital for a seizure disorder should be taught:
never to discontinue the drug abruptly. Explanation: Phenobarbital should always be tapered, not stopped abruptly, or seizures from the child's dependency on the drug can result.
After teaching a group of students about neural tube disorders, the instructor determines that additional teaching is needed when the students identify this as a neural tube defect.
Arnold-Chiari malformation
Which nursing action should be included in the care plan to promote comfort in a 4-year-old child hospitalized with meningitis?
Avoid making noise when in the child's room. Explanation: Meningeal irritation may cause seizures and heightens a child's sensitivity to all stimuli, including noise, lights, movement, and touch. Frequent rocking, presence of a younger sibling, and bright lights would increase stimulation.
The nurse is collecting data from a child who may have a seizure disorder. Which nursing observations suggest an absence seizure?
Minimal or no alteration in muscle tone, with a brief loss of responsiveness or attention Explanation: Absence seizures are characterized by a brief loss of responsiveness with minimal or no alteration in muscle tone. They may go unrecognized because the child's behavior changes very little. A sudden loss of muscle tone describes atonic seizures. A frozen position describes the appearance of someone having akinetic seizures. A brief, sudden contraction of muscles describes a myoclonic seizure.
When assessing a neonate for seizures, what would the nurse expect to find? Select all that apply.
Tachycardia Elevated blood pressure Jitteriness Ocular deviation
The nurse helps position a child for a lumbar puncture. Which statement describes the correct positioning for this procedure?
"For a lumbar puncture, the child will be placed in a side-lying position with knees bent and neck flexed to assist with arching the back." Correct positioning for a lumbar puncture is to place the child on his or her side with the neck flexed and knees bent and drawn up to their chest. This helps to keep the back arched as much as possible. Newborns may be seated upright with their head bent forward. The child is not placed prone; this does not allow the back to be arched.
The nurse is preparing discharge education for the caregivers of a child with a seizure disorder. Which goal of treatment is priority for this client?
The child will remain free from injury during a seizure.
A 6-year-old has had a viral infection for the past 5 days and is having severe vomiting, confusion, and irritability, although he is now afebrile. During the assessment, the nurse should ask the parent which question?
"Did you use any medications like aspirin for the fever?" Explanation: Severe and continual vomiting, changes in mental status, lethargy, and irritability are some of the signs and symptoms of Reye syndrome, which can occur as a result of ingesting aspirin or aspirin-containing products during a viral infection. Tylenol (acetaminophen) is allowed for viral infections in the school-age child. The type of fluids consumed during the illness has nothing to do with Reye syndrome. The temperature rise would be important for a much younger child because of the chance of febrile seizures, but not in this age child.
The nurse is using the pediatric Glasgow Coma Scale to assess a child's level of consciousness. What would the nurse assess? Select all that apply.
Eye opening Verbal response Motor response Explanation: The pediatric Glasgow Coma Scale assesses level of consciousness using three parts: eye opening, verbal response, and motor response.
A nurse is assessing a 3-year-old child for possible bacterial meningitis. Which sign would indicate irritation of the meninges?
Positive Kernig sign Explanation: A positive Kernig sign can indicate irritation of the meninges. A positive Brudzinski sign also is indicative of the condition. A positive Chadwick sign is a bluish discoloration of the cervix indicating pregnancy.
While observing a child, the nurse notes that the child's arms and legs are extended and pronated. During shift hand-off, the nurse reports potential damage to:
the midbrain. The observations indicate decerebrate posturing, which occurs with damage to the midbrain. Decorticate posturing as evidenced by arm adduction, elbow flexion with arms over the chest, and wrist flexion with fisted hands indicates damage to the cerebral cortex. Damage to the cranial nerves would be manifested by defects in motor and/or sensory function, depending on the cranial nerves affected. Meningeal irritation, as with bacterial meningitis, is manifested by opisthotonos in an infant. With this position, the head and neck are hyperextended to relieve discomfort.
The nurse cares for a 7-year-old child with new-onset seizure disorder. Which prescription will the nurse anticipate for this client?
use of anticonvulsant medications Explanation: Complete control of seizures can be achieved for most people through the use of anticonvulsant drug therapy. These medications are typically used first as treatment for seizure disorders. Frequent temperature assessment would only be useful in febrile seizures. Ketogenic diets (high in fat, low in carbohydrates, and adequate in protein) cause the child to have high levels of ketones, which help to reduce seizure activity. Diet is generally used when medications cannot control a child's seizure activity. Stimulating the left vagus nerve intermittently with electrical pulses may reduce seizure frequency. This requires surgically implanting a stimulator under the skin and is approved for children 12 and older.
A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. The nurse would include which recommendation in the nursing plan?
Decrease environmental stimulation Explanation: A child with the diagnosis of meningitis is much more comfortable with decreased environmental stimuli. Noise and bright lights stimulate the child and can be irritating, causing the child to cry, in turn increasing intracranial pressure. Vital signs would be taken initially every hour and temperature monitored every 2 hours. Children with bacterial meningitis are usually much more comfortable if allowed to lie flat because this position doesn't cause increased meningeal irritation.
After a difficult birth, the nurse observes that a newborn has swelling on part of his head. The nurse suspects caput succedaneum based on what evidence?
The swelling crosses the midline of the infant's scalp.
To detect complications as early as possible in a child with meningitis who's receiving IV fluids, monitoring for which condition should be the nurse's priority?
Cerebral edema Explanation: The child with meningitis is already at increased risk for cerebral edema and increased intracranial pressure due to inflammation of the meningeal membranes; therefore, the nurse should carefully monitor fluid intake and output to avoid fluid volume overload. Renal failure and cardiogenic shock aren't complications of IV therapy. The child with a healthy heart wouldn't be expected to develop left-sided heart failure.
The nurse is caring for a 6-year-old child with an external ventricular drainage device. The nurse is concerned about the minimal drainage in the past few hours. What actions by the nurse are indicated? Select all that apply.
Check tubing clamps to ensure they are open. Ensure the tubing is not kinked.
The nurse is preparing an inservice for the staff about shaken baby syndrome. When planning to review risk factors, what should be included? Select all that apply.
Teen parents Infant with colic Premature infants Financial concerns in the family. Explanation: Shaken baby syndrome refers to the violent shaking of an infant or child that results in traumatic injury to the child. Risk factors include single parenting, young parents, a child who is born prematurely, a child having chronic health problems, and financial concerns in the family.
A nurse is reviewing the results of a lumbar puncture of a child. The nurse identifies which results as being abnormal? Select all that apply.
specific gravity of 1.011 cloudy in color granulocytes are present Explanation: Normal appearance of cerebrospinal fluid (CSF) is clear and colorless. The presence of granulocytes suggests a cerebrospinal fluid infection. Normal specific gravity is 1.004 to 1.008. Trace amounts of protein, glucose, lymphocytes, and body salts are normal.
Dexamethasone is often prescribed for the child who has sustained a severe head injury. Dexamethasone is a(n):
steroid. Explanation: Increased intracranial pressure (ICP) may be caused by several factors: head trauma, birth trauma, hydrocephalus, infection, and/or tumors. Whatever the reason, the brain swells and becomes inflamed. Dexamethasone is a steroid. A steroid may be prescribed to reduce inflammation and pressure on vital centers of the brain. mannitol= may be used to decrease edema. An anticonvulsant= is used with increased ICP to prevent seizures. An antihistamine= would not be warranted for the treatment of a head injury.
The nurse is caring for an infant who is at risk for increased intracranial pressure. What statement by the parent would alert the nurse to further assess the child's neurological status?
"She has been irritable for the last hour....seems like she is just upset for some reason." Explanation: Irritability in an infant can be a sign of declining neurological function. Because infants are not able to answer questions pertaining to person, place and time, their neurological assessment must be catered to their level of development. The other responses would be typical and normal for an infant.
The nurse has just admitted a 17-year-old diagnosed with bacterial meningitis. The parents of the adolescent tell the nurse, "We just don't understand how this could have happened. Our child has always been healthy and also just received a booster vaccine last year?" How should the nurse respond?
"I understand your frustration. Unfortunately immunizations are not 100% effective in preventing the infection." Explanation: Showing empathy while letting the parents know that vaccines are not 100% effective is the best response. Questioning them about being sure would not be the best response unless there was reason to believe their information was not accurate. There is nothing to lead the nurse to believe that a different strain of bacteria caused the infection, or that the child's immune system is compromised.
The nurse is preparing a room for a child being admitted with meningitis. What is the appropriate action by the nurse?
Gather appropriate equipment and signage for respiratory isolation precautions. Explanation: Children with meningitis are placed on respiratory precautions for 24 hours after the start of antibiotic therapy to prevent transmission of the infection to other family members or health care providers. While a child is on respiratory isolation, they will typically not be allowed out of their rooms to play. Due to pain when their neck is flexed, most children are most comfortable without a pillow. Reducing stimulation can help to promote rest for the child.
A child who has been having seizures is admitted to the hospital for diagnostic testing. The child has had laboratory testing and an EEG, and is scheduled for a lumbar puncture. The parents voice concern to the nurse stating, "I don't understand why our child had to have a lumbar puncture since the EEG was negative." What is the best response by the nurse?
The lumbar puncture can help rule out any infection in fluid surrounding the brain and spinal cord as the cause of the seizures." Explanation: Lumbar punctures are performed to analyze cerebrospinal fluid (CSF) to rule out meningitis or encephalitis as a cause of seizures. A normal EEG does not rule out epilepsy because seizure activity rarely occurs during the actual testing time. A 24-hour or longer EEG can help in diagnosing a seizure disorder. Just telling the parents that it needs to be done, to be patient, or it is a routine does not address the parents' concerns.
The nurse is caring for a near-term pregnant woman who has not taken prenatal vitamins or folic acid supplements. Which congenital defect is most likely to occur based on the mother's prenatal history?
A neural tube defect
When caring for a child who has a history of seizures, which nursing interventions would be appropriate? Select all that apply.
The nurse pads the crib or side rails before a seizure. The nurse positions the child on the side during a seizure. The nurse stays with the child and calls for help when a seizure begins. The nurse has oxygen available to use during a seizure. The nurse teaches the caregivers regarding seizure precautions.
The nurse is reinforcing teaching with the caregivers of a child who has had a head injury and is being discharged. Which statement made by the caregiver indicates an accurate understanding of the follow-up care for this child?
"Even if the flashlight bothers him, we will check his eyes." Explanation: The child's pupils are checked for reaction to light every 4 hours for 48 hours. If the child falls asleep, he or she should be awakened every 1 to 2 hours to determine that the level of consciousness has not changed. No analgesics or sedatives should be administered during this period of observation. The caregiver should observe the child for at least 6 hours for vomiting or a change in the child's level of consciousness. The caregiver should notify the health care provider immediately if the child vomits more than three times, but if the child vomits once, returning to the care provider immediately is not needed.
The nurse is caring for a child who has suffered a febrile seizure. While speaking with the child's parents, which statement by a parent indicates a need for further education?
"I hate to think that I will need to be worried about my child having seizures for the rest of his life." Explanation: Febrile seizures occur most often in preschool children but can occur as late as 7 years of age. They occur when the child has a rapid rise in temperature and are not associated with the development of seizures later in life. Administering correct dosages of acetaminophen and ibuprofen, checking temperatures at night, and anticipating fevers associated with the administration of live vaccines are all ways to prevent the development of febrile seizures.
A 7-year-old client has been complaining of headache, coughing, and an aching chest. The care provider makes a diagnosis of a viral infection. The child's mother tells the nurse that when she first said she had a headache, the child's father gave her half of an adult aspirin. The mother has heard of Reye syndrome and asks the nurse if her child could get this. Which statement would be the best response by the nurse?
"This might or might not be a problem. Watch your daughter for signs of lethargy, unusual irritability, confusion, or vomiting. If you notice any of these, bring her to the emergency room immediately so she can be checked for Reye syndrome." Explanation: Reye syndrome usually occurs after a viral illness, particularly after an upper respiratory infection or varicella (chickenpox). Administration of aspirin during the viral illness has been implicated as a contributing factor. As a result, the American Academy of Pediatrics recommends that aspirin or aspirin compounds not be given to children with viral infections. The symptoms appear within 3 to 5 days after the initial illness: The child is recuperating unremarkably when symptoms of severe vomiting, irritability, lethargy, and confusion occur. Immediate intervention is needed to prevent serious insult to the brain, including respiratory arrest.
The emergency room nurse is taking a history of a 1-year-old child whose parent said that she had a "fit" at home. Which inquiry would be best to start with?
What happened just before the seizures?" Explanation: Asking what happened just before the seizure will suggest whether the episode was a seizure or a breath-holding event, which is frequently precipitated by an expression of anger or frustration. Cyanotic breath holding can be accompanied by clinical movements, as can seizures. Both types of events render the child unconscious. One would expect concerned, caring treatment from the parents regardless of the cause.
The nurse is caring for an adolescent who suffered a thoracic spinal cord injury 8 weeks ago. While assessing the adolescent, the nurse notes a blood pressure of 185/95 mm Hg, heart rate of 130 beats/minute, flushed face, and a report of a severe headache. What is the priority action by the nurse?
Assess the adolescent's indwelling urinary catheter to see if it is obstructed. Explanation: Autonomic dysreflexia is an emergent situation that is caused by a full bladder in a child with a spinal cord injury. It is characterized by extreme hypertension, tachycardia, flushed face and severe occipital headache. Assessing and emptying the bladder is the first action in treating this disorder. Placing the child in high-Fowler and providing a fan does not address the underlying cause of the autonomic dysreflexia. The nurse will need to notify the health care provider but should do this after assessing the client's bladder and indwelling bladder catheter.
What information is most correct regarding the nervous system of the child?
As the child grows, the gross and fine motor skills increase. Explanation: As the child grows, the quality of the nerve impulses sent through the nervous system develops and matures. As these nerve impulses become more mature, the child's gross and fine motor skills increase in complexity. The child becomes more coordinated and able to develop motor skills.
While in a pediatric client's room, the nurse notes that the client is beginning to have a tonic-clonic seizure. Which nursing action is priority?
Protect the child from hitting the arms against the bed. Explanation: Keeping the child safe during a seizure is the highest priority. The nurse will protect the child from hitting the arms on the bed or other nearby objects. If the seizure continues, lorazepam may be indicated to stop the seizure. The client would be referred to a neurologist for follow-up care; however, this is not a priority. Dietary therapy is considered for clients with chronic seizure disorders who do not respond to medication therapy.
The mother of a toddler tells the nurse during a routine well-child appointment that she is concerned because, "It seems like my son is falling and hitting his head all of the time." What is the best response by the nurse?
"Due to the size of their heads and immature neck muscles falling is common, but I will let the physician know your concerns." Explanation: The head of the infant and young child is large in proportion to the body, and is the fastest-growing body part during infancy and continues to grow until the child is 5 years old. In addition, the infant's and child's neck muscles are not well developed. Both of these differences lead to an increased incidence of head injury from falls. The nurse should still let the physician know the mother's concerns in case there is another issue causing the falls.
A pregnant client asks if there is any danger to the development of her fetus in the first few weeks of her pregnancy. How should the nurse respond?
"During the first 3 to 4 weeks of pregnancy, brain and spinal cord development occur and are affected by nutrition, drugs, infection, or trauma." Explanation: Brain and spinal cord development occur during the first 3 to 4 weeks of gestation. Infection, trauma, teratogens (any environmental substance that can cause physical defects in the developing embryo and fetus), and malnutrition during this period can result in malformations in brain and spinal cord development and may affect normal central nervous system (CNS) development. Good health before becoming pregnant is important but must continue into the pregnancy. Hardening of bones occurs during 13 to 16 weeks gestation, and the respiratory system begins maturing around 23 weeks' gestation.
During the physical assessment of a 2½-month-old infant, the nurse suspects the child may have hydrocephalus. Which sign or symptom was observed?
Dramatic increase in head circumference Explanation: A dramatic increase in head circumference is a symptom of hydrocephalus, suggesting that there is a build-up of fluid in the brain. Only one pupil that is dilated and reactive is a sign of an intracranial mass. Vertical nystagmus indicates brain stem dysfunction. A closed posterior fontanel (fontanelle) would be frequently seen by this age.
The nurse caring for an infant with craniosynostosis, specifically positional plagiocephaly, should prioritize which activity?
Moving the infant's head every 2 hours Explanation: Positional plagiocephaly can occur because the infant's head is allowed to stay in one position for too long. Because the bones of the skull are soft and moldable, they can become flattened if the head is allowed to remain in the same position for a long period of time. Massaging the scalp will not affect the skull. Measuring the intake and output is important but has no effect on the skull bones. Small feedings are indicated whenever an infant has increased intracranial pressure, but feeding an infant each time he fusses is inappropriate care.
absence seizures
This type of seizure is more common in girls than it is in boys. You might see a blank facial expression after a sudden stoppage of speech. This type of seizure is usually short, lasting for no more than 30 seconds. You might have mistaken this type of seizure for lack of attention Loss of motor activity accompanied by a blank stare
A child was just brought into the emergency department after falling off a skateboard. The parents report that their child lost consciousness briefly and they noticed watery drainage coming from the nose. What action should the nurse take first?
Notify the emergency department physician of the information the parents reported Explanation: If clear liquid fluid is noted draining from the ears or nose, the physician should be notified immediately. If the fluid tests positive for glucose, this is indicative of leaking. The other assessments can continue after notifying the physician of these findings.