Peds Chapter 23

What disease processes require airborne precautions? (Select all that apply.)

Measles Varicella Tuberculosis In addition to Standard Precautions, use airborne precautions for patients known or suspected to have serious illnesses transmitted by airborne droplet nuclei. Examples of such illnesses include measles, varicella (including disseminated zoster), and tuberculosis. Pertussis and meningitis require droplet precautions.

At which age should a nurse keep teaching time short (5 minutes)?

Toddler Toddlers have limited time concept, and teaching time should be kept short (5-10 minutes).

When checking the intravenous (IV) site on a child, the nurse should take which action?

Look at the site while palpating the area. To appropriately check the intravenous (IV) site, the nurse should look at the site and palpate the area. The other options would not be adequate assessments of the site.

An 11-month-old hospitalized boy is restrained because he is receiving intravenous (IV) fluids. His grandmother has come to stay with him for the afternoon and asks the nurse if the restraints can be removed. What nurse's response is best?

"That is fine as long as you are with him." The restraints are necessary to protect the IV site. If the child has appropriate supervision, restraints are not necessary. The nurse should remove the restraints whenever possible. When parents or staff members are present, the restraints can be removed and the IV site protected. Parental permission is not needed for restraint removal.

The nurse is administering an IM injection into a vastus lateralis muscle of a 6-month-old infant. What should the length of the needle and amount to be given be?

5/8 to 1 inch; 0.5 to 1.0 ml The length of a needle for an infant should be 5/8 to 1 inch, and the amount of solution should not exceed 1 ml.

The practitioner has ordered a liquid oral antibiotic for a toddler with otitis media. The prescription reads 1 1/2 tsp four times per day. What should the nurse consider in teaching the mother how to give the medicine?

A hollow-handled medication spoon is advisable, and the medication should be equally spaced while the child is awake. A hollow-handled medication spoon allows the mother to measure the correct amount of medication. The order is written for four times a day; every 6 hours dosing is not necessary. There is no indication that the mother is not able to adhere to the medication regimen. She is asking for clarification so she can properly care for her child. Long-acting intramuscular antibiotics are not indicated. Household teaspoons vary greatly and should not be used.

A 4-year-old girl is admitted to outpatient surgery for removal of a cyst on her back. Her mother puts the hospital gown on her, but the child is crying because she wants to leave on her underpants. What is the most appropriate nursing action at this time??

Allow her to wear her underpants. It is appropriate for the child to leave her underpants on. If necessary, the underpants can be removed after she has received the initial medications for anesthesia. This allows her some measure of control in this procedure. The mother should not be required to make the child more upset. The child is too young to understand what hospital policy means.

A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as acetaminophen. How should the nurse respond to the parents?

Antipyretics are of no value in treating hyperthermia Unlike with fever, antipyretics are of no value in hyperthermia because the set point is already normal. Cooling measures are used instead. Antipyretics do not cause seizures. Malignant hyperthermia is a genetic myopathy that is triggered by anesthetic agents. Antipyretic agents do not have this effect. Acetaminophen can result in liver damage if too much is given or if the liver is already compromised. Other antipyretics are available, but they are of no value in hyperthermia.

Frequent urine tests for specific gravity are required on a 6-month-old infant. What method is the most appropriate way to collect small amounts of urine for these tests?

Aspirate urine from cotton balls inside the diaper with a syringe without a needle. To obtain small amounts of urine, use a syringe without a needle to aspirate urine directly from the diaper. Diapers with superabsorbent gels absorb the urine; if these are used, place a small gauze dressing or cotton balls inside the diaper to collect the urine and aspirate the urine with a syringe. For frequent urine sampling, the collection bag would be too irritating to the child's skin. It is not feasible to tape a small medicine cup to the inside of the diaper; the urine will spill from the cup.

What is the best method to verify the placement of a nasogastric tube before each use?

Aspiration of stomach contents Visual inspection and pH check of stomach contents is a reliable method of determining placement before each use. Radiologic examination should be obtained after initial placement but would be too cumbersome to do before each use. Auscultation is an unreliable method to confirm tube placement because of the similarity of sounds produced by air in the bronchus, esophagus, or pleural space. Verification of tape placement on the tube can be inaccurate if the tube has moved within the tape or become dislodged from the stomach.

The nurse is preparing to administer a liquid medication by a nasogastric feeding tube. What is the first thing the nurse should do?

Check the pH of the gastric aspirate. The most accurate way to check the position of the nasogastric tube is by checking the pH. Auscultation as a verification tool is reliable only 60% to 80% of the time and should not be used without additional methods. The tube should not be flushed or the medication administered until placement of the tube is checked.

The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever. What nursing action is appropriate?

Check to be sure the Tylenol dose does not exceed 15 mg/kg. Nurses must have an understanding of the safe dosages of medications they administer to children, as well as the expected actions, possible side effects, and signs of toxicity. The recommended doses of acetaminophen should never be exceeded.

A child who has cystic fibrosis is admitted to the pediatric unit with methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse recognizes that in addition to a private room, the child is placed on what precautions?

Contact MRSA is an increasingly significant source of hospital-acquired infections. This organism meets the criteria of being epidemiologically important and can be transmitted by direct contact. Gowns and gloves should be worn when exposed to potentially contagious materials, and meticulous hand washing is required. S. aureus is not an organism that is spread through airborne or droplet mechanisms. Additional precautions, beyond Standard Precautions, are needed to prevent spread of this organism.

Using knowledge of child development, what approach is best when preparing a toddler for a procedure?

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

The nurse is preparing a 9-year-old boy before obtaining a blood specimen by venipuncture. The child tells the nurse he does not want to lose his blood. What approach is best by the nurse?

Discuss with him how his body is always in the process of making blood. School-age children can understand that blood can be replaced. Explain the procedure to him using correct scientific and medical terminology. The venipuncture will be uncomfortable. It is inappropriate to tell him it will not hurt. Even though the nurse considers it a simple procedure, the boy is concerned. Telling him not to worry will not allay his fears.

The nurse gives an injection in a patient's room. How should the nurse dispose of the needle?

Dispose of the syringe and needle in a rigid, puncture-resistant container in the patient's room. All needles (uncapped and unbroken) are disposed of in a rigid, puncture-resistant, tamper-proof container located near the site of use. Consequently, these containers should be installed in the patient's room. Needles and syringes are disposed of uncapped and unbroken. A used needle should not be transported to an area distant from use for disposal.

A laboratory technician is performing a blood draw on a toddler. The toddler is holding still but crying loudly. The nurse should take which action?

Do nothing. It's Okay for a child to cry during a painful procedure. The child should be allowed to express feelings of anger, anxiety, fear, frustration, or any other emotion. It is natural for children to strike out in frustration or to try to avoid stress-provoking situations. The child needs to know that it is all right to cry.

A 7-year-old is identified as being at risk for skin breakdown. What intervention should the nursing care plan include?

Ensuring that nutritional intake meets requirements Children who are hospitalized and NPO (taking nothing by mouth) for several days are at risk for nutritional deficiencies and skin breakdown. If NPO status is prolonged, parenteral nutrition should be considered. Massaging bony prominences can cause deep tissue damage. This should be avoided. Although parents can participate, turning the child is the nurse's responsibility. If the child is alert and can move, position shifts should be done more frequently. If the child does not move, the nurse should reposition every 2 hours. The number of linens is not an issue. The child should not be dragged across the sheet. Children should be lifted and moved to avoid friction and shearing.

A 10-year-old child requires daily medications for a chronic illness. Her mother tells the nurse that the child continually forgets to take the medicine unless reminded. What nursing action is most appropriate to promote adherence to the medication regimen?

Establish a contract with her, including rewards Many factors can contribute to the child's not taking the medication. The nurse should resolve those issues such as unpleasant side effects, difficulty taking medicine, and time constraints before school. If these factors do not contribute to the issue, then behavioral contracting is usually an effective method to shape behaviors in children. Time-outs provide negative reinforcement. If part of a contract, negative consequences can work, but they need to be structured. Discussing with her mother the damaging effects of her rescuing the child is not the most appropriate action to encourage compliance. For a school-age child, parents should refrain from nagging and rescuing the child. This child is old enough to partially assume responsibility for her own care. If the child brings her medicine containers to each appointment so they can be counted, this will help determine if the medications are being taken, but it will not provide information about whether the child is taking them by herself.

What is an advantage of the ventrogluteal muscle as an injection site in young children?

Free of significant nerves and vascular structures Being free of significant nerves and vascular structure is one of the advantages of the ventrogluteal site. In addition, it is considered less painful than the vastus lateralis. The major disadvantage is lack of familiarity by health professionals and controversy over whether the site can be used before weight bearing. The vastus lateralis is a more accessible site. The ventrogluteal muscle site has safely been used from newborn through adulthood. Clinical guidelines address the need for the child to be walking. The site has less subcutaneous tissue, which facilitates intramuscular deposition of the drug rather than subcutaneous.

A preschool child needs a dressing change. To prepare the child, what strategy should the nurse implement?

Give choices when possible but avoid delay Involving children helps to gain their cooperation. Permitting choices gives them some measure of control. The other options would not be appropriate for a preschool child.

What play activities should the nurse implement to encourage fluid intake for a child? (Select all that apply.)

Have a tea party Use a crazy straw Cut gelatin into fun shapes Make ice pops using the child's favorite juice Play activities to encourage fluid intake for a child include tea parties, crazy straws, cutting gelatin into fun shapes, and making ice pops using the child's favorite juice. Small cups, not large Styrofoam cups, should be used.

A 16-year-old girl comes to the pediatric clinic for information on birth control. The nurse knows that before this young woman can be examined, consent must be obtained from which source?

Herself Contraceptive advice is one of the conditions that is considered "medically emancipated." The adolescent is able to provide her own informed consent.

A 2-year-old child has to receive Rocephin IM injections every 12 hours. What nursing intervention should be implemented for the child?

Hold the child while rocking in a chair after each injection. After the procedure, the child continues to need reassurance that he or she performed well and is accepted and loved. The other options are not appropriate for a toddler.

A bone marrow biopsy will be performed on a 7-year-old girl. She wants her mother to hold her during the procedure. How should the nurse respond?

Holding may help your child relax The mother's preference for assisting, observing, or waiting outside the room should be assessed, as well as the child's preference for parental presence. The child's choice should be respected. This will most likely help the child through the procedure. If the mother and child agree, then the mother is welcome to stay. Her familiarity with the procedure should be assessed and potential safety risks identified (mother may sit in chair). Hospital policies should be reviewed to ensure that they incorporate family-centered care.

When teaching a mother how to administer eye drops, where should the nurse tell her to place them?

In the conjunctival sac when the lower eyelid is pulled down The lower eyelid is pulled down, forming a small conjunctival sac. The solution or ointment is applied to this area. The medication should not be administered directly on the eyeball. The lacrimal duct is not the appropriate placement for the eye medication. It will drain into the nasopharynx, and the child will taste the drug.

Guidelines for intramuscular administration of medication in school-age children include what standard?

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

The nurse has just collected blood by venipuncture in the antecubital fossa. What should the nurse do next?

Keep the child's arm extended and apply pressure to the site for a few minutes. Applying pressure to the site of venipuncture stops the bleeding and aids in coagulation. Pressure should be applied before a bandage or gauze pad is applied.

What strategies should the nurse implement to assist in feeding a sick child? (Select all that apply.)

Make mealtimes pleasant Avoid foods that are highly seasoned Provide finger foods for young children Ensure a variety of foods, textures, and colors To assist in feeding a sick child mealtimes should be pleasant; highly seasoned foods should be avoided; finger foods should be provided for young children; and a variety of foods, textures, and colors should be ensured. Small portions, not large, should be served.

What interventions should the nurse implement to prevent a pressure ulcer in a critically ill child? (Select all that apply.)

Nutrition consults Using skin moisturizers Turning the child every 2 hours Using draw sheets to minimize shear Interventions found to prevent pressure ulcers in critically ill children include nutrition consults, using skin moisturizers, turning the child every 2 hours, and using draw sheets to minimize shear. Dryweave underpads, not underpads with plastic, should be used to reduce moisture.

A 14-year-old adolescent is hospitalized with cystic fibrosis. What nursing note entry represents best documentation of his breakfast meal?

One pancake, eggs, and 240 mL OJ Specific information is necessary for hospitalized children. It is essential to be able to identify caloric intake and eating patterns for assessment and intervention purposes. That he tolerated breakfast well only provides information that the child did not become ill with the meal. Even if he finished all his breakfast, an evaluation cannot be completed unless the quantity of food ordered is known. Nutritional information is essential, especially for children with chronic illnesses.

An appropriate method for administering oral medications that are bitter to an infant or small child should be to mix them with which?

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

The nurse needs to take the blood pressure of a preschool boy for the first time. What action would be best in gaining his cooperation?

Permit him to handle the equipment and see the cuff inflate and deflate before putting the cuff in place. A preschooler is at the stage of preoperational thought. The nurse needs to explain the procedure in simple terms and allow the child to see how the equipment works. This will help allay fears of bodily harm. Blood pressure measurement is used for assessment, not therapy, and will not help him get well faster. Although the parent will be able to support the child, he may still be uncooperative. Also, the assessment of blood pressure may be needed before the parent is available. Explaining to a preschooler how the blood flows through the artery and why the blood pressure is important is too complex.

What methods should the nurse use to measure compliance to a treatment plan? (Select all that apply.)

Pill counts Chemical assays Direct observation Monitoring therapeutic response Assessment of compliance must include direct measurement techniques. Pill counts, chemical assays, direct observation, and monitoring therapeutic response are direct measurement techniques. Third-party reporting would not always be available and would not be a method to measure compliance.

The nurse is caring for a 12-year-old child who is on fall precautions secondary to seizures. What interventions should be included in the child's care plan? (Select all that apply.)

Place a call light and desired items within reach Have the child wear an appropriate-size gown and nonskid footwear Prevention of falls requires alterations in the environment, including keeping call light and desired items within reach and having the child wear appropriate-size gowns and nonskid footwear. The bed should be in the lowest position possible with all the side rails up; at least a dim light should be left on at night; and personal belongings and clutter should not be on the floor—they should be in a cabinet.

Parents are being taught how to feed their infant using a newly placed gastrostomy tube (G-tube). What is essential information for the parents to receive?

Position the infant on the right side during and after the feeding. Positioning on the right side during and after feedings helps minimize the risk of aspiration. It is not necessary to verify placement before each feeing. G-tubes are inserted into the stomach and sutured in place. If the tube is through the skin, it is in the stomach. Feedings should be given by gravity flow. The plunger may be used to initiate the feeding, but then the formula should be allowed to flow. Beefy red tissue around the G-tube site is normal granulation tissue that is expected.

A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When preparing for a lumbar puncture, what should the nurse do?

Prepare the child for conscious sedation being used for the procedure. Because of the urgency of the child's condition, conscious sedation should be used for the procedure. Pediatric spinal trays have smaller needles than do adult trays. EMLA should be applied approximately 60 minutes before the procedure; the emergency nature of the spinal tap precludes its use. A spinal tap is not a simple procedure and does have associated risks; analgesia will be given for the pain.

What is a priority intervention for an infant with a temporary colostomy for Hirschsprung disease?

Protecting the skin around the colostomy Protection of the peristomal skin is a major priority. Well-fitting appliances and skin protectants are used. Teaching how to irrigate a colostomy is not necessary because colostomies are not irrigated in infants. The colostomy is usually reversed within 6 months to 1 year. The parents, not the infant, need to be prepared for the surgery.

A 5-year-old child returns from the pediatric intensive care unit after abdominal surgery. The orders state to monitor vital signs every 2 hours. On assessment, the nurse observes that the child's heart rate is 20 beats/min less than it was preoperatively. What should be the nurse's next action?

Recheck the pulse and blood pressure in 15 minutes. In a 5-year-old child, this is a significant change in vital signs. The nurse should assess the child to see if his condition mirrors a drop in heart rate. The assessment and vital signs should be redone in 15 minutes to determine whether the child's condition is stable. When a disparity in vital signs or other assessment data is observed, the nurse should reassess sooner. Most parents will not know their child's heart rate. It is important to determine how the child is recovering from surgery. The nurse should collect additional information before notifying the surgeon. This includes blood pressure, respiratory rate, and pain status.

What are the advantages of an implanted port (Port-a-Cath)? (Select all that apply.)

Reduced risk of infection Reduced cost for the family Placed completely under the skin The advantages of an implanted port include reduced risk of infection, reduced cost for the family, and placed completely under the skin. Because it is implanted and must be accessed, it is not easy to use for self-administered infusions, and removal does require a surgical procedure.

A child, age 7 years, has a fever associated with a viral illness. She is being cared for at home. What is the principal reason for treating fever in this child?

Relief of discomfort The principal reason for treating fever is the relief of discomfort. Relief measures include pharmacologic and environmental intervention. The most effective is the use of pharmacologic agents to lower the set point. Although the nurse can reassure the child that the illness is temporary, the child is often uncomfortable and irritable. Intervention helps the child and family minimize the discomfort. Most fevers result from viral, not bacterial, infections. Few life-threatening events are associated with fever. The use of antipyretics does not seem to reduce the incidence of febrile seizures.

A 6-year-old boy is hospitalized for intravenous antibiotic therapy. He eats very little on his "regular diet" trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. What nursing action is the most appropriate?

Request these favorite foods for him Loss of appetite is a symptom common to most childhood illnesses. To encourage adequate nutrition, the nurse should request favorite foods for the child. The foods he likes provide nutrition and can be supplemented with additional fruits and vegetables. Ice cream and other desserts should not be used as rewards or punishment.

What disease processes require contact isolation? (Select all that apply.)

Rotavirus Hepatitis A Respiratory syncytial virus In addition to Standard Precautions, use contact precautions for patients known or suspected to have serious illnesses easily transmitted by direct patient contact or by contact with items in the patient's environment. Examples of such illnesses include rotavirus, hepatitis A, and respiratory syncytial virus. Streptococcal pharyngitis and mycoplasmal pneumonia require droplet precautions.

To facilitate the administration of an oral medication to a preschool-age child, what action should the nurse take?

Set limits about the need to take medication and offer praise immediately after the task is accomplished. Nurses who approach children with confidence and who convey the impression that they expect to be successful are less likely to encounter difficulty. It is best to approach a child as though cooperation is expected. The medication should not be placed in a favorite liquid or food. Allowing the child time to express resistance will delay administration of the medication.

A nurse must do a venipuncture on a 6-year-old child. What consideration is important in providing atraumatic care?

Show the child the equipment to be used before the procedure. To provide atraumatic care the child should be able to see the equipment to be used before the procedure begins. Use the smallest gauge needle that permits free flow of blood. A two-try-only policy is desirable, in which two operators each have only two attempts. If insertion is not successful after four punctures, alternative venous access should be considered. Restrain the child only as needed to perform the procedure safely; use therapeutic hugging.

The nurse needs to start an intravenous (IV) line on an 8-year-old child to begin administering intravenous antibiotics. The child starts to cry and tells the nurse, "Do it later, okay?" What action should the nurse take?

Start the IV line and then allow for expression of feelings. A school-age child may try to delay the procedure, but it is best to complete the procedure and allow time for the child to express his or her feelings. The nurse should not postpone administering the antibiotic, change it to PO, or wait to start the IV line until the child is ready.

The nurse is preparing to obtain a nasal washing from a child. What equipment should the nurse gather for the procedure? (Select all that apply.)

Syringe with tubing Sterile normal saline Nasal washings may be obtained to identify viral pathogens and guide therapy in some respiratory conditions. The child is placed supine, and 1 to 3 ml of sterile normal saline is instilled with a sterile syringe (without a needle) into one nostril. The contents are aspirated with a syringe with 5 cm (2 inches) of 18- to 20-gauge tubing. The saline is quickly instilled and then aspirated to recover the nasal specimen. A tracheal suction catheter would not trap the mucus. Normal saline is used, not sterile water. A sterile swab is used for a throat culture, not for nasal washings.

The clinic nurse is teaching parents about when to call the office immediately for a child with a fever. What should the nurse include in the teaching session? (Select all that apply.

The child has a stiff neck The fever is over 40.6 (105 F) The child is younger than 2 months Parents should call the office immediately if a child has a fever over 40.6° C (105° F), the child is younger than 2 months, or the child has a stiff neck. Parents are to call within 24 hours if the fever went away for more than 24 hours and then returned or the fever has lasted for more than 3 days.

A 1-month-old infant is admitted to the hospital. The infant's mother is 17 years old and single and lives with her parents. Who signs the informed consent for the 1-month-old infant?

The infant's mother An emancipated minor is one who is legally under the age of majority but is recognized as having the legal capacity of an adult under circumstances prescribed by state law, such as pregnancy, marriage, high school graduation, independent living, or military service

A 6-year-old child needs to drink 1 L of GoLYTELY in preparation for a computed tomography scan of the abdomen. To encourage the child to drink, what should the nurse do?

Use little cups and make a game to reward him for each cup he drinks. One liter of GoLYTELY is difficult for many children to drink. By using small cups, the child will find the amount less overwhelming. Then a game can be made in which some type of reward (sticker, reading another page of a book) is given for each cup. A large cup of ice would make it more difficult because the child would see it as too much and ice adds additional fluid to be consumed. Negative reinforcement may work if the child wishes to be out of his room. A practitioner may or may not be angry if he does not finish drinking by a set time; this is a threat that may or may not be true. If the child is having difficulty drinking, this would most likely not be effective.

The nurse on a pediatric unit is writing guidelines for age-specific preparation of children for procedures based on developmental characteristics. What guideline is accurate?

Use simple diagrams of anatomy and physiology to explain a procedure to a school-age child. To assist the school-age child in meeting Erickson's developmental stage of industry, using simple diagrams of anatomy and physiology to explain a procedure is the accurate guideline. Toddlers should be told about a procedure right before the procedure. School-age children should know about the procedure in advance, not right before, and parents should be present for procedures for infants and toddlers.

A toddler is being sent to the operating room for surgery at 9 AM. As the nurse prepares the child, what is the priority intervention?

Verifying that the child and procedure are correct The most important intervention is to ensure that the correct child is going to the operating room for the identified procedure. It is the nurse's responsibility to verify identification of the child and what procedure is to be done. If an antibiotic is ordered, administering it is important, but correct identification is a priority. Clear liquids can be given up to 2 hours before surgery. If the child was NPO (taking nothing by mouth) since midnight, intravenous fluids should be administered. Parents should be encouraged to accompany the child to the preoperative area. Many institutions allow parents to be present during induction.

A child has a central venous access device for intravenous (IV) fluid administration. A blood sample is needed for a complete blood count, hemogram, and electrolytes. What is the appropriate procedure to implement for this blood sample?

Withdraw a blood sample equal to the amount of fluid in the device, discard, and then withdraw the sample needed. The blood specimen obtained must reflect the appropriate hemodilution of the blood and electrolyte concentration. The nurse needs to withdraw the amount of fluid that is in the device and discard it. The next sample will come from the child's circulating blood. With a central venous device, the trauma of a separate venipuncture can be avoided. The blood sample will be diluted with either the IV fluid being administered or the saline.