PEDS Practice: Ch. 29 Nursing Care During a Pediatric Emergency

Assessment of a child reveals a tension pneumothorax. The nurse would prepare the child for:

needle thoracotomy. A needle thoracotomy is indicated for tension pneumothorax to relieve the air collected in the space. Intubation is indicated for apnea and in situations in which the airway cannot be maintained. Suctioning would be indicated for excessive airway secretions that influence airway patency. Defibrillation is used to stimulate or alter the heart's electrical rhythm.

The condition of an 11-year-old boy who is on mechanical ventilation begins to deteriorate. What action would the nurse do next?

Check to see if the tracheal tube is displaced. Use the mnemonic DOPE for troubleshooting when the status of a child who is intubated deteriorates. This means checking for displacement and disconnections first. Checking the ventilator, suctioning for obstruction, and examining for signs of pneumothorax would come later

The nurse is caring for a 4-year-old boy who is receiving mechanical ventilation. Which intervention is the priority when moving this child?

Checking the CO2 monitor for a yellow display Exhaled CO2 monitoring is recommended when a child has been intubated. It provides quick, visual assurance that the tracheal tube remains in place and that the child is being adequately ventilated. When moving the child, maintaining tube placement would be crucial. The other interventions would also be appropriate but not as essential as monitoring the child's exhaled CO2 level. Unlike the other interventions, exhaled CO2 monitoring can provide an early sign of a problem.

When developing the plan of care for a 10-month-old infant in septic shock, which intervention would the nurse most likely include?

Administering intravenous dopamine as ordered Although isotonic intravenous solutions such as saline, blood transfusion, and urinary catheter insertion are important for any child with shock, children experiencing septic shock often require larger volumes of fluid as a result of the increased capillary permeability. Thus, fluid alone may not improve the status of a child with septic shock, necessitating the use of vasoactive medications such as dopamine. Saline is the first choice for restoring fluid volume, but this child will most likely need vasoactive medications. Children in shock from trauma may require blood transfusions to restore volume. Once fluids are given, a urinary catheter will be placed to monitor urine output.

Administration of which medication reverses the histamine release and hypotension that are seen in anaphylaxis?

Epinephrine Epinephrine reverses histamine release and hypotension due to anaphylaxis.

The off-duty nurse is in the park and is present when a child collapses. Which step should be performed first?

Implement head tilt-chin lift maneuver. When initiating rescue care to a child implementation of CPR is indicated before activation of the EMS. The first step in the rescue is the establishment of a patent airway. The head tilt-chin lift is used in children.

A 10-year-old boy with congenital heart disease is in shock. Which nursing intervention would be most appropriate for this child?

Assessing for pulmonary edema from fluid overload Assessing for pulmonary edema from fluid overload is the most appropriate intervention. Pulmonary edema is rare but may occur in children with preexisting cardiac conditions or severe chronic pulmonary disease. Assessing for changes in mental status and alertness, monitoring urine output, and palpating for improved pulses and capillary refill are valid interventions for managing shock of any kind.

The child's physician requests that the nurse should notify her if the child's urine output is less than 1 mL/kg of body weight each hour. The child weighs 56 lb (25.46 kg). Calculate the minimum amount of urine output the child should produce each hour. Record your answer using a whole number.

25 Urine output should be calculated using weight in kilograms. 25.46 kg x 1 mL/kg = 25.46 mL/hour The child must produce 25 mL/hour

The nurse prepares to defibrillate a child weighing 38 pounds. The nurse would plan to administer how many joules of energy initially?

35 The nurse would plan to administer 2 joules/kg. 38 pounds/2.2 = 17.27 kg x 2 = 35 joules

A 7-year-old girl is in the intensive care unit following a bicycle accident. Which would be most helpful in providing support to the girl's parents?

Providing honest answers in a reassuring manner Providing honest answers to the parents' questions and concerns in a reassuring manner will provide the most support. Procedures and treatment plans should be explained in terms they can understand and repeated patiently, if need be. Encouraging the parents to read to their daughter will involve them in their child's care and help normalize the situation for the child.

The nurse is caring for the family of a pediatric client during resuscitative efforts of their child following an accident. Which response by the nurse would be best?

"I am here to answer your questions and be with you during this difficult time." The nurse would provide honest answers in a reassuring way. The nurse would avoid giving false reassurance and being judgmental.

The nurse must calculate the adolescent's cardiac output. The child's heart rate is 76 beats per minute and the stroke volume is 75 mL. Calculate the child's cardiac output. Record your answer using a whole number.

5700 Cardiac output (CO) is equal to heart rate (HR) times ventricular stroke volume (SV). That is, CO = HR x SV 76 beats per minute x 75 mL = 5,700

Which medication is used for symptomatic bradycardia unresponsive to ventilation and oxygenation?

Atropine Atropine is used for symptomatic bradycardia unresponsive to ventilation and oxygenation. Sodium bicarbonate is used for metabolic acidosis. Naloxone reverses the effect of opioids. Calcium carbonate is used for documented or suspected hypocalcemia, hyperkalemia, hypermagnesemia, and calcium channel blocker overdose.

A young client in the intensive care unit is in a coma after a severe head injury. The primary nurse is teaching a nursing student how to assess the client's level of consciousness using a coma scale. What type of scale could be used for this purpose?

Glasgow scale The Glasgow Coma Scale is used to grade comas according to level of consciousness. The Apgar score is assigned immediately after delivery to determine how the infant tolerated the birth. Wong-Baker FACES and the visual analogue scales are used to rate pain.

The nurse is caring for a child brought to the emergency room by the babysitter. The babysitter reports the child was playing and acting "fine" but started to be "sick and get worse" all of a sudden after lunch. The babysitter denies any obvious reason or situation leading to the child's decline. What would the nurse further assess for?

Ingestion of a toxin When an otherwise healthy child suddenly deteriorates without a known cause, the nurse should suspect a toxic ingestion. A near drowning, cardiac arrhythmia, or traumatic injury would manifest with specific assessment findings.

The nurse is caring for a child who presented with in supraventricular tachycardia (SVT). The nurse is preparing to administer IV adenosine. How should the nurse administer this medication?

Over 1 to 2 seconds. Adenosine should be given rapidly over 1 to 2 seconds followed with a rapid saline flush.

When caring for a child experiencing difficulty breathing which position will be most beneficial for the child?

Sitting upright When experiencing difficulty breathing, an individual will likely achieve most comfort sitting upright.

The nurse is assessing the neurologic status of an infant. What would the nurse identify as a nonreassuring finding?

Lack of interest in surroundings An infant who is not interested in the environment is a cause for concern. Vigorous crying is a reassuring sign. Making eye contact with the nurse is a reassuring finding. A normal anterior fontanel is soft and flat and would be considered a reassuring finding.

A young child comes to the emergency department. The child's mother reports that he was hit in the head and other body areas with a baseball bat. Upon further examination, the child becomes hypotensive. What does the nurse suspect is happening?

Shock from bleeding points other than the head injury Shock with hypotension is rare during an isolated head injury. If a child is in shock, investigate for bleeding points other than the head.

The nurse has completed teaching a CPR course for a local day care. Which statement by a participant indicates a need for further education?

"I will place the heel of my hand on the sternum of a 9-month-old when performing CPR." The correct hand placement for an infant is two fingers placed one fingerbreadth below the nipple line. Placing the heel of one hand on the sternum is the correct placement for a child.

Cardiopulmonary resuscitation (CPR) is in progress on an 8-year-old boy who is in shock. Which nursing intervention is priority?

Inserting an intraosseous needle via the femoral route Fluid resuscitation is the priority intervention for a child in shock who is receiving CPR. Gaining access via the femoral route will not interfere with CPR efforts. A large-bore IV would be used to gain peripheral venous access, which may be unattainable in children who have significant vascular compromise. Blood samples and urinary catheter placement can wait until fluid is administered.

The child's ability to perfuse is poor due to inadequate circulation. The physician writes an order for the child to receive 20 mL of normal saline for each kilogram of body weight. The child will receive the normal saline as a bolus through a central intravenous line. The child weighs 78 lb (35.46 kg). Calculate the amount of normal saline the nurse should administer as a bolus. Record your answer using a whole number.

709 Dose should be calculated using weight in kilograms. 35.456 kg x 20 mL/kg = 709.1 mL. When rounded to the nearest whole number = 709 mL.

A 13-year-old boy has had a near-drowning experience. The nurse notices he has labored breathing and a cough. What is the priority intervention?

Administer 100% oxygen by mask. Management of the near-drowning victim focuses on assessing his airway, breathing, and circulation (ABCs) and correcting hypoxemia. Administering oxygen is the primary intervention to assist breathing. It is best to let the child assume the most comfortable position for him. Checking capillary refill time helps determine ineffective tissue perfusion. Providing sedation is an intervention for pain that will be assessed after effective breathing is established.

The nurse is assessing the respiratory status and lungs of a 6-year-old child. What finding would the nurse report immediately?

Minimal air movement through the lungs Minimal or no air movement requires immediate intervention because this child's status is severely compromised. Breath sounds over the trachea typically are high pitched. Breath sounds over the peripheral lung fields are lower pitched. Normally percussion over air-filled lungs reveals resonant sounds.

When assessing a client in an emergency situation, to guide the assessment the nurse should be aware that most pediatric cardio-pulmonary arrests stem from what cause?

Airway and breathing problems Most pediatric arrests are related primarily to airway and breathing, and usually only secondarily to the heart. This information guides the nurse to always assess the airway first in case of an emergency involving cardiopulmonary arrest.

Which nursing diagnosis would be appropriate for teaching interventions for a single mother who leaves her toddler unattended in the bathtub?

Risk for suffocation Death from drowning occurs from suffocation. Nearly half of all drowning victims are children under the age of 5. Most drowning deaths in young children occur because of inadequate supervision of a bathtub or pool

A 5-year-old girl is breathing spontaneously but is unable to maintain an airway. What action would be the priority?

Inserting an oropharyngeal airway Inserting an oropharyngeal airway will help ensure that the child maintains a patent airway. Placing a towel under the shoulders would be helpful for opening the airway if this child were an infant. A tracheal tube would not be appropriate since the child is breathing spontaneously and able to maintain her ventilatory effort. Repositioning her using the head tilt/chin lift won't help if she can't maintain an airway independently.

The parents of a preschool child are distraught as they carry their limp child into the emergency room. The parents report the child fell approximately 10 foot from a large slide and hit his head "hard enough to knock him out." What is the nurse's next action?

Perform a jaw-thrust technique to assess the patency of the airway The nurse would first evaluate the airway, assessing its patency. Position the airway in a manner that promotes good air flow. Since cervical spine injury is a possibility, do not use the head tilt-chin lift maneuver; use only the jaw-thrust technique for opening the airway. The description of the injury would be suspicious for cervical injury. The nurse would evaluate the child's airway before evaluating pain scale and managing cervical concerns, although the nurse is managing cervical concerns by not performing a head tilt-child lift maneuver. A pulse oximeter measurement would not be the priority.

The nurse is assessing a 6-week-old infant in the home setting. The nurse notes the infant has a regular breathing pattern with brief periods of apnea followed by a respiratory rate of 40. What would the nurse further assess in the infant?

Skin color and heart rate Infants less than 2 months (or premature), may display periodic breathing. The infant who is experiencing period breathing looks pink and has a normal heart rate and the nurse would not need to intervene further. The infant's birth weight, Apgar scores, lung fields and blood pressure are important to assess, but not specifically to the infant with period breathing.

When assessing a young child who is experiencing decompensated shock, what would the nurse expect to find?

Tachypnea In decompensated shock, the child displays decreased blood pressure and level of consciousness (stupor or coma), and tachypnea or signs of respiratory failure. In compensated shock, the child becomes tachycardic in an effort to increase cardiac output. The BP remains normal, capillary refill time may be prolonged (more than 2 seconds), and the child may become irritable because of increasing hypoxia.

Which finding from the history of a child with extensive burns would make you most alert to assess for respiratory complications?

The child was trapped in a closed burning bedroom. When a child is confined in a closed space during a fire, he or she can inhale a great deal of smoke, causing respiratory tract burns or irritation.

The nursing instructor is speaking with a group of nursing students about medication used in rapid sequence intubation. Which statement by a student indicated a need for further education?

"Ketamine is the anesthetic typically used for children who have suffered head trauma and need to be intubated." Ketamine can cause increased intracranial pressure and should not be used in children who have suffered head trauma. Atropine can reduce the risk of bradycardia. Succinylcholine is the gold standard drug used during intubation. Combining midazolam with other narcotics can increase the risk of respiratory depression.

The nurse is caring for a child experiencing a cardiac arrest. The nurse has administered IV epinephrine at 1315. At what time can the nurse administer another dose of epinephrine?

1320. Epinephrine may be administered IV, intraosseous (IO) or via and ET tube. During CPR, it may be repeated every 3 to 5 minutes.

A teen has been critically injured in a fall from the bleachers at school. The school nurse is on site. What action should be taken by the nurse to ensure a patent airway?

Perform the jaw thrust maneuver. The injuries have resulted from a fall. If cervical spine injury is a possibility, do not use the head tilt-chin lift maneuver; use only the jaw-thrust technique for opening the airway. Turning the child on the side or rotating the head is contraindicated.

The child presents to the emergency department via ambulance in uncompensated SVT at a rate of 262 beats per minute. The nurse receives an order to administer adenosine IV. In addition to adenosine, what would the nurse bring to the bedside in preparation to administer the adenosine?

A generous saline flush to follow the IV medication Adenosine IV is given rapidly (over 1 or 2 seconds) and is followed by a generous saline flush followed by a rapid (to assure the medication has entered the vessel). The nurse would assess the child's blood pressure but not specifically in relationship to the administration of adenosine. The parents would not sign a consent for this medication. Vomiting is not a side effect of adenosine.

The nursing instructor is speaking with a group of nursing students about rapid cardiopulmonary assessment. Which statement by a student would indicate a need for further education?

"I will place the child on a cardiac monitor. I will use this to assess the child's heart rate." Always evaluate the presence of a heart rate by auscultation of the heart or by palpation of central pulses. Never use the cardiac monitor to determine if the child has a heart rate. The presence of a cardiac rhythm is not a reliable method for evaluation of the ability to perfuse the body. If a child does not improve with 100% oxygen, the next step is to administer oxygen via a bag-valve-mask. The brachial artery is the correct place to check for a pulse in an infant. Establishment of IO access should be attempted if a peripheral IV is not able to be obtained within 3 attempts or 90 seconds.

A 4-year-old girl has been admitted to the emergency department after accidently ingesting a cleaning product. Which treatment is most likely appropriate in the immediate treatment of the girl's poisoning?

Administration of activated charcoal Activated charcoal is the most common treatment for many poisonings and is more effective and safe than induced vomiting or gastric lavage. Rehydration is likely necessary, but this does not actively treat the girl's poisoning.

The nurse is collecting a brief health history from the parents of a 3-year-old child brought to the emergency department experiencing a cardiac emergency. What questions are appropriate for inclusion? Select all that apply.

"Has your child had any recent illnesses?" "What foods or drugs is your child allergic to?" "Tell me about any coughing or wheezing you may have noticed when your child has been playing lately." When a child is being treated for a cardiac emergency a brief health history is needed. This history must highlight possible problems and causes of the illness being experienced. Questions about recent illnesses can show possible links to the cardiac emergency. Information about drug and food allergies is needed as this child will likely need to receive medications and knowing potential allergies is of importance. Wheezing and coughing may signal cardiac or respiratory concerns and should be investigated. The number of children in the home and activities the child enjoys are of interest but are not of emergent value.

The nurse is performing CPR on a child who is a victim of a near-drowning experience. How should the nurse open the child's airway to provide breaths?

Jaw-thrust maneuver Cervical spine precautions should be used in any child suffering trauma or near drowning. The proper way to open the airway in a child in this case is the jaw thrust method. The head tilt-chin lift procedure is used in clients without cervical spine injuries. The two hands encircling method is the method for performing compressions on an infant during two-person CPR. There is no such method as the tongue thrust.

The nurse is caring for a child. Upon assessing the child the nurse notes, a heart rate of 235, abnormal P waves, weak peripheral pulses and a decreased level of consciousness. The nurse is aware that this child is presenting in which cardiac arrhythmia?

Uncompensated SVT Signs and symptoms for uncompensated SVT include a heart rate >220, abnormal P waves and signs of shock such as altered level of consciousness, poor perfusion and weak pulses. Compensated SVT signs and symptoms include a heart rate of >220 with an alert, well-perfused child. Ventricular tachycardia includes wide QRS complexes with no P waves, with or without a pulse. Ventricular fibrillation signs and symptoms include chaotic ventricular activity with no P, QRS, or T waves present

Which assessment finding would indicate to the health care team the child would need to be re-intubated due to improper placement of the endotracheal tube?

Breath sounds heard over the abdominal area Indications the tube is accidentally inserted into the esophagus include auscultation of breath sounds over the abdominal region. Indications the tracheal tube is correctly placed include symmetrical chest rise, water vapor on the inside of the tube, and a rise in oxygen saturation.

The nurse is preparing an in-service program on pediatric cardiopulmonary resuscitation. The nurse would include a discussion that cardiopulmonary arrest in infants and children is most likely the result of:

respiratory failure. Cardiopulmonary arrest in infants and children typically results from disorders that lead to respiratory failure and shock. In adults, the most common causes of cardiopulmonary arrest are lethal arrhythmias secondary to heart disease. Although neurologic trauma can lead to respiratory failure, it alone is not the most likely factor.

An 8-year-old girl with tachycardia is alert, breathing comfortably, and exhibiting signs of adequate tissue perfusion. Which nursing intervention would be most appropriate for this child?

Applying ice to the child's face The child is exhibiting compensated supraventricular tachycardia (SVT). Vagal maneuvers such as ice to the face or blowing through a straw that is obstructed are priority interventions for compensated SVT. Oxygenating and ventilating the child as ordered are interventions for bradycardia. Epinephrine is given for bradycardia. Initiating cardiac compressions is the priority intervention for collapsed (pulseless) rhythms.

After assessing a child's airway, breathing, and circulation (ABCs), what would the nurse do next?

Assess level of consciousness. Once the ABCs are completed, the nurse's next step is to assess the child's level of consciousness or disability. This would be followed by removing the child's clothing and diaper (exposure) to assess for underlying signs of illness or injury. Next, full vital signs are taken while facilitating the family presence, followed by giving comfort by managing pain and providing emotional support. The acronym ABCDEFG is a useful reminder of the order of assessment: airway, breathing, circulation, disability, exposure, full vital signs and facilitating family, and giving comfort.

The nurse is caring for a child in an emergency situation. When placing a cardiac monitor on the child, the nurse notes wide QRS complexes with no P waves. The child does not have a pulse. What interventions should be performed on this child? Select all that apply.

Epinephrine Defibrillation CPR A child presenting with no pulse and an ECG monitor showing wide QRS complexes with no P waves is in pulseless ventricular tachycardia. Treatment for this arrhythmia includes CPR, defibrillation, epinephrine and treatment of the underlying cause. Atropine is used to treat bradycardias. Adenosine is used to treat SVTs.

A 12-year-old boy has broken his arm and is showing signs and symptoms of shock. Which action should the nurse take first?

Establish a suitable IV site. The goal of treating shock is to restore circulating blood volume. This requires that vascular access be obtained to administer fluids and vasoactive drugs. Hyperventilation is reserved for temporary treatment of severe intracranial pressure. Analgesics should not be administered prior to neurologic and cardiovascular examination being performed. Chelation therapy is a treatment for metallic poisoning.

The nurse is participating in performing cardiopulmonary resuscitation for an 8-year-old child. Which findings indicate the need to review and modify the technique being used? Select all that apply.

The chest is rising on the right side and not on the left side. The abdomen begins to distend. When cardiopulmonary resuscitation is being performed the chest should be observed for expansion. Expansion should be equal on both the right and left sides of the chest. Regurgitation may result in CPR and does not necessarily signal a problem with the technique being employed. Improvements in the client's color signal the condition is improving. Distension of the abdomen should be monitored for as it may cause problems.

The nurse is providing support to the parents of a 10-year-old boy receiving emergency care. The boy is their foster child. Which comment will be most effective?

"Hold your child's hand while this is going on." The atmosphere during an emergency can be chaotic and overstimulating. Keep the parents or other family with the child whenever possible. Involve the parents in the child's care; tell the parents in concrete terms what they can do to support the child (e.g., hold the child's hand and talk quietly to him or her). Attempt to talk quietly and soothingly and provide comfort measures. Involving parents in the care helps them to cope. Tell them in concrete terms what they can do to help. Talking about hypovolemia may be too technical. When in doubt, simplify. Many professional organizations, such as the Emergency Nurses Association and the American Heart Association, support giving parents the option to be present during resuscitation efforts. Any caregiver with a parental role should remain with the child when possible.