CH 51 - PEDS - PrepU - Week 5

A 3-year-old child has sustained injuries from a fall. Once the airway is secured, what interventions would be next? You Selected: Stabilize the cervical spine. Correct response: Stabilize the cervical spine. Explanation: If head or spine injuries are suspected, then after the airway is opened, the cervical spine must be stabilized to prevent damage. Checking the mouth for debris is part of securing an airway. Administering oxygen and IV access occur after the C-spine is stabilized. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1986. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1986 Add a Note Question 2 See full question 14s Report this Question The nurse is attempting to establish peripheral vascular access in a child requiring pediatric advanced life support. The nurse determines that intraosseous access is necessary based on the fact that the nurse was unsuccessful in establishing access after how many attempts within 90 seconds? You Selected: Three Correct response: Three Explanation: No more than three attempts should be made within 90 seconds to obtain peripheral vascular access. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 3rd ed., Philadelphia, Wolters Kluwer, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1990. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1990 Add a Note Question 3 See full question 7s Report this Question The nurse notes absent breath sounds in the right upper, middle, and lower lung fields of a 24-month-child. What question by the nurse to the parents of the child would be most appropriate? You Selected: "Was your child playing with a toy with small parts?" Correct response: "Was your child playing with a toy with small parts?" Explanation: Breath sounds that are absent on one side only are indicative of a pneumothorax or foreign body aspiration. The nurse would further assess the child for choking hazards. The nurse would ask the parent about asthma, allergies, and immunizations, but not specifically in relationship to an absent breath sound on one side (unilateral absent breath sound). Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 2006. Chapter 51: Nursing Care During a Pediatric Emergency - Page 2006 Add a Note Question 4 See full question 8s Report this Question 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? You Selected: "I will place the child on a cardiac monitor. I will use this to assess the child's heart rate." Correct response: "I will place the child on a cardiac monitor. I will use this to assess the child's heart rate." Explanation: 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. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1990. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1990 Add a Note Question 5 See full question 1m 30s Report this Question When creating a care plan for a child with a head injury, the nurse uses the nursing diagnosis of Risk for excess fluid volume related to administration of hypertonic solution. Which is an appropriated outcome evaluation for this diagnosis? You Selected: The child shows no evidence of any altered thought process. Correct response: The child's lungs remain clear to auscultation. Explanation: Appropriate outcomes for the diagnosis of Risk for excess fluid volume related to administration of hypertonic solution include lungs are clear to auscultation, respiratory rate, heart rate, and blood pressure remain normal for age of child, and urine specific gravity of 1.003 to 1.030, not 1.030 to 1.033. Although the child's parents should understand the child's treatment, this is not an appropriate outcome for this nursing diagnosis.

A 3-year-old child has sustained injuries from a fall. Once the airway is secured, which of the following interventions would be done next? You Selected: Stabilizing the cervical spine Correct response: Stabilizing the cervical spine Explanation: If head or spine injuries are suspected, then after the airway is opened, the cervical spine must be stabilized to prevent damage. Checking the mouth for debris is part of securing an airway. Administering oxygen and establishing IV access would be done after the C-spine is stabilized. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 3rd ed., Philadelphia, Wolters Kluwer, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 2016. Chapter 51: Nursing Care During a Pediatric Emergency - Page 2016 Add a Note Question 2 See full question 8s Report this Question A 6-year-old girl who is being treated for shock is pulseless with an irregular heart rate of 32 bpm. Which intervention is priority? You Selected: Initiate cardiac compressions Correct response: Initiate cardiac compressions Explanation: The American Heart Association (AHA) emphasizes the importance of cardiac compressions in pulseless clients with arrhythmias, making this the priority intervention in this situation. Current AHA recommendations are for defibrillation to be administered once followed by five cycles of CPR. The AHA now recommends against using multiple doses of epinephrine because they have not been shown to be helpful and may actually cause harm to the child. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 2015. Chapter 51: Nursing Care During a Pediatric Emergency - Page 2015 Add a Note Question 3 See full question 9s Report this Question The nurse is caring for a 9 month-old infant in the emergency department following a traumatic injury. The infant weighs 21.5 pounds. In order to provide adequate fluid resuscitation, the nurse plans to infuse 20 mL/kg of lactated Ringer's as an IV fluid bolus. How many mL will the nurse administer? (Round your answer to the nearest whole number.) _________ Your Response: 195 Correct response: 195 Explanation: The infant older than 1 month would receive 20 mL/kg of normal saline or LR for fluid resuscitation via a large bore IV. The infant weighs 9.77 kg (21.5/2.2) so 9.77 x 20 mL = 195.4545 mL rounded to 195 mL. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1990. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1990 Add a Note Question 4 See full question 8s Report this Question 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? You Selected: "Ketamine is the anesthetic typically used for children who have suffered head trauma and need to be intubated." Correct response: "Ketamine is the anesthetic typically used for children who have suffered head trauma and need to be intubated." Explanation: 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. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 2005. Chapter 51: Nursing Care During a Pediatric Emergency - Page 2005 Add a Note Question 5 See full question 1m 11s Report this Question 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? You Selected: 1325. Correct response: 1320. Explanation: Epinephrine may be administered IV, intraosseous (IO) or via and ET tube. During CPR, it may be repeated every 3 to 5 minutes.

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? You Selected: "Hold your child's hand while this is going on." Correct response: "Hold your child's hand while this is going on." Explanation: 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. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1996. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1996 Add a Note Question 2 See full question 7s Report this Question 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: You Selected: respiratory failure. Correct response: respiratory failure. Explanation: 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. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1985. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1985 Add a Note Question 3 See full question 8s Report this Question A 6-year-old girl in shock is receiving dobutamine. What would the nurse most likely do? You Selected: Monitor for ventricular arrhythmias. Correct response: Monitor for ventricular arrhythmias. Explanation: Reference: Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1987. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1987 Add a Note Question 4 See full question 8s Report this Question A 13-year-old boy has had a near-drowning experience. The nurse notices he has labored breathing and a cough. Which of the following would be the priority? You Selected: Administering 100% oxygen by mask Correct response: Administering 100% oxygen by mask Explanation: Management of the near-drowning victim focuses on assessing the ABCs and correcting hypoxemia. Administering oxygen is the primary intervention to assist breathing. It is best to let the child assume his own most comfortable position. 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. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 3rd ed., Philadelphia, Wolters Kluwer, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 2016. Chapter 51: Nursing Care During a Pediatric Emergency - Page 2016 Add a Note Question 5 See full question 7s Report this Question A 9-year-old has suffered a severe anaphylactic reaction and is seriously ill. The nurse is providing support to the parents. Which statement by the nurse would be most effective in assisting the parents to cope? You Selected: "How can I help you get through this?" Correct response: "How can I help you get through this?" Explanation: Using open-ended questions elicits the parents' thoughts and fears and helps the nurse assess the issues at hand. Questions that can be answered with "yes" or "no" are less effective. Parents should be encouraged to stay with the child. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 3rd ed., Philadelphia, Wolters Kluwer, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1996. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1996 Add a Note Question 6 See full question 8s Report this Question A nurse is assessing a child brought to the emergency department. The child has a fever of 102.4 degrees F. The nurse continues the assessment, integrating knowledge that which of the following reflects the effect of fever on the basal metabolic rate? You Selected: Tachypena Correct response: Tachypena Explanation: Fever increases the basal metabolic rate, resulting in tachycardia, tachypena, and increased oxygen demand. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 3rd ed., Philadelphia, Wolters Kluwer, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 2011. Chapter 51: Nursing Care During a Pediatric Emergency - Page 2011 Add a Note Question 7 See full question 8s Report this Question A 12-year-old boy has broken his arm and is showing signs and symptoms of shock. Which of the following would the nurse do first? You Selected: Establish a suitable IV site. Correct response: Establish a suitable IV site. Explanation: 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. Drawing blood for type and cross match would be once vascular access is obtained and fluid and drug therapy has been initiated. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 3rd ed., Philadelphia, Wolters Kluwer, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 2007. Chapter 51: Nursing Care During a Pediatric Emergency - Page 2007 Add a Note Question 8 See full question 7s Report this Question A nurse manager is debriefing a group of co-workers who had just finished caring for a child who suffered a cardiac arrest. One of the co-workers stated, "Why did they let the family stay while we were working on the child?" What is the best response by the nurse? You Selected: "Allowing the family to stay during the resuscitation may assist the family in coping." Correct response: "Allowing the family to stay during the resuscitation may assist the family in coping." Explanation: Studies have shown that family presence during resuscitation may assist with family coping. It is up to the family if they want to stay but this is not the best response. It does not matter if the family members are health care workers or not. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1996. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1996 Add a Note Question 9 See full question 9s Report this Question While assessing a child with a suspected skull fracture, the nurse notes clear fluid draining from the child's nose. What is the priority action by the nurse? You Selected: Test the fluid with a glucose reagent strip. Correct response: Test the fluid with a glucose reagent strip. Explanation: Clear fluid draining from the nose or ear may be cerebrospinal fluid (CSF). One way to test to determine if it is CSF is to test for the presence of glucose with a glucose reagent strip. CSF will test positive for glucose. If CSF is present, the child should never blow the nose forcefully. While providing a tissue with instructions to not blow the nose is appropriate, it is not the priority intervention. Clear fluid draining from the nose is documented as rhinorrhea; otorrhea is clear fluid draining from the ear. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 3rd ed., Philadelphia, Wolters Kluwer, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1413. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1413 Add a Note Question 10 See full question 1m 23s Report this Question The nurse has been caring for a child who suffered a severe burn 2 days ago. The nurse notes that the child's hematocrit level is 32%. What is the best action by the nurse? You Selected: No action is needed at this time because this is a normal finding. Correct response: No action is needed at this time because this is a normal finding. Explanation: About 48 hours after a burn, inflammation starts to decrease. The extracellular fluid from the burn site is reabsorbed into the bloodstream. This can cause temporary hypervolemia, which will cause the heart rate to increase and the hematocrit to decrease. Once the child begins diuresis, the hypervolemia will correct. While assessing the child is always an appropriate action, the low hematocrit is expected at this time. The child will not need a blood transfusion.

A 9-year-old has suffered a severe anaphylactic reaction and dies. The nurse is providing support for the grieving parents. Which comment would best help them cope? You Selected: "How can I help you get through this?" Correct response: "How can I help you get through this?" Explanation: The experience of an emergency situation and an unexpected death is very frightening to parents. The nurse plays a key role in providing empathy and support. Using open-ended questions elicits the parents' thoughts and fears and helps the nurse assess the issues at hand. Questions that can be answered with "yes" or "no" are less effective. The nurse should provide honest answers in a reassuirng manor and never give false reassurances such as "it's going to be alright." That is something that can not be promised. Parents should be encouraged to stay with the child until they are ready to leave. Moving them to the lounge may cause more emotional distress. Calling the chaplain is a good support for the family but only if the family wishes chaplaincy services. Eating would be the least thought for parents shortly after their child has died. The nurse offering this to the parents may be very uncomfortable in the situation and can only offer a tangible solution for an emotional problem. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 3rd ed., Philadelphia, Wolters Kluwer, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1996. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1996 Add a Note Question 2 See full question 8s Report this Question Administration of which medication reverses the histamine release and hypotension that are seen in anaphylaxis? You Selected: Epinephrine Correct response: Epinephrine Explanation: Epinephrine reverses histamine release and hypotension due to anaphylaxis. It increases the heart rate and systemic vascular resistance. Diphenhydramine and ranitidine are histamine blockers. They are used for milder forms of allergic reactions. Atropine is an anticholinergic. It causes tachycardia, inhibits secretions and relaxes smooth muscles. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1987. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1987 Add a Note Question 3 See full question 11s Report this Question A child is exhibiting symptomatic bradycardia that has been unresponsive to ventilation and oxygenation. Which of the following would the nurse expect to be administered? You Selected: Atropine Correct response: Atropine Explanation: 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. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 3rd ed., Philadelphia, Wolters Kluwer, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1987. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1987 Add a Note Question 4 See full question 9s Report this Question The nurse is called into a toddler's room. The child's mother says "he's having trouble breathing." What should the nurse do first? You Selected: Assess patency of the child's airway. Correct response: Assess patency of the child's airway. Explanation: The first step in airway evaluation and management is assessing the patency of the child's airway. Depending on the assessment findings, the nurse may place oxygen and a pulse oximeter on the child. Notification of the physician needs to occur but the nurse must assess the child first. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1999. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1999 Add a Note Question 5 See full question 42s Report this Question The nurse is caring for a child who will be given activated charcoal due to an unintentional poisoning. Which statement by a parent indicates a need for further education? You Selected: "The charcoal will help to deactivate the poison that is in my child's system." Correct response: "I need to check my child's stools for the next few days; if they are black, that means there is blood in the stool." Explanation: Activated charcoal is excreted through the bowel over the next 3 days; stools may appear black, which can be misinterpreted as blood in the stool. The charcoal can deactivate a swallowed poison. The child can either drink the charcoal, or if the child is unable to swallow it, it can be administered via an NG tube. The charcoal can be mixed with water and a sweet syrup to make it more palatable for the child.

Fever increases the basal metabolic rate resulting in: You Selected: Tachypnea Correct response: Tachypnea Explanation: Fever increases the basal metabolic rate, resulting in tachycardia, tachypnea, and increased oxygen demand. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 3rd ed., Philadelphia, Wolters Kluwer, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1998. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1998 Add a Note Question 2 See full question 24s Report this Question The nurse is assessing the neurologic status of an 11-month-old girl. Which finding would be cause for concern? You Selected: Inspection shows a sluggish pupillary reaction. Correct response: Inspection shows a sluggish pupillary reaction. Explanation: A sluggish pupillary reaction may occur with increased intracranial pressure, which would be cause for concern. A closed posterior fontanel in an 11-month-old would be a normal finding. Crying and looking around are encouraging signs indicating improved neurologic status. Opening the eyes when being spoken to is an encouraging sign. Reference: Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1990. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1990 Add a Note Question 3 See full question 8s Report this Question A 10-year-old boy with congenital heart disease is in shock. Which nursing intervention would be most appropriate for this child? You Selected: Assessing for pulmonary edema from fluid overload Correct response: Assessing for pulmonary edema from fluid overload Explanation: 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. Reference: Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 2010. Chapter 51: Nursing Care During a Pediatric Emergency - Page 2010 Add a Note Question 4 See full question 10s Report this Question Assessment of a child reveals a tension pneumothorax. The nurse would prepare the child for: You Selected: needle thoracotomy. Correct response: needle thoracotomy. Explanation: 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. Reference: Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1986. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1986 Add a Note Question 5 See full question 21s Report this Question The nurse is caring for a comatose school-age child receiving gastrostomy tube feedings. The nurse aspirates 15 ml of stomach contents prior to administering a feeding. What is the most appropriate action by the nurse? You Selected: Replace the stomach contents and continue with the feedings as prescribed. Correct response: Replace the stomach contents and continue with the feedings as prescribed. Explanation: The nurse should always aspirate NG or gastrostomy tubes for stomach contents to check for tube placement and assess gastric residual amounts prior to administering feedings. Always return any amount of stomach reside aspirated so the child does not loose large amounts of stomach acid. The amount of 15 ml is a very small amount of gastric contents and should not interfere with feedings.

A child has fallen off of a swing at the playground and her father states that she became groggy. After assessing a child's airway, breathing, and circulation (ABCs), what would the nurse do next? You Selected: Assess level of consciousness. Correct response: Assess level of consciousness. Explanation: 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. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 2018. Chapter 51: Nursing Care During a Pediatric Emergency - Page 2018 Add a Note Question 2 See full question 11s Report this Question A 5-year-old girl is breathing spontaneously but is unable to maintain an airway. What action would be the priority? You Selected: Inserting an oropharyngeal airway Correct response: Inserting an oropharyngeal airway Explanation: 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. Reference: Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1999. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1999 Add a Note Question 3 See full question 9s Report this Question The nurse is assessing the neurologic status of an infant. What would the nurse identify as a nonreassuring finding? You Selected: Lack of interest in surroundings Correct response: Lack of interest in surroundings Explanation: 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. Reference: Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1990. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1990 Add a Note Question 4 See full question 9s Report this Question 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. Your Response: 25 Correct response: 25 Explanation: 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 Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 2009. Chapter 51: Nursing Care During a Pediatric Emergency - Page 2009 Add a Note Question 5 See full question 11s Report this Question 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. Your Response: 709 Correct response: 709 Explanation: 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.

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? You Selected: Applying ice to the child's face Correct response: Applying ice to the child's face Explanation: 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. Reference: Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 2014. Chapter 51: Nursing Care During a Pediatric Emergency - Page 2014 Add a Note Question 2 See full question 9s Report this Question The nurse is caring for a 2-year-old that has been rushed to the urgent care clinic immediately after swallowing an unknown number of acetaminophen tablets. Which of the followingwould the nurse expect to implement first? You Selected: Perform a gastric lavage Correct response: Perform a gastric lavage Explanation: If the child ingested the pills within the last 60 minutes, a gastric lavage and administration of activated charcoal would be the preferred treatment. Once the acetaminophen is in the blood stream, N-acetylcysteine may be administered. Chelation therapy is used for metal poisoning. IV fluid replacement is used to treat hypovolemic shock. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 3rd ed., Philadelphia, Wolters Kluwer, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 2017. Chapter 51: Nursing Care During a Pediatric Emergency - Page 2017 Add a Note Question 3 See full question 8s Report this Question A child is exhibiting symptomatic bradycardia that has been unresponsive to ventilation and oxygenation. Which of the following would the nurse expect to be administered? You Selected: Atropine Correct response: Atropine Explanation: 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. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 3rd ed., Philadelphia, Wolters Kluwer, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1987. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1987 Add a Note Question 4 See full question 44s Report this Question The health care team is performing cardiopulmonary resuscitation on a child following a suspected poisoning. Which action by the nurse would indicate that cardiopulmonary resuscitation is warranted? You Selected: The nurse assesses the child's heart rate at 45 and begins chest compressions Correct response: The nurse assesses the child's heart rate at 45 and begins chest compressions Explanation: The child with a pulse of less than 60 beats per minute should receive chest compressions to maintain adequate perfusion and circulation. The nurse would assess for injuries, the child's neurological status and respiratory complications after cardiopulmonary resuscitation has stabilized the child. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1993. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1993 Add a Note Question 5 See full question 9s Report this Question 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? You Selected: Jaw-thrust maneuver Correct response: Jaw-thrust maneuver Explanation: 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.

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A 13-year-old adolescent has had a near-drowning experience. The nurse notices the client has labored breathing and a cough. What is the priority intervention? You Selected: Administer 100% oxygen by mask. Correct response: Administer 100% oxygen by mask. Explanation: Management of the near-drowning victim focuses on assessing the client's airway, breathing, and circulation (ABCs) and correcting hypoxemia. Administering oxygen is the primary intervention to assist breathing. It is best to let the adolescent assume the most comfortable position for him or her. Checking capillary refill time helps determine ineffective tissue perfusion, but it does not provide an intervention for the labored breathing. Providing sedation is an intervention for pain. Pain is assessed after the ABCs and neuro assessments are completed. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 2016. Chapter 51: Nursing Care During a Pediatric Emergency - Page 2016 Add a Note Question 2 See full question 7s Report this Question Which nursing diagnosis would be appropriate for teaching interventions for a single mother who leaves her toddler unattended in the bathtub? You Selected: Risk for suffocation Correct response: Risk for suffocation Explanation: 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. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 2016. Chapter 51: Nursing Care During a Pediatric Emergency - Page 2016 Add a Note Question 3 See full question 9s Report this Question A home care nurse provides health education to parents regarding the care of their toddler. Which precaution should the nurse suggest the parents take to protect the toddler from drowning? You Selected: Avoid unattended baths for the toddler. Correct response: Avoid unattended baths for the toddler. Explanation: The parents should not leave the toddler for an unattended bath. Toddlers are naturally inquisitive, and instructing them to stay away from the pool or teaching them that water is dangerous is insufficient to ensure safety. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 2016. Chapter 51: Nursing Care During a Pediatric Emergency - Page 2016 Add a Note Question 4 See full question 15s Report this Question A 13-year-old boy has had a near-drowning experience. The nurse notices he has labored breathing and a cough. Which of the following would be the priority? You Selected: Administering 100% oxygen by mask Correct response: Administering 100% oxygen by mask Explanation: Management of the near-drowning victim focuses on assessing the ABCs and correcting hypoxemia. Administering oxygen is the primary intervention to assist breathing. It is best to let the child assume his own most comfortable position. 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. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 3rd ed., Philadelphia, Wolters Kluwer, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 2016. Chapter 51: Nursing Care During a Pediatric Emergency - Page 2016 Add a Note Question 5 See full question 9s Report this Question 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 feet from a large slide and hit his head "hard enough to knock him out." What is the nurse's next action? You Selected: Perform a jaw-thrust technique to assess the patency of the airway Correct response: Perform a jaw-thrust technique to assess the patency of the airway Explanation: 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 the respiratory status and lungs of a 6-year-old child. What finding would the nurse report immediately? You Selected: Minimal air movement through the lungs Correct response: Minimal air movement through the lungs Explanation: 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. Reference: Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1999. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1999 Add a Note Question 2 See full question 9s Report this Question A 3-year-old child has sustained injuries from a fall. Once the airway is secured, which of the following interventions would be done next? You Selected: Stabilizing the cervical spine Correct response: Stabilizing the cervical spine Explanation: If head or spine injuries are suspected, then after the airway is opened, the cervical spine must be stabilized to prevent damage. Checking the mouth for debris is part of securing an airway. Administering oxygen and establishing IV access would be done after the C-spine is stabilized. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 3rd ed., Philadelphia, Wolters Kluwer, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 2016. Chapter 51: Nursing Care During a Pediatric Emergency - Page 2016 Add a Note Question 3 See full question 13s Report this Question 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 in mL/min. Record your answer using a whole number. Your Response: 76 Correct response: 5700 Explanation: 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 mL/min Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 2007. Chapter 51: Nursing Care During a Pediatric Emergency - Page 2007 Add a Note Question 4 See full question 19s Report this Question 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? You Selected: Skin color and heart rate Correct response: Skin color and heart rate Explanation: 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. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1998. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1998 Add a Note Question 5 See full question 23s Report this Question 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. You Selected: "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." "Has your child had any recent illnesses?" Correct response: "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." Explanation: 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.

Assessment of a child reveals a tension pneumothorax. The nurse would prepare the child for: You Selected: needle thoracotomy. Correct response: needle thoracotomy. Explanation: 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. Reference: Ricci, S. S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1986. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1986 Add a Note Question 2 See full question 11s Report this Question The nurse is assessing an 8-year-old child in the emergency department. Which assessment finding would be a priority and alert the nurse to intervene immediately? You Selected: Minimal air movement in the lung fields Correct response: Minimal air movement in the lung fields Explanation: The nurse must immediately intervene when there is minimal air movement in the lung fields. The child is severely compromised at this time. The assessment findings of a pleural friction rub and an expiratory wheeze would require further assessment but are not as high of priority as minimal air movement. The systolic blood pressure of 86 is a normal finding for an 8-year-old child (70 + twice the age in years would be 70 + 16). Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1999. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1999 Add a Note Question 3 See full question 16s Report this Question 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? You Selected: A generous saline flush to follow the IV medication Correct response: A generous saline flush to follow the IV medication Explanation: 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. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1987. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1987 Add a Note Question 4 See full question 8s Report this Question 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? You Selected: Perform the jaw thrust maneuver. Correct response: Perform the jaw thrust maneuver. Explanation: 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. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1999. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1999 Add a Note Question 5 See full question 21s Report this Question A nurse is assessing the blood pressure of a 5-year-old child brought into the emergency department after being involved in a motor vehicle accident. Which systolic blood pressure would the nurse identify as a cause for concern? You Selected: 70 mm Hg Correct response: 70 mm Hg Explanation: According to the Pediatric Advanced Life Support guidelines, the minimum acceptable systolic blood pressure is 60 for the neonate, 70 for the infant aged 1 to 12 months, and 70 plus twice the age in years for children aged 1 to 10 years (e.g., a 5-year-old should have a minimal systolic blood pressure of 80: 70 + [2 x5] = 80). For children older than age 10, the minimum acceptable systolic blood pressure is 90 mm Hg.

The nurse is attempting to establish peripheral vascular access in a child requiring pediatric advanced life support. The decision to use the intraosseous route would be made if the nurse were unsuccessful after how many attempts within 90 seconds? You Selected: Three Correct response: Three Explanation: No more than three attempts should be made within 90 seconds to obtain peripheral vascular access. Reference: Ricci, S. S., Kyle, T., & Carman, S., Maternity and Pediatric Nursing, 3rd ed., Philadelphia, Wolters Kluwer, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 1990. Chapter 51: Nursing Care During a Pediatric Emergency - Page 1990 Add a Note Question 2 See full question 8s Report this Question 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? You Selected: Administration of activated charcoal Correct response: Administration of activated charcoal Explanation: 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. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 2017. Chapter 51: Nursing Care During a Pediatric Emergency - Page 2017 Add a Note Question 3 See full question 9s Report this Question 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. Your Response: 709 Correct response: 709 Explanation: 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. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 2009. Chapter 51: Nursing Care During a Pediatric Emergency - Page 2009 Add a Note Question 4 See full question 16s Report this Question The nurse is caring for a child who has had an endotracheal tube placed and is hooked to a ventilator. When assessing the child, the nurse notes that they child is exhibiting signs of poor oxygenation. What should the nurse do? Select all that apply. You Selected: Assess tracheal tube placement. Assess for the presence of decreased breath sounds on one side of the chest. Assess for tracheal tube obstruction. Correct response: Assess tracheal tube placement. Assess for the presence of decreased breath sounds on one side of the chest. Assess for tracheal tube obstruction. Assess the ventilator equipment, checking to see that all tubing is connected correctly. Explanation: If the child begins to exhibit signs of poor oxygenation, perform a quick assessment. Auscultate the lungs for equal air entry and determine the heart rate. Are the breath sounds equal? Is the heart rate normal for age? Perform a quick survey of the equipment and look for any disconnected tubes or kinks in the tubing. Determine oxygen saturation levels via pulse oximeter and evaluate the end-tidal CO2 color. Use the mnemonic "DOPE" for troubleshooting when the status of a child who is intubated deteriorates: D = Displacement. The tracheal tube is displaced from the trachea. O = Obstruction. The tracheal tube is obstructed (e.g., with a mucous plug). P = Pneumothorax. Usually a pneumothorax results in a sudden change in the child's assessment. The signs of a pneumothorax include decreased breath sounds and decreased chest expansion on the side of the pneumothorax. Subcutaneous emphysema may be noted over the chest. In the case of tension pneumothorax, there may be a sudden drop in heart rate and blood pressure. E = Equipment failure. Relatively simple problems as previously discussed, such as a disconnected oxygen supply, can cause the child to deteriorate. Culprits such as a leak in the ventilator circuit or a loss of power are other types of equipment failure that may be responsible. Reference: Ricci, S.S., Kyle, T., Carman, S. Maternity and Pediatric Nursing, 3rd ed. Philadelphia: Wolters Kluwer Health, 2017, Chapter 51: Nursing Care During a Pediatric Emergency, p. 2006. Chapter 51: Nursing Care During a Pediatric Emergency - Page 2006 Add a Note Question 5 See full question 10s Report this Question The nurse is assessing a child with a suspected head injury. The child opens the eyes only in response to the nurse placing pressure in the child's nail bed. What score on the Glasgow coma scale for eye opening should the nurse assign based on this assessment finding? You Selected: 2 Correct response: 2 Explanation: In the eye opening section of the Glasgow coma scale, eye opening only in response to painful stimuli would be a score of 2. Spontaneous eye opening is a 4, opening in response to speech is a 3, and no eye opening in response to painful stimuli is a 1.