Chapter 22: Health Care Adaptations for the Child and Family

1. What is the best pulse location for the nurse to use when assessing the pulse rate on a 12-month-old infant? a. Brachial b. Apical c. Radial d. Femoral

ANS: B Apical pulses are advised for children under age 5 years.

14. A 4-year-old asks tearfully if the IM injection will hurt. What is the nurse's most effective response? a. "No. It is over before you know it." b. "Yes. It will sting a little." c. "No. Would you like to see the syringe?" d. "Yes. Your mom and I are going to hold you to help you be still."

ANS: B Truthful answers will give a child a realistic expectation and help establish trust in the nurse.

15. Where is the best site for giving an IM injection to a 15-month-old child? a. Ventrogluteal muscle b. Dorsogluteal muscle c. Deltoid muscle d. Vastus lateralis muscle

ANS: D The vastus lateralis muscle is free of major blood vessels and nerves and can be used in children of any age.

21. An infant's dry diaper weighs 2.5 grams. The wet diaper weighs 47 grams. How would the nurse record the infant's urine output? a. 47 mL b. 44.5 mL c. 43.5 mL d. 40.5 mL

ANS: B Urine output is determined by calculating the difference in weight between the wet diaper and a dry diaper. One gram is equivalent to one milliliter of output. 47 - 2.5 = 44.5 grams = 44.5 mL of urine.

11. The prescription for a 4-month-old is penicillin G 150,000 units intramuscularly bid. The drug is supplied as a unit dose of 600,000 units in a 5-mL vial. How many milliliters (mL) should the nurse provide? a. 1.25 b. 1.4 c. 1.6 d. 1.8

ANS: A 600,000_mL 5 mL ´ 150,000 = 1.25 mL This dose would have to be given in divided doses as only 0.5 to 1 mL should be injected in one site on an infant.

9. Which restraint is most appropriate for the insertion of an intravenous line in a scalp vein of an infant? a. Mummy b. Clove hitch c. Jacket d. Elbow

ANS: A A mummy restraint would be used to restrain an infant for insertion of an intravenous line in a scalp vein.

6. Gentamicin ear drops are prescribed for a 4-year-old child. How would the nurse position the auricle when administering the ear drops? a. Up and back b. Down and back c. Up and out d. Down and out

ANS: A For children 3 years of age and older, the auricle is gently pulled upward and backward to straighten the canal.

10. How often should a child who has a continuous intravenous infusion should be assessed? a. Hourly b. Every 2 hours c. Every 3 hours d. Every 4 hours

ANS: A The nurse must assess hourly an intravenous infusion for complications, such as inflammation and infiltration.

26. Which specific drug(s) should be checked with a second licensed nurse prior to administration? (Select all that apply.) a. Insulin b. Digoxin c. Vasodilators d. Calcium salts e. Anticoagulants

ANS: A, B, D, E Insulin, hypoglycemics, narcotics, digoxin, inotropic drugs, anticoagulants, potassium, and calcium salts all must be checked by a licensed nurse prior to administration.

25. Informed consent for a minor guarantees that the parent or legal guardian understands what aspect(s) of a procedure? (Select all that apply.) a. Purpose of the procedure b. Risks associated with the procedure c. That no suit can be brought for damages d. That the document must be signed and witnessed e. That information was given

ANS: A, B, D, E The informed consent establishes that the patient, parent, or legal guardian understands the purpose and risks of the procedure. It also establishes that the patient, parent, or legal guardian understands what they have been told; the document should be signed and witnessed.

28. What should the nurse assess to determine the method of transportation for a pediatric patient? (Select all that apply.) a. Age b. Race c. Vital signs d. Distance to travel e. Level of consciousness

ANS: A, D, E The means by which the child is transported within the unit and to other parts of the hospital depends on age, level of consciousness, and how far the child must travel.

23. The pediatric nurse completes an assessment on all patients assigned during evening shift at the hospital. Which patient assessment requires immediate intervention? a. Toddler with an axillary temperature of 99° F b. School-age child with widening pulse pressure c. Infant pulse rate of 100 beats per minute d. Adolescent with a respiratory rate of 28 breaths per minute

ANS: B A widening pulse pressure can indicate increased ICP; therefore it is the priority. An axillary temperature of 99° F, infant pulse of 100 bpm, and adolescent respiratory rate of 28 are expected assessments.

18. Which observation on entering the hospital room lets the nurse know that there is a need for the parents to receive safety education to prevent unintentional injury? a. The blanket is not tucked into the mattress. b. Diapers and wipes are stacked at the foot of the crib. c. The crib side is locked in the up position. d. Pillows are stacked on the bedside table.

ANS: B Disposable diapers and supplies must be kept out of the infant's reach to prevent accidental suffocation.

13. What emergency action should be implemented for airway obstruction in the infant? a. Six to 10 midsternal thrusts b. Five back blows followed by five chest thrusts c. Five chest thrusts followed by five back blows d. Abdominal thrusts until the object is expelled

ANS: B Five back blows followed by five chest thrusts is the appropriate intervention for airway obstruction in the infant.

24. A 15-year-old patient returns to the pediatric unit following a lumbar puncture. What initial position will the nurse maintain for this patient? a. Left side-lying b. Supine c. Prone d. Semi-Fowler's

ANS: B The adolescent may avoid post-lumbar puncture headache by lying flat for some time.

3. The nurse instructed an adolescent female about collecting a clean-catch urine specimen. What statement made by the adolescent led the nurse to determine she understood the instructions? a. "I should wash my perineum with soap and water, then begin to urinate." b. "I clean the perineum from front to back with an antiseptic wipe before I urinate." c. "I'll collect the first stream of urine in a sterile container." d. "I will discard the first void and collect a freshly voided specimen 30 minutes later."

ANS: B To obtain a clean-catch specimen, the perineum is cleansed with an antiseptic wipe from front to back.

27. A 3-year-old patient is admitted to the pediatric unit with a fever of 103° F. Which actions will the nurse implement? (Select all that apply.) a. Assess rectal temperature every 4 hours. b. Administer Acetaminophen as ordered. c. Assess skin turgor. d. Restrict fluids. e. Assess level of consciousness.

ANS: B, C, E When evaluating the degree of illness in a febrile child, the nurse should assess and record response of the child to cuddling, alertness, hydration, sociability, and quality of cry. A quiet, lethargic child who does not respond readily to the environment may be acutely ill. Because dehydration is a common problem in infants and children, skin turgor should be assessed. Antipyretics also provide comfort and may aid in enabling the child to consume fluids, lessening the risk of dehydration. Rectal temperatures are not recommended for pediatric patients.

2. The nurse preparing to administer medication to a 2-month-old infant discovers there is no ID bracelet on the child. What should be the next action by the nurse? a. Give the medication after confirming the child's name from the foot of the crib. b. Ask the charge nurse to give the medicine. c. Confirm the identity with the charge nurse, make a new bracelet, and give the medicine. d. Delay the medication until the admissions office can supply a new ID bracelet.

ANS: C After confirmation of the child's identity with the charge nurse and making a new bracelet, the medication can be safely given. All patients should be identified before treatment.

5. A parent tells the nurse, "I'm not sure how to give this medicine to my infant." How would the nurse teach the parent to best administer an oral suspension? a. Pour the medication into a small cup and allowing the infant to drink it. b. Place the medication in a nipple and having the infant suck the nipple. c. Use an oral syringe and placing the medication in the side of the infant's mouth. d. Administer the medication with a dropper onto the back of the infant's tongue.

ANS: C An oral syringe is a useful device for measuring small quantities of medications for infants. The syringe is placed midway back, at the side of the mouth.

16. What factor does the nurse explain affects the infant's physiological response to medications? a. Faster metabolism in the liver b. Slower intestinal transit c. Immature kidney function d. Increased secretion of hydrochloric acid

ANS: C Immature kidney function prevents effective excretion of drugs from the body in infants less than 1 year of age.

17. What intervention should the nurse implement after topical administration of hydrocortisone cream to the buttocks and abdomen of an infant? a. Diaper the infant snugly with a disposable diaper. b. Cover the area with a transparent dressing. c. Apply a cloth diaper. d. Place the infant on a plastic pad, undiapered.

ANS: C Plastic coverings increase the absorption of drugs. The diaper should be cloth, or the infant should be left undiapered on a cloth pad.

12. Which intervention will the nurse implement when suctioning a tracheostomy? a. Suction for two to three breaths. b. Clear the catheter with water after suctioning for reuse. c. Apply suction for no more than 15 seconds. d. Establish a regular schedule for suctioning.

ANS: C Suctioning should be limited to 15 seconds.

7. Why is a tympanic thermometer considered more accurate than other types of thermometers? a. The thermometer probe is blunt and wide. b. It takes a brief time to register. c. The tympanic membrane shares circulation with the hypothalamus. d. The tympanic membrane and the brain have the same temperature.

ANS: C The accuracy of the tympanic thermometer is attributable to the fact that the tympanic membrane and the hypothalamus share the same circulation.

20. The nurse is caring for a 4-year-old child. What will the nurse expect the child's daily urinary output to be? a. 400 to 500 mL b. 500 to 600 mL c. 600 to 700 mL d. 700 to 1000 mL

ANS: C The average daily excretion of urine for a 4-year-old child is 600 to 700 mL.

22. The nurse instructs the mother of a 2-year-old who is taking iron supplements for anemia that some foods reduce the absorption of iron. What would be the best example provided by the nurse? a. Red meat b. Green, leafy vegetables c. Acidic fruit juices d. Egg yolks

ANS: D Egg yolks and starches reduce the absorption of iron in the digestive tract and should be limited for persons taking an iron supplement.

19. A 9-year-old child is preparing for a lumbar puncture. What position will the nurse explain the child will assume for this procedure? a. "On your stomach with your head turned to the side." b. "On your side, keeping the legs bent and the head arched back." c. "On your back with your legs extended straight out." d. "On your side with the knees bent and the head close to the knees."

ANS: D The child is positioned on his or her side with the knees flexed, and the head is brought down close to the flexed knees.

4. Which strategy might the nurse use when administering oral medications to a young child who is reluctant? a. Mix the medication with chocolate milk. b. Tell the child that the medication is candy. c. Give the medication quickly if the child is crying. d. Offer the child fruit juice after the medication is swallowed.

ANS: D The nurse can offer a chaser of water, fruit juice, or a carbonated beverage after the medication has been swallowed. Medications should not be mixed with food or drinks with important nutrients such as milk because the child may develop distaste for it.

8. Which intervention is correct when a nurse is administering a gastrostomy feeding by gravity? a. Discard the residual and increase the volume of feeding by the amount of residual. b. Flush the gastrostomy tube with 2 to 4 ounces of water before the feeding. c. Refill the syringe with formula after it has completely emptied. d. Position the child on the right side after a feeding.

ANS: D To prevent regurgitation and aspiration, the child is placed in the Fowler's position or on the right side to promote gastric emptying after a gastrostomy tube feeding.