Chapter 37: Nursing Care of a Family when a Child Needs Diagnostic or Therapeutic Modalities

The nurse needs to provide instructions to a school-age girl about how to obtain a clean catch midstream urine specimen. Which instructions are best?

*Clean the labia from front to back, then void a small amount into the toilet before collecting in the cup.* For girls, clean the labia from front to back using a cleansing pad or cotton balls saturated with the agency's designated cleaning solution. During the child's voiding, ask the parent to collect a "midstream" sample into a sterile container provided. It is unnecessary to catheterize a school-age child to get a clean catch urine specimen. Urinating into the cup is part of the process, but it follows cleaning the labia and voiding a small amount into the toilet. A urine collection bag is used for infants, not school-age children.

A 9-year-old child requires gastrostomy tube feedings to meet nutritional requirements. How will the nurse suggest these feedings should be arranged to be least disruptive to the child's daily activities?

*Feed the child continuously throughout the night using a feeding pump.* Feeding the child continuously throughout the night can provide significant nutrition without overburdening the gastrointestinal tract and can free the child from interference with school activities. The health aide doing the feeding and the child assuming that responsibility do interfere. Using a more dense nutritional preparation is likely to create gastrointestinal problems.

The nurse is caring for a 6-year-old child who has multisystem trauma due to a motor vehicle accident. The child is receiving total parenteral nutrition (TPN). What is a recommended nursing intervention for children on TPN?

*Initially, check blood glucose levels frequently, such as every 4 to 6 hours, to evaluate for hyperglycemia.* Initially, the nurse should check blood glucose levels frequently, such as every 4 to 6 hours, to evaluate for hyperglycemia. Throughout TPN therapy, the nurse should be vigilant in monitoring the infusion rate, and report any changes in the infusion rate to the physician or nurse practitioner immediately. Adjustments may be made to the rate, but only as ordered by the physician or nurse practitioner. If for any reason the TPN infusion is interrupted or stops, the nurse should begin an infusion of a 10% dextrose solution at the same infusion rate as the TPN. TPN can be administered continuously over a 24-hour period, or after initiation it may be given on a cyclic basis, such as over a 12-hour period during the night.

A nurse will explain to a child's caregiver any procedure that is to be done. What is the primary reason for this explanation?

*It helps to reduce anxiety.* Although it is a client's right to know everything about his or her care, in this case the caregiver is not the client. Communication helps to develop rapport and trust, but the main purpose of explaining procedures to the caregiver of a child is to reduce anxiety. Doing this also will help decrease the child's anxiety.

A toddler has a peripheral IV and has pulled it out twice on one shift. The nurse decides to apply an elbow restraint on the right arm to prevent the client from pulling the IV out again. What interventions would the nurse implement in caring for a client in elbow restraints? Select all that apply.

*Pin the restraint to the child's shirt for stability. Ensure that the restraint does not go too high under the axillae. Check the skin under the restraint every 1 to 2 hours. Tongue depressors can be used to construct the restraint.* Elbow restraints are used for protection of IV sites, prevention of placing objects in the mouth, and other problems where the nurse does not want the child to be able to bend the elbow. The nurse must remove the restraint and examine the skin every 1 to 2 hours. For stability, the nurse pins the restraint to the child's shirt to keep it from slipping down. Non-commercial elbow restraints are composed of vertical pockets that are filled with tongue depressors to stabilize the restraint. The nurse does not remove the restraint from the child when the parent is in the room because children are far too quick to take a chance on them pulling a needed IV out again.

A nurse working with a client who has an elevated temperature notices that the child is beginning to shiver. Which of the following should the nurse do immediately?

*Stop whatever intervention is being done to lower the temperature.* Removing clothing and excess covering from a child with a fever permits additional cooling through evaporation. If a child starts to shiver, whatever method is being used to lower the temperature should be stopped. Shivering indicates the child is chilling, which will cause the body temperature to increase.

The nurse is administering a gavage feeding through a nasogastric feeding tube. Which nursing intervention is the highest priority?

*The nurse verifies the position of the feeding tube.* Verifying the position of the tube to ensure that the tube is in the stomach by aspirating stomach contents is the highest priority. This is a top priority because of the danger of aspiration if the tube is not in the stomach but rather in the esophagus or the lung.

The nurse is administering a prescribed bolus gavage feeding. Which action would be incorrect in performing this procedure?

*Verify placement by auscultating for sounds in the stomach when air is inserted.* Auscultating for sounds when air is injected into the stomach is no longer considered recommended for verifying tube placement because it has been found unreliable as a confirmation of position.

A pediatric nurse wants to determine an accurate amount of urine output for a diapered baby. Which is the most effective method?

*Weigh a diaper before use and mark with weight, then weigh after and subtract the weight of the diaper.* Diapers can be readily used as a method of measuring urine output. Weigh a diaper before it is placed on an infant and record this weight conspicuously (e.g., mark it on the front of the plastic covering with a ballpoint pen). Reweigh the diaper after it is wet and subtract the difference to determine the amount of urine present. This difference will be in grams, but because 1 g = 1 ml, the amount can be recorded in milliliters. This is the most accurate measure of output for an infant. This knowledge makes the answer that measuring output is impossible an incorrect answer. For just everyday intake and output, counting the number of wet diapers is adequate. Using a urine collection device is not always accurate because many times urine leaks around the bag.

How will the nurse measure urine output in the hospitalized toddler who is partially potty trained?

*Weigh the wet pull-up or diaper and subtract the weight of a dry diaper.* A toddler who is partially potty trained is likely to regress during the stress of hospitalization and need diapering. Subtracting dry weight in grams from wet weight reveals the number of milliliters of urine excreted. The other output measurement methods will not be accurate.

Following the repair of a cleft palate, the nurse places an 18-month-old child in restraints. The caregivers are with the child and will stay in the room at all times. Which type of restraints would the nurse most likely use for this child?

*elbow restraint* An elbow restraint prevents the child from being able to bend the elbows and thus prevents the child from reaching or touching the face or head areas.

A nurse is starting an intravenous (IV) line in the antecubital fossa of a small child. What restraint would be best for the nurse to use to maintain patency of the IV?

*elbow restraint* Elbow restraints are wrapped around the child's arm and tied securely to prevent the child from bending the elbow. They are often made of muslin or other materials in two layers. Pockets wide enough to hold tongue depressors are placed vertically in the width of the fabric. The top flap folds over to close the pockets. Care must be taken to ensure that the elbow restraints fit the child properly.

The charge nurse is teaching a new nurse how to assess vital signs of an infant. The mentor knows that teaching was effective when the nurse takes which measurement first?

*respirations* Respirations should be measured before an infant is disturbed because the respiratory rate increases with crying. Apical pulse, temperature, and blood pressure measurement typically wakes the infant and leads to distress and crying. Therefore, observing respirations is best done first, before the infant is crying.

The nurse is conducting teaching with the caregivers of a child who is being discharged from the pediatric unit. The care provider has recommended the child have moist heat applications at home. In conducting teaching with this caregiver, the nurse will teach the caregiver to use which of the following to provide the moist heat

*towels dampened with hot water* Towels can be used to provide moist heat. They should not be warmed in the microwave because the microwave may unevenly heat the towels, which in turn may burn the child. Dry heat may be applied by means of an electric heating pad, a K-pad (a unit that circulates warm water through plastic-enclosed tubing), or a hot-water bottle. Many children, however, have been burned because of the improper use of hot-water bottles; therefore, these devices are not recommended.

An 8-month old infant has a colostomy placed following abdominal surgery for removal of a section of bowel. The stoma is 2/3 full, draining liquid stool and the bag appears inflated. What actions would the nurse take in caring for this client? Select all that apply.

Examine the skin around the stoma site for redness or irritation. Look at the infant's intake to determine if any foods could be causing gas. Empty the bag and record the output. In caring for an infant with a colostomy, the nurse empties the contents of the bag on a regular basis, rinses it out, closes it again, but does not discard it each time it is emptied. The nurse also inspects the skin around the stoma for any redness or skin breakdown. Since the bag was inflated initially, the nurse should review the infant's intake to note if the infant is consuming any gas-causing foods and recommend limiting them. The bag is never left off for any length of time due to the constant stooling pattern of the infant.

A 14-year-old adolescent is stating flank pain that keeps them up at night. The nurse instructs the adolescent in obtaining a clean catch urine specimen. Place the steps in order from first to last for preparing an adolescent female for a clean catch urine specimen. Use all options.

Verify the prescription from the health care provider. Explain the procedure to the adolescent. Have the adolescent spread their labia and clean front to back with the wipe. Have the adolescent urinate a small amount into the toilet. Have the adolescent void into the urine specimen cup. Have the adolescent empty their bladder into the toilet.

A new graduate nurse is asking the nurse preceptor about enemas in pediatrics. The preceptor explains that the use of enemas in children is warranted under which circumstances? Select all that apply.

fecal impaction preparation for surgery Hirschsprung disease prep for a colonoscopy Enemas are rarely used with children unless they are used as therapy for fecal impaction, Hirschsprung disease, a part of preparation for surgery, or a diagnostic test. Enemas would not be used for bloating or constipation.