Chapter 39

What is the most appropriate statement for the nurse to make to a 5-year-old child who is undergoing a venipuncture?

"This will hurt like a pinch. I'll get someone to help hold your arm still so it will be over fast and hurt less."

The advantages of the ventrogluteal muscle as an injection site in young children include which of the following? (Select all that apply.)

--Less painful than vastus lateralis --Free of important nerves and vascular structures --Easily identified by major landmarks

The nurse is preparing for the admission of an infant who will have several procedures performed. In which situation is informed consent required? (Select all that apply.)

--Lumbar puncture --Bone marrow aspiration

A child with congestive heart failure is placed on a maintenance dosage of digoxin. The dosage is 0.07 mg/kg/day, and the child's weight is 7.2 kg. The physician prescribes the digoxin to be given once a day by mouth. Each dose will be _____ mg. Record your answer using one decimal place.

0.5

A child is receiving total parenteral nutrition (TPN; hyperalimentation). At the end of 8 hours, the nurse observes the solution and notes that 200 mL/8 hr is being infused rather than the ordered amount of 300 mL/8 hr. The nurse should adjust the rate so that how much will infuse during the next 8 hours?

300 mL

The nurse administering a bitter oral medication to an infant or small child should mix the medication with what substance?

A teaspoon of jam or ice cream

When liquid medication is given to a crying 10-month-old infant, which approach minimizes the possibility of aspiration?

Administering the medication with a syringe (without needle) placed along the side of the infant's tongue.

The most appropriate nursing action to implement when a preschooler being prepped for outpatient surgery refused to allow the parent to remove his/her underwear?

Allow the child to wear their underpants

What nursing consideration is related to the administration of oxygen (O2) in an infant?

Arterial oxygen saturation (SaO2) readings are used to guide O2 therapy

Frequent urine testing for specific gravity and glucose are required on a 6-month-old infant. How should the nurse collect small amounts of urine for these tests?

Aspirate urine from cotton balls inside the diaper with a syringe

It is important to make certain that sensory connectors and oximeters are compatible since wiring that is incompatible increases the risk of which injury?

Burns under sensors

What information should the nurse include when teaching parents how to care for a child's gastrostomy tube at home?

Clean around the insertion site daily with soap and water.

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

Demonstrate the procedure on a doll

The nurse gives an injection in a patient's room. Which method should the nurse use to dispose of the needle?

Dispose of syringe and needle in a rigid, puncture-resistant container in patient's room.

What intervention should the nurse implement when suctioning a child with a tracheostomy?

Ensuring that each pass of the suction catheter take no longer than 10 seconds.

A 3 year old has a 102° F fever associated with a viral illness that has not responded to acetaminophen. The nurse's action should be based on what knowledge about fevers in children?

Fevers such as this are common with viral illnesses.

What is an appropriate intervention to encourage food and fluid intake in a hospitalized child?

Give high-quality foods and snacks whenever child expresses hunger.

When teaching a mother how to administer eyedrops, where should the nurse instruct to place them?

In the conjunctival sac that is formed when the lower lid is pulled down

What is an important nursing consideration when performing a bladder catheterization on a young boy?

Insert 2% lidocaine lubricant into the urethra

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

Insert the needle quickly, using a dart-like motion

After collecting blood by venipuncture in the antecubital fossa, what intervention should the nurse implement in order to assure control of any bleeding?

Keep arm extended, and apply pressure to the site for a few minutes.

Which nursing action is the most appropriate when applying a face mask to a child prescribed oxygen therapy?

Make sure the mask fits properly

The nurse monitoring a child for signs and symptoms of malignant hyperthermia should be alert for which early sign of this disorder?

Muscle rigidity

In preparing to give "enemas until clear" to a young child, the nurse should select which solution?

Normal saline

When caring for a child with an intravenous infusion, the nurse should include which intervention in the plan of care?

Observing the insertion site frequently for signs of infiltration

When administering a gavage feeding to a school-age child, the nurse should implement what intervention to assure safety?

Position the child on the right side after administering the feeding.

A 2-year-old child comes to the emergency department demonstrating signs of dehydration and hypovolemic shock. Which best explains why an intraosseous infusion is started?

Rapid venous access is not possible.

A 6-year-old child is hospitalized for intravenous (IV) antibiotic therapy. He eats little on his "regular diet" trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. Which is the best nursing action?

Request these favorite foods for him

What important consideration in providing atraumatic care should the nurse consider when preforming a venipuncture on a 6-year-old child?

Restrain the child only as needed to perform venipuncture safely

What intervention is appropriate when administering tepid water or sponge baths prescribed for hyperthermia in children?

Stop the bath if the child begins to chill.

The nurse is cleaning multiple facial abrasions on a 9-year-old who was brought to the emergency department by his/her mother. When the child begins crying and screaming loudly, what intervention should the nurse implement to best manage this situation?

Tell the child it is okay to cry and scream

The nurse is planning how to best prepare a 4-year-old child for some diagnostic procedures. What guideline should the nurse consider when preparing a preschooler for a diagnostic procedure?

Telling the child that procedures are never a form of punishment.

What should the nurse consider when having consent forms signed for surgery and procedures on children?

The risks and benefits of a procedure are part of the consent process.

What nursing action is appropriate for specimen collection?

Use Standard Precautions when handling body fluids.

What critical information should the nurse incorporate into care when using restraints on a child?

Use the least restrictive type of restraint

The nurse is caring. What skin care interventions for an unconscious child should be included in the plan of care?

Using drawsheet to move child in bed to reduce friction and shearing injuries

Which is the preferred site for intramuscular injections in infants?

Vastus lateralis

The nurse wore gloves during a dressing change. When the gloves are removed, the nurse should perform which initial action?

Wash hands thoroughly

What procedure is recommended to facilitate a heelstick on an ill neonate to obtain a blood sample?

Wrap foot in a warm washcloth