Exam 5-Peds

A child with a fracture has had a reduction and casting. The child complains of tingling, burning, and inability to move the extremity. There is a weak pulse and the skin is pale gray. Which should the nurse expect? Compartment syndrome Malunion Infection Osteomyelitis

Compartment syndrome

A 4-month-old infant is being treated for talipes equinovarus (clubfoot). The infant has a cast change every 2 to 3 weeks. When the infant is brought to the well-baby clinic for a routine visit, a nurse evaluates the foot in the cast. Which assessments should the nurse include? Select all that apply. Color of the toes of the foot in the cast Pedal pulses of both feet Range of motion of the foot in the cast Movement of the toes of the foot in the cast Knee flexion and extension of the affected leg

Color of the toes of the foot in the cast and Movement of the toes of the foot in the cast Skin color will indicate adequate (e.g., same color as the rest of the body's skin) or impaired (e.g., dusky, cyanotic) circulation in the foot in a cast. Movement will indicate unimpaired neural transmission in the foot. Pedal pulses will not be accessible on the foot in a cast. A foot cannot be put through its full range of motion with a cast in place. Knee flexion and extension are irrelevant; the knee is not involved with a foot in a cast.

While assessing a school-aged child who has just had a short arm cast applied to a fractured right wrist, the nurse discovers that the fingers of the right hand are cool. What should the nurse do first? Compare the temperature of the two hands. Clip the edge of the cast to reduce pressure. Elevate the right arm to reduce the swelling. Inform the healthcare provider of the circulatory impairment

Compare the temperature of the two hands. Cool fingers are a sign of circulatory impairment caused by the pressure of the cast; however, the finding that both hands feel cool indicates that some factor other than circulatory impairment is responsible. The cast should not be adjusted without prior notification of the healthcare provider. Further assessment to determine the cause of temperature change is indicated before remedial action such as elevating the right arm is taken. Further assessment is needed before the practitioner is informed.

A nurse is providing instructions to the parents of a child with scoliosis regarding the use of a brace. Which statement by the parents indicates a need for further instruction? "I will apply lotion under the brace to prevent skin breakdown." "I will encourage my child to perform prescribed exercises." "I will have my child wear soft fabric clothing under the brace." "I will avoid the use of powder because it will cake under the brace."

"I will apply lotion under the brace to prevent skin breakdown."

When assessing a toddler with Autism Spectrum Disorder (ASD), what characteristic findings or behaviors should the nurse expect? Select all that apply. Flat, blank facial expression The desire to hug the nurse Laughing when pulse is taken Enjoys climbing on stairs and furniture Inability to maintain eye contact

Flat, blank facial expression Laughing when pulse is taken inability to maintain eye contact Toddlers with Autism Spectrum Disorder (ASD) have communicative and behavioral impairment and developmental delay; they struggle with social communication and social interaction. Characteristic findings the nurse would expect in a toddler with ASD include a flat affect, inappropriate laughing while measuring the pulse, lack of eye contact, and humming or grunting. The toddler with autism also tends to overrespond to environmental stimuli. Toddlers with ASD will rarely hug anyone and would not enjoy climbing on stairs or furniture.

A 9-year-old child has a fractured tibia, and a full leg cast is applied. Which assessment findings should the nurse immediately report to the healthcare provider? Select all that apply. Inability to move the toes Increased urine output Pedal pulse of 90 beats/min Tingling sensation in the foot

Inability to move the toes. Tingling sensations in the foot. A cast is not flexible and can inhibit circulation. Cold toes, loss of sensation in toes, pain, and inability to move the toes should be reported immediately. A tingling sensation in the foot may indicate excessive pressure on the nerves and circulatory system in the casted extremity. A fiberglass cast dries within minutes; if it remains damp, it should be reported before 4 hours have elapsed. Increased urine output is not significant; it may be related to increased fluid intake. The expected pulse rate for a 9-year-old child ranges from 70 to 110 beats/min.

During a newborn assessment for developmental dysplasia of the hip (DDH), the nurse elicits the Ortolani sign. How does the nurse explain this finding to the child's mother? It is a clicking of the hip when it is manipulated. It is a broadening of the perineum. It is shortening of the affected leg. It is drooping of the hip on one side of the body.

It is a clicking of the hip when it is manipulated. With specific manipulation, an audible click may be heard or felt as the femoral head slips into the acetabulum. Broadening of the perineum is associated with bilateral dislocation. The apparent shortening of one leg is the Allis sign. A unilateral droop of one hip is the Trendelenburg sign; it occurs in a child with developmental dysplasia of the hipLinks to an external site. when the child bears weight.

The Gower sign can be elicited by having the patient perform which of the following? Rise from a squatting position Close the eyes and touch the nose with alternating index fingers Hop on one foot and then the other Bend from the waist to touch the toes

Rise from a squatting position

A ventroperitoneal shunt is inserted in a 4-month-old infant with hydrocephalus. Which signs of shunt failure should the nurse teach the parents during preparations for the infant's discharge? Select all that apply. Vomiting Dehydration Sunken eyeballs Distended fontanels Abdominal distention

Vomiting, Distended fontanells

After orthopedic surgery a 15-year-old adolescent reports pain and rates it a 5 on a scale of 0 to 10. A nurse administers the prescribed 5 mg of oxycodone every 3 hours as needed. Two hours after having been given this medication, the adolescent reports pain and rates it a 10 of 10. What action should the nurse take next? Request that the primary healthcare provider evaluate the need for additional medication. Administer another dose of oxycodone within 30 minutes. Report the adolescent's apparent idiosyncratic reaction to oxycodone. Tell the adolescent that additional medication cannot be given for 1 more hour.

request that the primary healthcare provider evaluate the need for additional medication. The nurse has made the assessment that the medication has been ineffective in relieving the adolescent's pain for the duration that it was prescribed to cover. This information should be communicated to the primary healthcare provider for evaluation. The prescription is for administration every 3 hours; legally the drug may be given only within these guidelines. There are no data to support an idiosyncratic reaction to the oxycodone; the amount of medication was probably inadequate for the adolescent's pain tolerance level. The nurse should not ignore the adolescent's need for pain relief.

A mother whose infant was found to have cerebral palsy at 6 months of age asks why she was not told that her baby had cerebral palsy when the infant was born. How should the nurse respond? "Until there's control of voluntary movement, a diagnosis can't be confirmed." "The neurological lesions changed as your baby matured." "Joint deformities don't appear until after 6 months of age." "The staff members didn't want to alarm you until it was necessary."

"Until there's control of voluntary movement, a diagnosis can't be confirmed." Cortical control of voluntary muscles occurs between 2 and 4 months of age. The neurological lesions are fixed and will neither progress nor regress. Cerebral palsy is not diagnosed on the basis of the presence of joint deformities; these may develop later because of spastic muscle imbalance. Parents have a right to be informed of their child's diagnosis as soon as possible.

An infant who has been found to have developmental dysplasia of the hip (DDH) is being examined in the pediatric clinic. What clinical finding does the nurse expect to identify during the physical assessment? Limited abduction of the affected hip Downward and inward rotation of the affected hip Inability to flex and extend the hip on the affected side Free abduction of the affected hip when placed in the frog position

Limited abduction of the affected hip. Abduction of the hip is limited infant with DDH because the head of the femur slips out of the acetabulum and is unable to rotate. Rotation of the hip is unaffected. The hip can be flexed on the affected side. Free abduction of the affected hip is impossible; the frog position may be used in the treatment of DDH.

After closure of a newborn's myelomeningocele, what essential nursing intervention must be included in the plan of care? Measuring head circumference daily Monitoring for serous drainage from the nares Limiting leg movement Decreasing environmental stimuli

Measuring head circumference daily The surgical closure of the sac decreases the absorptive surface and eliminates a route by which the spinal fluid drains. Because the cranial sutures have not closed, the skull will expand if fluid increases, causing hydrocephalus. The lower extremities of most infants with myelomeningocele are partially or completely paralyzed; performing careful range-of-motion exercise is an important part of nursing care. There is no reason to decrease environmental stimuli for infants who have had surgical correction of a myelomeningocele unless they also have seizures. Observing for serous drainage from the nares is not expected, because damage to the meninges of the brain is not a factor in the surgical treatment of myelomeningocele.

A nurse is caring for an infant who has just undergone myelomeningocele repair. What should the nursing plan of care include? Monitoring for cerebrospinal fluid leakage Maintaining a supine position Teaching clean catheterizations to parents Applying sterile moist dressings to the incision

Monitoring for cerebrospinal fluid leakage Leakage of cerebrospinal fluid indicates incomplete closure of the defect and must be reported. The supine position is contraindicated, because it places pressure on the surgical site. Teaching clean catheterization is not appropriate at this time. Moist dressings are applied before surgery, not after, to prevent drying of the sac.

Which action should the nurse take when providing postoperative nursing care to a child after insertion of a ventriculoperitoneal shunt? Monitoring for increased temperature. Administer narcotics for pain control. Check the urine for glucose and protein. Test cerebrospinal fluid leakage for protein.

Monitoring for increased temperature Monitoring the temperature allows the nurse to assess for infection, the most common and the most hazardous postoperative complication after ventriculoperitoneal (VP) shunt placement. Typically, pain after insertion of a VP shunt is mild, requiring the use of mild analgesics. Usually, narcotics are not administered because they alter level of consciousness, making assessment of cerebral function difficult. Neither proteinuria or glycosuria is associated with shunt placement. Cerebrospinal fluid leakage commonly occurs with head injury. It is not usually associated with shunt placement

An infant with hydrocephalus has a ventriculoperitoneal shunt surgically inserted. What nursing care is essential during the first 24 hours after this procedure? Monitoring the infant for increasing intracranial pressure Medicating the infant for pain Placing the infant in a high Fowler position Positioning the infant on the side that has the shunt

Monitoring the infant for increasing intracranial pressure The shunt may become obstructed, leading to an accumulation of cerebrospinal fluid and increased intracranial pressure. Although providing pain relief for the infant is an important part of postsurgical care, monitoring for potentially severe complications such as increased intracranial pressure takes precedence. Positioning the infant flat helps prevent complications that may result from a too-rapid reduction of intracranial fluid. The infant is positioned off the shunt to prevent pressure on the valve and incision area.

While in the playroom a school-aged child exhibits twitching of the right arm and leg that almost immediately progresses to a generalized tonic-clonic seizure with clenched jaws. What is the best action for the nurse to take after moving the child to the floor? Moving objects away from the child Taking the other children to their rooms Inserting a plastic airway into the child's mouth Positioning a large pillow under the child's head

Moving objects away from the child objects should be moved away from the child. It is unsafe to leave the child during the seizure to take other children to their rooms. Attempting to open clenched jaws may result in injury to the child's teeth and jaw. Positioning a large pillow under the child's head may cause airway occlusion by forcing the neck onto the chin; a small, flat blanket will be more effective.

An infant with a myelomeningocele is admitted to the pediatric intensive care unit. While the infant is awaiting surgical correction of the defect, what is the most appropriate nursing intervention? Placing the infant in the prone position Using disposable diapers Performing neurologic checks above the site of the lesion Washing the area below the defect with a nontoxic antiseptic

Placing the infant in the prone position The prone position is the best position for preventing pressure on the sac. Diapers should not be applied because they may irritate or contaminate the sac. Assessment of the area below the defect is essential in determining motor and sensory function. There is no indication for the use of an antiseptic.

What safety instruction should a nurse teach a 10-year-old child with diminished sensation in the legs because of cerebral palsy? Test the temperature of the water before a bath. Tighten brace straps securely before ambulating. Set the clock twice during the night to change position. Look down at the legs when crutch-walking to check how they are positioned.

Test the temperature of the water before a bath. Individuals whose thermoreceptive senses are impaired are unable to detect changes or degrees of temperature. They must be taught to first test the temperature in any water-related activity to prevent scalding and burning. Overtightening of brace straps may lead to circulatory impairment or skin breakdown. The child with cerebral palsy has uncontrolled movement of voluntary muscles and does not need to change positions at night to prevent skin breakdown. Looking down at the legs when crutch-walking is dangerous because this action alters the center of gravity; with practice the child will be able to place the legs in the appropriate position for walking without looking down.

A nurse is concerned about helping the parents of an infant with cerebral palsy set long-term goals for the family. What is most important to understand when setting long-term goals? Unknown extent of the disability requires continual adjustments. Cognitive impairments require special education. Progressive deterioration requires future institutionalization. Diminished immune responses require protection from infection.

Unknown extent of the disability requires continual adjustments. The infant is too young for specific long-term plans; different problems may manifest as the child grows older. Children with cerebral palsy may or may not have cognitive impairments. Cerebral palsy does not get progressively worse; placement outside the home depends on the child's needs and the parents' abilities and desires. There is no relationship between cerebral palsy and a lowered immune response.