NCLEX PN Prep: Child Health

The registered nurse (RN) teaches the parents of a hospitalized 3-month-old about separation anxiety. The practical nurse notices that the parents still seem concerned about leaving the infant while they work and so reinforces the information provided by the RN. Which statement by one of the parents indicates that the teaching has been effective? A. "At this age, my baby will not cry because we are leaving." B. "I know my baby will feel abandoned when we leave." C. "My baby is too young to sense my anxiety about leaving." D. "My baby understands that we will return later in the day."

Correct Answer: A. "At this age, my baby will not cry because we are leaving." Separation or stranger anxiety occurs when the primary caregivers leave the child in the care of others who are not familiar to the child. This behavior starts around age 6 months, peaks at age 10-18 months, and can last until age 3 years. Separation anxiety produces more stress than any other factor (eg, pain, injury, change in surroundings) for children in this age range. However, this reaction is normal and resolves as the child approaches age 3 years. A 3-month-old is too young to experience separation anxiety and can be soothed by any comforting voice. Incorrect Answer: [B. "I know my baby will feel abandoned when we leave."] A 3-month-old is not developmentally capable of fearing abandonment. [C. "My baby is too young to sense my anxiety about leaving."] A 3-month-old might sense a parent's anxiety but is cognitively unable to process it. [D. "My baby understands that we will return later in the day."] A 3-month-old cannot evaluate time and would not understand the concept of returning later in the day. Educational objective:Separation anxiety starts around age 6 months, peaks at age 10-18 months, and can last until age 3 years. It produces more stress than any other factor (eg, pain, injury, change in surroundings) for children in this age range. However, separation anxiety is normal and resolves by age 3 years.

A nurse is planning to complete a physical examination of a toddler. Which approach is an appropriate intervention by the nurse? A. Encourage the parent to be involved with the child B. Engage in physical contact by removing the toddler's outer clothing first C. Have medical equipment lying on a counter within view D. Perform an examination in a head-to-toe order

Correct Answer: A. Encourage the parent to be involved with the child The nurse should plan to assess the toddler client in a nonthreatening environment, taking time to develop rapport prior to beginning the examination. This can be achieved by talking to the toddler about favorite objects and slowly initiating contact. Parent involvement, such as holding the child and assisting the child with examination activities, reduces anxiety and encourages cooperation in toddler clients. Age-appropriate games or toys may be used if needed to gain the client's cooperation. Incorrect Answer: [B. Engage in physical contact by removing the toddler's outer clothing first] Use minimal physical contact initially, and have the parent remove the outer clothing. [C. Have medical equipment lying on a counter within view] Medical equipment may appear frightening to a toddler and should remain out of sight until needed. It may also be beneficial to allow the child to inspect and touch new pieces of equipment as they are used. [D. Perform an examination in a head-to-toe order] It is best to order a physical examination for a toddler from least to most invasive, which commonly means assessing ears, nose, and mouth toward the end of a visit. Head-to-toe ordered assessments are more appropriate for school-age children. Educational objective:The nurse should allow a parent to interact with the toddler and assist with the examination process to encourage client cooperation. Examination of a toddler should proceed from least to most invasive, allowing the client to inspect pieces of equipment before use. Use minimal physical contact initially.

A nurse is talking with the parent of a 6-year-old regarding sleep and rest. Which information should be included? A. Active play before bedtime promotes restful sleep B. Bedtime hours should be established C. Rest needs are related to the high rate of growth in this age group D. Seven to 8 hours of sleep are required

Correct Answer: B. Bedtime hours should be established During the school-age years (6-12), sleep needs of a child depend on health status, activity level, and age. Children in this age group need approximately 11 hours of sleep daily at age 5 and 9 hours at age 12. Children are often unaware of their level of fatigue. Bedtimes should be established to prevent fatigue the next day. Bedtime issues are usually not a concern, although many children retain bedtime rituals such as reading or listening to music. Incorrect Answer: [A. Active play before bedtime promotes restful sleep] Quiet activity (eg, coloring, reading) prior to bedtime should be planned to promote restful sleep. [C. Rest needs are related to the high rate of growth in this age group] Growth rate is slowed during the school-age years, which accounts for variations in sleep needs. [D. Seven to 8 hours of sleep are required] Children in this age group need approximately 11 hours of sleep daily at age 5 and 9 hours at age 12. Educational objective:Sleep needs of school-age children are dependent on health status, activity level, and age. Required sleep averages 11 hours (for 5-year-olds) to 9 hours (for 12-year-olds). It is important to establish bedtime hours and bedtime rituals. These children usually do not need daytime naps if they have slept well at night.

The nurse reinforcing teaching to the parents of a child diagnosed with cystic fibrosis will advise the parents to choose foods that satisfy which recommended diet? A. Gluten-free with added protein B. High calorie, high protein, high fat C. High protein, low fat, low phosphate D. High protein, low fat, low sodium

Correct Answer: B. High calorie, high protein, high fat In cystic fibrosis (CF), a protein responsible for transporting sodium and chloride is defective and causes the secretions from the exocrine glands to be thicker and stickier than normal. These abnormal secretions plug smaller airway passages and ducts in the gastrointestinal (GI) tract. The thick secretions block pancreatic ducts, resulting in a deficient amount of pancreatic enzymes entering the bowel to aid in digestion and nutrient absorption. Clients require multiple vitamin supplements and supplemental pancreatic enzymes that are administered with meals. To meet the growth needs of clients with CF, a diet high in calories, fat, and protein is required. Incorrect Answers: [A. Gluten-free with added protein ] A gluten-free diet is required for clients with celiac disease who cannot tolerate barley, rye, oats, or wheat (mnemonic: BROW). Low-phosphate diets are indicated for clients with certain kidney disorders. Low-sodium diets are indicated for volume overload states (eg, heart failure, ascites) and hypertension. [C. High protein, low fat, low phosphate] A gluten-free diet is required for clients with celiac disease who cannot tolerate barley, rye, oats, or wheat (mnemonic: BROW). Low-phosphate diets are indicated for clients with certain kidney disorders. Low-sodium diets are indicated for volume overload states (eg, heart failure, ascites) and hypertension. [D. High protein, low fat, low sodium] A gluten-free diet is required for clients with celiac disease who cannot tolerate barley, rye, oats, or wheat (mnemonic: BROW). Low-phosphate diets are indicated for clients with certain kidney disorders. Low-sodium diets are indicated for volume overload states (eg, heart failure, ascites) and hypertension. Educational objective:Cystic fibrosis causes damage to the gastrointestinal tract and pancreas, leading to impaired absorption of nutrients and resulting growth deficits. Clients must consume a diet high in calories, fat, and protein.

A 12-month-old is found to have a moderately elevated blood lead level. Which of the following is the most serious concern for this child? A. Gastrointestinal bleeding B. Growth retardation C. Neurocognitive impairment D. Severe liver injury

Correct Answer: C. Neurocognitive impairment Lead poisoning still occurs in the United States, although not as often as in previous decades. A common source of exposure is lead-based paints found in houses built before 1978, when such paint was banned. Blood lead level (BLL) screenings are recommended at ages 1 and 2, and up to age 6 if not previously tested. Because lead poisoning particularly affects the neurological system, elevated BLLs (≥5 mcg/dL [0.24 µmol/L]) are dangerous in young children due to immature development of the brain and nervous system. A mild to moderate increase in BLL can manifest with hyperactivity and impulsiveness; prolonged low-level exposure can cause developmental delays, reading difficulties, and visual-motor issues. Extremely elevated BLLs can lead to permanent cognitive impairment, seizures, blindness, or even death. Incorrect Answer: [A. Gastrointestinal bleeding] Gastrointestinal bleeding is a concern for clients with iron poisoning but has no link to lead toxicity [B. Growth retardation] Although delays in physical growth can result from chronic lead toxicity, the danger of permanent damage to the neurological system is a higher priority, particularly for young children. Growth retardation more commonly occurs with chronic anemia or pituitary disorders. [D. Severe liver injury] Lead poisoning is most threatening to the kidneys and neurological system; liver injury typically does not occur. Severe liver damage is closely associated with acetaminophen overdose or Reye syndrome. Educational objective:Lead poisoning can lead to many severe complications of the neurological system (eg, developmental delays, cognitive impairment, seizures). Elevated blood lead levels are particularly dangerous in young children due to immature development of the brain and nervous system.

The nurse is caring for a 4-year-old client with cystic fibrosis who uses a high-frequency chest wall oscillation (HFCWO) vest for chest physiotherapy. After reinforcing education with the client's parents, which statement by a parent requires further teaching? A. "I will allow my child to have a snack while using the HFCWO vest to encourage cooperation." B. "I will give my child the nebulized bronchodilator treatment during therapy with the HFCWO vest." C. "I will perform manual chest percussion on my child if the HFCWO vest is broken or unavailable." D. "My child will use the HFCWO vest once in the morning, once in the evening, and as needed."

Correct Answer: A. "I will allow my child to have a snack while using the HFCWO vest to encourage cooperation." Chest physiotherapy (CPT) describes techniques of airway clearance, which is an important component of treatment for clients with cystic fibrosis that loosens and drains thick respiratory secretions. CPT can be performed by percussing (ie, clapping) the chest with a cupped hand or by wearing an inflatable high-frequency chest wall oscillation (HFCWO) vest. The HFCWO vest inflates and deflates rapidly, causing vibration over the chest wall and mobilizing secretions into the large airways that the child can expectorate. The HFCWO vest's rapid vibrations may induce nausea and vomiting in some clients. Therefore, the client should avoid meals and snacks 1 hour before, during, or 2 hours following CPT to prevent gastrointestinal upset. The nurse may suggest other more appropriate ways to ensure compliance with CPT, such as allowing the child to watch a favorite television show or reading the child a story while wearing the HFCWO vest. Incorrect Answers: [B. "I will give my child the nebulized bronchodilator treatment during therapy with the HFCWO vest."] Nebulized bronchodilators are often given before or during CPT treatments to open the airways and mobilize secretions. [C. "I will perform manual chest percussion on my child if the HFCWO vest is broken or unavailable."] CPT can be administered using various methods, including percussion (ie, clapping) of the chest wall with cupped hands. [D. "My child will use the HFCWO vest once in the morning, once in the evening, and as needed."] CPT should be performed at least twice a day, and more often if needed. Educational objective:Chest physiotherapy (CPT) is an important component of treatment for clients with cystic fibrosis. A high-frequency chest wall oscillation vest is a common method of performing CPT, but treatments should occur 1 hour before or 2 hours after eating to avoid gastrointestinal upset (eg, nausea, vomiting).

The nurse is reviewing discharge instructions with the parents of a child who just had a tracheostomy. Which statement made by the parents indicates teaching has been effective? A. "I will always travel with two tracheostomy tubes, one of the same size and one a size smaller." B. "I will immediately change the tracheostomy tube if my child has difficulty breathing." C. "I will provide deep suctioning frequently to prevent any airway obstruction." D. "I will remove the humidifier if my child starts developing more secretions."

Correct Answer: A. "I will always travel with two tracheostomy tubes, one of the same size and one a size smaller." In the event of an accidental decannulation or another urgent need to change a tracheostomy tube, the most important action is to quickly replace the tube as it is the client's only means to ventilate. Clients should always carry two spare tracheostomy tubes, one the same size and one a size smaller. If the tube is not easily replaced or is meeting resistance, the smaller tube should be used. Incorrect Answers: [B. "I will immediately change the tracheostomy tube if my child has difficulty breathing."] Changing a tracheostomy tube is a high-risk procedure that should be done only if respiratory distress is noted and other interventions (eg, suctioning) have failed. Mucus plugs (ie, thickening and buildup of mucus due to dehydration) are one of the most common causes of respiratory distress. [C. "I will provide deep suctioning frequently to prevent any airway obstruction."] A tracheostomy should be suctioned frequently to maintain airway patency. However, deep suctioning should be reserved for clients in respiratory distress due to the risk of injury. Tracheostomy tubes should be suctioned to the specified depth using a measurement marked on the tube, to provide safe, effective suctioning. [D. "I will remove the humidifier if my child starts developing more secretions."] Humidification is crucial for clients with a tracheostomy as the upper airway, which provides natural humidity for inhaled air, is bypassed. Humidification helps keep secretions thin and reduces formation of mucus plugs. The humidifier should not be removed if the child develops more secretions as this is the intended effect. Educational objective:Clients with a tracheostomy should always carry two spare tubes, one the same size and one a size smaller, to ensure that the tube can be replaced quickly and effectively.

The nurse is attending an end-of-year school family picnic. Which situation needs an immediate intervention? A. A 2-year-old eating a hot dog unsupervised B. A 3-year-old playing alone in a wading pool C. A 4-year-old tossing a beach ball D. A 5-year-old climbing on monkey bars

Correct Answer: A. A 2-year-old eating a hot dog unsupervised Foreign body aspiration (FBA) is one of the most common causes of accidental injury and death in children under age 5. Of the objects commonly ingested by children (coins, toys, food), it is food that is the most common cause of aspiration. The trachea of a child is much smaller than that of an adult, placing the child at higher risk for choking on food. In addition, young children have underdeveloped swallowing mechanisms, including lack of muscle tone and immature teeth, and are still learning to chew correctly. Food items that are round and slippery, such as hot dogs, hard candies, whole grapes, and cherries, are particularly risky for young children. They can wedge tightly in the trachea, completely blocking the airway and causing death within a few minutes. The 2-year-old is at high risk of choking with every bite of the hot dog. Incorrect Answer: [B. A 3-year-old playing alone in a wading pool] All children need supervision when in and around water, no matter what the depth. However, this child is in no immediate danger. [C. A 4-year-old tossing a beach ball] A beach ball could be a bit bulky for a 4-year-old, but it is lightweight and poses no danger. [D. A 5-year-old climbing on monkey bars] Climbing on monkey bars is an appropriate outdoor activity for a 5-year-old and will help develop motor coordination and upper-body strength. Educational objective:Foreign body aspiration is a leading cause of accidental injury and death in small children due to tracheal anatomy and underdeveloped swallowing mechanisms. Food items that are particularly risky for a toddler include those that are round and slippery, sticky, or hard and rough.

The nurse assesses a child with intussusception. Which assessment findings require priority intervention? A. Abdominal rigidity with guarding B. Absence of tears in crying child with IV start C. Blood-streaked mucous stool in diaper D. Sausage-shaped right-sided mass on palpation

Correct Answer: A. Abdominal rigidity with guarding Intussusception occurs when part of the intestine telescopes into another adjacent part and causes a blockage. This leads to swelling and decreased blood supply to the intestine. Tissue death as well as perforation to the bowel may result. If perforation occurs, the client could develop peritonitis in which the peritoneum in the abdomen becomes inflamed due to infection. This can quickly lead to sepsis and multiple organ failure. Peritonitis is characterized by fever, abdominal rigidity, guarding, and rebound tenderness. This condition can be fatal if it is not treated quickly. Incorrect Answer: [B. Absence of tears in crying child with IV start] Absence of tears in a painful procedure during which the client is crying is a sign of dehydration. This is very common in clients with intussusception and should be treated. IV fluids should be started, and the client's hydration status (vital signs, mucus membranes, capillary refill) should be assessed frequently. [C. Blood-streaked mucous stool in diaper] A classic sign of intussusception is blood-streaked mucous stool, sometimes referred to as "currant jelly-like" stool. This is expected with intussusception. Treatment is an enema of either air or barium to unfold the intestine. [D. Sausage-shaped right-sided mass on palpation] A "sausage-shaped" right-sided mass is commonly felt on palpation in clients with intussusception. This is an expected finding for this condition. Educational objective:Intestinal perforation and peritonitis are common complications of intestinal obstruction (eg, intussusception). Peritonitis is characterized by fever, abdominal rigidity, guarding, and rebound tenderness and is a surgical emergency.

The nurse prepares a 7-year-old client for an influenza injection. The nurse explains that the client will receive "medicine under the skin," and the client is visibly anxious. Which nursing intervention is appropriate? A. Ask the child to count to 10 during injection B. Ask the parent to hold the child's arms tightly C. Explain to the child that the injection will not hurt D. Keep the injection needle out of the child's view

Correct Answer: A. Ask the child to count to 10 during injection Children are often fearful of injections, exhibiting unpredictable and/or uncooperative behavior. The nurse should explain the procedure to the child using simple, age-appropriate language (eg, "medicine under the skin") to reduce anxiety. According to Piaget's cognitive developmental stages, school-age children develop concrete thought and may fear a loss of control. To improve the child's sense of control, the nurse should offer a specific, task-based coping technique (eg, counting aloud, deep breathing) Incorrect Answer: [B. Ask the parent to hold the child's arms tightly] A caregiver should hold or embrace a child during the injection process, with the child on the caregiver's lap or standing in front of a seated caregiver. Tightly holding the child's arms is extreme and may distress the child and caregiver. [C. Explain to the child that the injection will not hurt] The child should be told the truth about pain that accompanies an injection. The nurse should use appropriate language, such as "the skin may hurt for a minute," and emphasize that the pain is quick and transient. [D. Keep the injection needle out of the child's view] Keeping objects that may alarm the child out of view is an appropriate intervention for a toddler but not for a school-age child. Hiding a procedural object from a 7-year-old will hinder rapport with the nurse and may heighten the child's anxiety. Educational objective:School-age children possess concrete thinking and fear loss of control. When administering an injection to a school-age child, the nurse should offer a specific, task-based coping technique (eg, instruct the child to count aloud or breathe deeply) to increase the child's sense of control and thereby reduce anxiety.

A nurse is caring for a child with acute glomerulonephritis. Frequent monitoring of which of the following is a priority? A. Blood pressure B. Hematuria C. Intake and output D. Peipheral edema

Correct Answer: A. Blood pressure Acute glomerulonephritis (AGN) in children is an immune complex disease most commonly induced by prior group A beta-hemolytic streptococcal infection of the skin or throat. A latent period of 2-3 weeks occurs between the streptococcal infection (eg, pharyngitis) and the symptoms of AGN. Clinical manifestations include periorbital and facial/generalized edema, hypertension, and oliguria, which are primarily due to fluid retention (decreased kidney filtration). The urine is tea-colored and cloudy due to the presence of protein and blood. Although most clients recover spontaneously within days, severe hypertension is an anticipated complication that must be identified early. Monitoring and control of blood pressure are most important as they prevent further progression of kidney injury and development of hypertensive encephalopathy or pulmonary edema. Incorrect Answers: [B. Hematuria] Hematuria is common with AGN. It is usually minimal and resolves spontaneously. Monitoring is important but not a priority. [C. Intake and output] The most important measure of fluid status is a daily weight as it identifies fluid retention and response to treatment. Monitoring intake and output is important but is not the priority action over hypertension monitoring and control. [D. Peipheral edema] Monitoring for edema is important but not the priority. Moderate sodium restriction is needed, especially if hypertension and edema are present. Otherwise, avoiding high-sodium foods and having no added salt in the diet may be adequate measures. Educational objective:Acute glomerulonephritis is most often caused by recent streptococcal infection. Nursing care is focused on monitoring vital signs (particularly blood pressure) and fluid status, avoiding salt in the diet, and conserving energy.

The nurse is collecting data on the psychosocial development of a 2-year-old. What is the priority finding that should be reported to the supervising registered nurse? A. Does not talk or respond when spoken or read to B. Likes to imitate others by playing house and talking on the telephone C. Refuses to go to sleep without a particular stuffed animal and a bedtime story D. Says "no" to everything and has temper tantrums

Correct Answer: A. Does not talk or respond when spoken or read to Toddlers experience a phenomenal growth in language skills. They have many ways of communicating, some of them nonverbal; however, they enjoy and learn as family members and others talk and read to them. When toddlers do not enjoy these interactions or are not expressing themselves verbally, speech and hearing deficits should be explored. Many deficits in speech and hearing are correctable; otherwise, therapy may enhance quality of life. Incorrect Answers: [B. Likes to imitate others by playing house and talking on the telephone] Imitating others is a normal stage of psychosocial development for toddlers. They adapt to their role in the family unit and society by imitating the same-sex parent. [C. Refuses to go to sleep without a particular stuffed animal and a bedtime story] Ritualism is common in toddlers and provides a sense of security. The rituals may become more evident when the child's regular caregiver is replaced with someone new (eg, babysitter). [D. Says "no" to everything and has temper tantrums] Toddlers are trying to express themselves and gain independence over their own bodies and actions. Temper tantrums are also a way of relieving stress. Toddlers say "no" to express their independence. Educational objective:If toddlers are not expressing themselves verbally and do not enjoy and learn as family members talk or read to them, speech and hearing deficits should be explored.

The nurse is reinforcing education to the parents of an adopted 5-year-old about how best to share details of the child's adoption. Which developmentally appropriate thought process does the nurse counsel the parents to anticipate? A. Feelings of responsibility for being placed for adoption B. Imagining what life would be like with a different family C. Inability to conceptualize adoptive and biological parents D. Worrying about what peers will say or think

Correct Answer: A. Feelings of responsibility for being placed for adoption Children age 3-6 (preschool) are in Piaget's preoperational stage of cognitive development. Children in the preoperational stage are developmentally capable of understanding adoption on a basic level; however, it may be difficult for them to understand the concept of having another family. At age 5, children may be unable to fully understand cause and effect and therefore ascribe inappropriate causes to phenomena (eg, scraped knee was caused by earlier misbehavior). Preschoolers who are adopted may believe they are responsible for being adopted and can develop separation anxiety and a fear of abandonment. Incorrect Answer: [B. Imagining what life would be like with a different family] School-aged children who are adopted may imagine how life would be different with their biological parents. They may be sensitive to physical differences between themselves and their adoptive family and feel a sense of loss when thinking of their biological family. [C. Inability to conceptualize adoptive and biological parents] Toddlers are in the preoperational stage of cognitive development and can generally think about only one idea at a time. They cannot think about all parts of an idea in terms of the whole, making it difficult to understand the difference between adoptive and biological parents. [D. Worrying about what peers will say or think] Adolescents have abstract thinking abilities that enable introspection about their adoption. Open and honest communication is important at this age. Educational objective:Preschool-aged children (age 3-6) are in Piaget's preoperational stage of cognitive development and therefore often ascribe inappropriate causes to phenomena. The adopted preschool-aged child may feel personally responsible for being adopted (eg, misbehavior led to placement for adoption).

A child is brought to the school nurse after having a permanent tooth knocked out during gym class. Which action by the nurse is appropriate? A. Gently rinse the tooth with sterile saline and reinsert it into the gingival cavity B. Gently scrub the root of the tooth to remove any debris, and wrap it in sterile gauze C. Place the tooth in water and transport the client to the nearest emergency department D. Wrap the tooth in sterile gauze and advise the parent to arrange for a dental appointment

Correct Answer: A. Gently rinse the tooth with sterile saline and reinsert it into the gingival cavity Dental avulsion (ie, tooth separated from the mouth) of a permanent tooth is a dental emergency. The priority nursing action is to rinse and reinsert the tooth into the gingival socket and hold it in place (eg, with a finger) until stabilized by a dentist. Reimplantation within 15 minutes of injury re-establishes blood supply, increasing the probability of tooth survival. If the tooth cannot be reinserted it should be kept moist by submerging it in commercially prepared solution (eg, Hanks Balanced Salt Solution), cold milk, sterile saline, or as a last resort—due to bacteria—saliva (eg, holding it under the tongue). Incorrect Answers: [B. Gently scrub the root of the tooth to remove any debris, and wrap it in sterile gauze] Scrubbing the root would damage it. The tooth should be gently rinsed with sterile saline or clean, running water. [C. Place the tooth in water and transport the client to the nearest emergency department] Placing the tooth in water (a hypotonic solution) would lyse the cells, killing the tooth. [D. Wrap the tooth in sterile gauze and advise the parent to arrange for a dental appointment] Wrapping the tooth in sterile gauze would dry it out. In addition, the nurse should arrange for immediate transfer to a dentist rather than advise the parent to schedule an appointment that might not be available for days. Educational objective:Dental avulsion is a dental emergency. The nurse should gently rinse off debris and reinsert the tooth into the gingival socket. If reimplantation is not possible, the tooth should be placed in a commercially prepared solution, cold milk, or sterile saline. The client should see a dentist immediately.

A nurse is reviewing the laboratory values of a 3-year-old with nephrotic syndrome. The nurse interprets the results to most clearly reflect which physiologic process related to nephrotic syndrome? A. Glomerular injury B. Hepatic impairment C. Inherited hypercholesterolemia D. Malnutrition

Correct Answer: A. Glomerular injury Nephrotic syndrome is a collection of symptoms resulting from various causes of glomerular injury. The 4 classic manifestations of nephrotic syndrome are as follows: · Edema - periorbital edema is usually the first sign; peripheral edema and ascites develop later due to fluid shifts · Massive proteinuria - caused by increased glomerular permeability · Hypoalbuminemia - resulting from excess protein loss in the urine Hyperlipidemia - related to increased compensatory protein and lipid production by the liver Additional symptoms include decreased urine output, fatigue, pallor, and weight gain. The most common cause of nephrotic syndrome in children is minimal change nephrotic syndrome, which is generally considered idiopathic. Less common secondary causes may be related to systemic disease or infection, such as glomerulonephritis, drug toxicity, or acquired immunodeficiency syndrome. Incorrect Answers: [B. Hepatic impairment] Ascites and edema are often associated with liver disease. However, these symptoms result from fluid shifts related to hypoalbuminemia in nephrotic syndrome. [C. Inherited hypercholesterolemia ] Lipid levels (normal total cholesterol: <200 mg/dL [5.2 mmol/L]) can increase with nephrotic syndrome as the liver produces increased lipids and proteins to compensate for protein loss. [D. Malnutrition] Although low serum albumin (normal: 3.5-5.0 g/dL [35-50 g/L]) could result from malnutrition, hypoalbuminemia in nephrotic syndrome is related to massive proteinuria (negative to trace protein on urinalysis is usually considered normal). Educational objective:Nephrotic syndrome is a collection of symptoms resulting from glomerular injury. The 4 characteristic manifestations are proteinuria, edema, hypoalbuminemia, and hyperlipidemia.

A newborn is being evaluated for possible esophageal atresia with tracheoesophageal fistula. Which finding is the nurse most likely to observe? A. Passed a normal brown stool B. Passed a stool mixed with blood C. Stopped crying D. Vomited a third time

Correct Answer: A. Passed a normal brown stool Most cases of intussusception are treated successfully without surgery using hydrostatic (saline) or pneumatic (air) enema. The nurse will monitor for passage of normal brown stool, indicating reduction of intussusception. If this occurs, the supervisory registered nurse should be notified immediately to modify the plan of care and stop all plans for surgery. Incorrect Answers: [B. Passed a stool mixed with blood] In intussusception, the stools are mixed with blood and mucus, giving a characteristic "currant jelly" appearance. This is an expected finding. [C. Stopped crying ] Pain in intussusception is typically intermittent, occurs every 15-20 minutes, and is accompanied by screaming and drawing up of the knees. Therefore, if a child stops crying, it may due to a short-term intermission from painful spasms rather than reduction of intussusception. [D. Vomited a third time] Intense pain causes spasms of the pyloric muscle that lead to vomiting after each episode. Vomiting tends to resolve once the intussusception is reduced. Educational objective:Reduction of intussusception is often performed with a saline or air enema. The supervisory registered nurse should be notified if there is passage of a normal stool as this indicates reduction of intussusception. All plans for surgery should be stopped, and the plan of care should be modified.

A child with autism spectrum disorder is being admitted to a medical-surgical unit. Which is the most appropriate nursing action? A. Placing the child in a private room away from the nurses' station B. Placing the child in a private room near the playroom C. Placing the child in a semi-private room near the nurses' station D. Placing the child in a semi-private room with another child with autism spectrum disorder

Correct Answer: A. Placing the child in a private room away from the nurses' station Children with autism spectrum disorder (ASD) often exhibit sensory processing problems; they may be hyper- or hypo-sensitive to sounds, lights, movement, touch, taste, and smells. A calming environment with minimal stimulation should be provided; a private room away from the nurses' station is the best location. The nurse can also facilitate a calming environment by: · Using a quiet or monotone voice when speaking to the child · Using eye contact and gestures carefully · Moving slowly · Limiting visual clutter · Maintaining minimal lighting · Providing the child with a single object to focus on Incorrect Answers: [B. Placing the child in a private room near the playroom] A private room is an appropriate placement; however, the noise and activity from the playroom may be distracting to the child with ASD. [C. Placing the child in a semi-private room near the nurses' station] A semi-private room near the nurses' station is likely to have a stimulating environment due to the noise, lighting, and work pace in the area. [D. Placing the child in a semi-private room with another child with autism spectrum disorder] Placing the child in a semi-private room with another child with ASD does not promote a calming environment. Educational objective:Because children with autism spectrum disorder often exhibit sensory processing problems, they need a calming environment with minimal stimulation.

The health care provider (HCP) prescribes a 10-day course of amoxicillin for a 1-year-old diagnosed with acute otitis media (AOM). Which instruction is most important for the nurse to review with the child's parents? A. Return to the office if the child does not improve within 48-72 hours B. Stop the antibiotic if the child develops diarrhea C. Stop the antibiotic if the child feels better after 72 hours D. Use over-the-counter decongestants to help with recovery

Correct Answer: A. Return to the office if the child does not improve within 48-72 hours AOM is an infection of the middle ear. Potential complications of AOM include hearing loss and spread of the infection. To prevent permanent damage, severe cases of AOM are treated with antibiotics. Amoxicillin is the standard treatment in most cases. However, if AOM symptoms do not improve within 48-72 hours of initiating antibiotic therapy, the client should return for further assessment. The HCP will then assess for other causes of persistent symptoms and determine if a different antibiotic is required to treat drug-resistant organisms. Following treatment with antibiotics, clients with AOM should be evaluated for complete infection resolution and screened for hearing impairment. Incorrect Answers: [B. Stop the antibiotic if the child develops diarrhea] Diarrhea is a frequent side effect of amoxicillin therapy that does not warrant treatment discontinuation. If the client develops fever and abdominal pain associated with diarrhea, it may indicate Clostridium difficile superinfection; this should be reported to the HCP. The medication is stopped immediately if the child develops an allergic reaction (eg, rash, shortness of breath, throat tightness). [C. Stop the antibiotic if the child feels better after 72 hours] Ear pain and fever often subside within the first few days of antibiotic treatment. However, the entire course should be completed as prescribed to treat the infection completely and prevent antibiotic resistance. [D. Use over-the-counter decongestants to help with recovery] Over-the-counter decongestants are ineffective for AOM treatment and may even delay the recovery process. Educational objective:If AOM symptoms do not improve within 48-72 hours of starting antibiotics, a follow-up visit is required to determine if a different antibiotic is necessary.

A 3-month-old child with developmental dysplasia of the hip (DDH) is being fitted for a Pavlik harness. Which statement made by the parent indicates a need for further instruction? A. "I should leave the harness on during diaper changes." B. "I will adjust the harness straps every 3-5 days." C. "I will inspect the skin under the straps 2-3 times daily." D. "The harness should keep my baby's legs bent and spread apart."

Correct Answer: B. "I will adjust the harness straps every 3-5 days." DDH is instability or dislocation of the hip joint that may be present at birth or develop during the first few years of life. Nonsurgical treatment methods such as the Pavlik harness are most successful when initiated during the first 6 months of life. After this time, surgery is generally required. The Pavlik harness is the most common tool used to treat early DDH. It maintains the infant's hips in a slightly flexed and abducted position (ie, legs bent and spread apart), allowing for proper hip development (Option 4). Pavlik harnesses are typically worn for 3-5 months or until the hip joint is stable. The straps are assessed every 1-2 weeks by the health care provider (HCP) and adjusted as necessary to account for infant growth. However, parents should not alter the strap placements at home as incorrect positioning can lead to damage to the nerves or vascular supply of the hip. Care of the infant wearing a Pavlik harness includes the following: · Assess skin 2-3 times daily for redness or breakdown under the straps · Dress the child in a shirt and knee socks under the harness to protect the skin · Apply diapers underneath the straps to keep the harness clean and dry · Leave the harness on at all times, unless otherwise indicated by the HCP Educational objective:The Pavlik harness is used in the treatment of DDH; it maintains the infant's hips in a slightly flexed and abducted position to allow for proper joint development. Strap adjustments should be performed by the HCP to allow for proper positioning and avoid nerve or vascular damage.

The parents of a hospitalized preschooler are concerned because their toilet-trained child has started wetting the bed. Which response by the nurse is most helpful? A. "Discipline your child by taking away playroom privileges." B. "It is normal for your child to regress while hospitalized." C. "Restricting fluids at nighttime will solve this problem." D. "Your child is acting out due to the hospitalization."

Correct Answer: B. "It is normal for your child to regress while hospitalized." Regression during hospitalization is a normal response to the stress of an unfamiliar environment, the fear and pain of invasive procedures, and the change in a child's normal routine. Toilet-trained children may start bed-wetting, and children who gave up the bottle or pacifier may ask for it. It is important for the nurse to explain that this behavior is completely normal and that the child will gain back previous milestones after discharge. Incorrect Answers: [A. "Discipline your child by taking away playroom privileges."] Firm discipline would be counterproductive at this time. Punishment by restricting playtime would create more stress for the child. [C. "Restricting fluids at nighttime will solve this problem."] Limiting fluids at nighttime, voiding before bedtime, and involving the child in planning (eg, changing wet linens) are all appropriate interventions for enuresis. However, the first step is to reassure the parents and then teach them therapeutic interventions. [D. "Your child is acting out due to the hospitalization."] Misbehaving is not an unusual behavior for a preschooler. Acting out would not be due exclusively to the hospitalization. Educational objective:Hospitalization can be very stressful for a child. Regressive behaviors during hospitalization are a normal response to changes in routine. The nurse should inform the caregivers that this behavior is temporary and that the child will regain lost milestones rapidly after discharge.

The ambulatory care nurse is reassessing an unvaccinated 4-month-old infant for fever, irritability, and open-mouthed drooling. After the infant is successfully treated for epiglottitis, the parents ask how this could have been avoided. Which response by the nurse would be most appropriate? A. "It's impossible to know for sure what could have caused this episode; please don't worry." B. "Most cases of epiglottitis are preventable by standard childhood immunizations." C. "There is nothing you could have done differently; the important thing is that your child is better." D. "Why are you concerned? We are still waiting on the final report from the lab."

Correct Answer: B. "Most cases of epiglottitis are preventable by standard childhood immunizations." It is essential for the nurse to present a calm, soothing, and reassuring attitude toward the parent and child while discussing the parents' concern. The parents will need further teaching about the importance of vaccinations, but the nurse should first address their concerns. The nurse discusses the topic with the parents without placing blame or guilt on the parents for choosing to decline vaccinations for their child. The majority of cases of epiglottitis are caused by Haemophilus influenzae type B (HiB) but may also be caused by other viruses, bacteria, fungi, or trauma. The prevalence of epiglottitis has decreased since the HiB vaccine has been routinely administered beginning at age 2 months. Incorrect Answers: [A. "It's impossible to know for sure what could have caused this episode; please don't worry."] This statement underrates the parents' feelings and demeans their concerns. It may cause the parents to stop sharing their feelings due to fear of being ridiculed or not taken seriously. [C. "There is nothing you could have done differently; the important thing is that your child is better."] This statement minimizes the parents' concern by belittling the parents and indicates that the nurse is unable to empathize with them. [D. "Why are you concerned? We are still waiting on the final report from the lab."] Asking the parents a "why" question implies criticism and makes the parents feel defensive, which could block communication. Educational objective:The prevalence of epiglottitis has decreased since Haemophilus influenzae type b vaccine has been routinely administered beginning at age 2 months. Some cases of epiglottitis are preventable, and parents should be educated on the risks of forgoing vaccinations for their children.

A nurse receives report on a group of clients. Which client should the nurse assess first? A. A preschool-age child with a harsh cough, expiratory wheezes, and mild intercostal retractions B. A toddler playing with small toys who appears in distress, has circumoral cyanosis, and cannot speak C. A toddler with a barking cough, infrequent inspiratory stridor, and oxygen saturation of 94% on room air D. An infant with an axillary temperature of 100.1 F (37.8 C) who is tugging at the left ear

Correct Answer: B. A toddler playing with small toys who appears in distress, has circumoral cyanosis, and cannot speak Aspiration of a foreign body occurs most often in the toddler age group. Swallowing of objects such as buttons, small parts of toys, or food particles can be life-threatening and result in airway obstruction due to the small diameter of the airway. Manifestations include choking, gagging, cyanosis, and inability to speak when the object is lodged in the larynx. Incorrect Answers: [A. A preschool-age child with a harsh cough, expiratory wheezes, and mild intercostal retractions] Although the client has mild retractions with wheezing and a harsh cough, a patent airway is present. This client may be experiencing expected manifestations of asthma, but this is not a life-threatening condition. [C. A toddler with a barking cough, infrequent inspiratory stridor, and oxygen saturation of 94% on room air] The client's manifestations are consistent with laryngotracheobronchitis (croup), which is generally caused by a parainfluenza virus. There is no respiratory challenge indicated by a 94% oxygen saturation on room air, and this not an emergency situation. [D. An infant with an axillary temperature of 100.1 F (37.8 C) who is tugging at the left ear] Otitis media is an infection or inflammation of the middle ear with the highest incidence at age 6-36 months; it occurs during the winter months. Acute onset presents with ear pain, irritability, fever, and pulling on the affected ear. Fluid can accumulate in the middle ear and create an environment for bacterial growth. Respiratory distress is not seen. Educational objective:Using the priorities of airway, breathing, and circulation, maintenance of airway function requires immediate intervention by a nurse.

As the nurse begins to assist with ambulation of a 9-year-old who is one day post appendectomy, the child cries out, "It hurts too much. I can't do it." What is the first action by the nurse? A. Administer an analgesic B. Assess the child's level of pain using a numeric rating scale C. Come back later in the day D. Tell the child, "Get up and walk if you want to go home soon."

Correct Answer: B. Assess the child's level of pain using a numeric rating scale Postoperative pain control is a priority intervention for a child of any age. However, the nurse needs to first perform an assessment of the child's pain to determine the appropriate pharmacological or non-pharmacological measure to implement. This assessment will also provide a baseline against which the effectiveness of the chosen pain relief method can be evaluated. A numeric pain scale can be used with most children who can count and understand the concept of numbers, generally at around age 5. The scale uses a straight line with divisions marked in units from 0-10; 0 is identified as no pain, 5 as moderate pain, and 10 as worst pain. Incorrect Answers: [A. Administer an analgesic] Analgesics (opiates and nonsteroidal antiinflammatory drugs), along with adjuvant analgesics, are appropriate pain control measures in children. However, pain should be assessed before medications are administered. [C. Come back later in the day] Returning later in the day allows the child to rest but does nothing to relieve current pain. [D. Tell the child, "Get up and walk if you want to go home soon."] This non-therapeutic response ignores the child's expressed pain and poses a threat that could be upsetting to the child. Educational objective:When a client is in pain, assessment is the first necessary nursing action. The pain assessment helps to determine the appropriate relief measure and serves as a baseline for evaluating the effectiveness of the chosen pharmacological or non-pharmacological measure.

The nurse is caring for a preschool-age child whose grandparent died 3 days ago. Which intervention is inappropriate? A. Assign the same nurses and caregivers to the child each day B. Avoid mentioning the loved one's death in the child's presence C. Explain the importance of being with the child to the parents D. Schedule time each day for age-appropriate play

Correct Answer: B. Avoid mentioning the loved one's death in the child's presence The preschool-age (3-5 years) child's view of death is related to their developmental stage. They believe death is temporary and reversible, similar to a prolonged nap. The child may ask repeatedly when the deceased individual will return, or they may feel guilty and responsible for the death because of their wishes or thoughts (magical thinking). Talking about the death in simple, accurate terms as often as needed helps the preschool-age child to process their loss. Avoiding discussion of the loved one's death is not therapeutic and may increase anxiety or cause confusion. Incorrect Answer: [A. Assign the same nurses and caregivers to the child each day] Familiar faces are comforting to the child, and consistently assigning the same nurses and caregivers promotes therapeutic relationships and trust. [C. Explain the importance of being with the child to the parents] When considering the idea of death, preschool-age children have significant fear of separation from their parents. Therefore, it is appropriate to explain the importance of remaining with the child as much as possible to the parents. [D. Schedule time each day for age-appropriate play] Play allows the child to cope with grief and provides an outlet to express or work through feelings/experiences that the child may not be able to vocalize. Educational objective:Therapeutic interventions for preschool-age children who are experiencing the death of a loved one include providing familiarity (eg, same nurses, parental presence), ensuring that time each day is devoted to play, and speaking openly to the child about the death as often as needed.

A nurse in a pediatric clinic is collecting data on a 30-month-old child. Which finding requires further evaluation? A. Bladder and bowel control achieved B. Current weight is 6 times greater than birth weight C. Head circumference increased by 1 in (2.5 cm) in the past year D. Resting heart rate is 120 beats per minute

Correct Answer: B. Current weight is 6 times greater than birth weight Weight gain slows during the toddler years with an average yearly weight gain of 4-6 lb (1.8-2.7 kg). By age 30 months, current weight should be approximately 4 times greater than birth weight. A toddler weighing 6 times the initial birth weight requires further evaluation. Family nutrition and meal habits should be discussed. Incorrect Answers: [A. Bladder and bowel control achieved] A toddler achieves bowel and bladder sphincter control by age 24 months as bladder capacity increases. [C. Head circumference increased by 1 in (2.5 cm) in the past year] Head circumference increases by 1 in (2.5 cm) during the second year and then slows to a growth rate of 0.5 in (1.25 cm) per year until age 5. [D. Resting heart rate is 120 beats per minute] A normal pulse in a 30 month old may range from 80 to 140. Educational objective:Weight gain slows during the toddler years. By age 30 months, a toddler's weight should be approximately 4 times greater than the birth weight.

A client diagnosed with acute glomerulonephritis has pitting edema in the lower extremities, a blood pressure of 170/80 mm Hg, and proteinuria. When the practical nurse is assisting in the development of a care plan for this client, which measurement is the most accurate indicator of fluid loss or gain and should therefore be included in the plan? A. Blood pressure measurements B. Daily weight measurements C. Severity of pitting edema D. Strict intake and output measurements

Correct Answer: B. Daily weight measurements The most accurate indicator of fluid loss or gain in an acutely ill client is weight as accurate measuring of intake and output and assessment of insensible losses may be difficult. A 2.2-lb (1-kg) weight gain is equal to 1,000 mL of retained fluid. Incorrect Answers: [A. Blood pressure measurements] Blood pressure measures the amount of pressure exerted on the arterial walls due to factors such as peripheral artery constriction or dilation, not just fluid volume status. [C. Severity of pitting edema] Pitting edema is not an accurate indicator as the fluid may shift from intravascular to interstitial spaces without an overall change in fluid gain or loss throughout the body. Educational objective:The most accurate indicator of fluid loss or gain in an acutely ill client is daily weight measurement.

The school nurse monitors an 8-year-old with a history of asthma. The nurse notes mild wheezing and coughing. Which action should the nurse perform first? A. Call the health care provider B. Determine the client's peak expiratory flow C. Notify the client's parents D. Remind the client about avoiding triggers

Correct Answer: B. Determine the client's peak expiratory flow Symptoms of an asthma exacerbation include wheezing, chest tightness, dyspnea, cough (may be nocturnal, dry, or productive), and retractions. A cough is often the earliest sign of an asthma exacerbation in children. Bronchospasm leads to CO2 trapping and retention. The bronchospasm forces the client to work harder to exhale, and the expiratory phase becomes prolonged. The nurse needs to further monitor this client to validate the severity of the exacerbation before implementing an intervention. By checking the client's peak expiratory flow, the nurse can determine the severity of the symptoms. The nurse will also need to evaluate the client's respiratory rate and lung sounds. Incorrect Answers: [A. Call the health care provider] Additional information is needed to determine the severity of the client's current condition before notifying the health care provider. [C. Notify the client's parents] The client's parents do need to be notified, and a discussion concerning asthma triggers is an important reinforcement of previous teaching by the registered nurse. However, these are not a priority as the client is currently symptomatic. [D. Remind the client about avoiding triggers] The client's parents do need to be notified, and a discussion concerning asthma triggers is an important reinforcement of previous teaching by the registered nurse. However, these are not a priority as the client is currently symptomatic. Educational objective:The nurse must determine the severity of a client's condition before implementing an intervention. By checking this client's peak expiratory flow, the nurse can determine the severity of the asthma symptoms.

A 7-month-old infant is admitted to the unit with suspected bacterial meningitis after receiving an initial dose of antibiotics in the emergency department. Frequent monitoring of which of the following is most important? A. Babinski reflex B. Fontanel assessment C. Pulse pressure D. Pupillary light response

Correct Answer: B. Fontanel assessment Bacterial meningitis is inflammation of the meninges of the brain and spinal cord caused by infection. General manifestations in infants and children age <2 include fever, restlessness, and a high-pitched cry. One common acute complication of bacterial meningitis is hydrocephalus, an increase in intracranial pressure (ICP) resulting from obstruction of cerebrospinal fluid flow. Increased ICP can progress to permanent hearing loss, learning disabilities, and brain damage. Bulging/tense fontanels and increasing head circumference are important early indicators of increased ICP in children. Frequent assessment for developing complications is vital for any client with suspected bacterial meningitis. Incorrect Answer: [A. Babinski reflex] The Babinski reflex can be present up to age 1-2 years and is a normal, expected finding; it does not indicate meningitis. [C. Pulse pressure] Pulse pressure is the difference between systolic and diastolic blood pressures. Widening of pulse pressure is one of the signs of Cushing's triad (systolic hypertension with widened pulse pressure, bradycardia, respiratory depression). These signs occur very late if increased ICP is not treated. Fontanel assessment provides an earlier indication of increased ICP. [D. Pupillary light response] Because meningitis clients are sensitive to light (photophobia), frequent assessment of pupillary light response will be uncomfortable. Severely increased ICP may alter pupillary response; however, this is a late complication of hydrocephalus. Fontanel assessment provides an earlier indication of a developing problem. Educational objective:Infants with bacterial meningitis can develop hydrocephalus. Bulging/tense fontanels and increasing head circumference are important early indicators of increased ICP in children and should be monitored to prevent long-term complications.

A nurse is reinforcing discharge teaching to the parent of a child who is postoperative following a tonsillectomy. Which finding should be reported as a priority? A. Ear pain B. Frequent swallowing C. Low-grade fever D. Objectionable mouth odor

Correct Answer: B. Frequent swallowing Tonsillectomy is usually performed as an outpatient procedure. Postoperative bleeding is an uncommon but important complication and it can last up to 2 weeks. It manifests with frequent or continuous swallowing and/or cough from the trickling blood; some clients may also develop restlessness. Discharge teaching includes: · Avoid coughing, clearing the throat, and blowing the nose to prevent hemorrhage · Limit physical activity · Milk products are discouraged due to their coating effect, which can prompt clearing of the throat · Oral mouth rinses, gargling, and vigorous tooth brushing should be avoided to prevent irritation Incorrect Answer: [A. Ear pain] The presence of slight ear pain, a low-grade fever, and objectionable mouth odor are common findings during the first 5-10 days after the procedure. Persistent moderate-to-severe earache, fever, or cough requires further evaluation. [C. Low-grade fever] The presence of slight ear pain, a low-grade fever, and objectionable mouth odor are common findings during the first 5-10 days after the procedure. Persistent moderate-to-severe earache, fever, or cough requires further evaluation. [D. Objectionable mouth odor] The presence of slight ear pain, a low-grade fever, and objectionable mouth odor are common findings during the first 5-10 days after the procedure. Persistent moderate-to-severe earache, fever, or cough requires further evaluation. Educational objective:Postoperative bleeding after a tonsillectomy is uncommon but can last up to 14 days after surgery. Continuous swallowing, restlessness, and frequent coughing are early indicators of bleeding. To prevent hemorrhage, the client should avoid clearing the throat, blowing the nose, and coughing.

The nurse is caring for an 11-year-old admitted for surgical treatment of a fractured femur who also has attention-deficit hyperactivity disorder, predominantly inattentive type. What is the priority nursing action? A. Encourage the child to keep up with school work B. Give the child a written schedule of daily activities C. Limit the number of visitors D. Reinforce verbal explanations of what to expect during hospitalization

Correct Answer: B. Give the child a written schedule of daily activities Children with attention-deficit hyperactivity disorder (ADHD), predominantly inattentive type, have trouble holding attention on tasks or play activities, experience difficulty organizing tasks and activities, and are easily distracted/side-tracked. They cannot give close attention to detail and dislike and/or avoid tasks that require mental effort over a long period. ` The key nursing intervention to help the child with ADHD adjust to hospitalization is providing a calm, structured, organized, and consistent environment. A written chart or list of daily activities will help remind the child of what to expect and what will happen at any given time. A structured environment helps these children organize their thoughts and activities. Incorrect Answers: [A. Encourage the child to keep up with school work] It is important for the child to keep up with school work to the fullest extent possible to not fall behind. Catching up will be more difficult for a child with ADHD than for a child without the diagnosis. A structured environment can help the child plan time for school work. [C. Limit the number of visitors] It is important that children with ADHD have visitors as they will likely have impaired social skills and may feel socially isolated. However, the number of visitors may need to be limited to avoid an overly distracting environment. [D. Reinforce verbal explanations of what to expect during hospitalization] Verbal explanations of what to expect during hospitalization can be provided in a clear, concise manner that allows the child to ask questions. However, because this child will be easily distracted, will not seem to listen when spoken to directly, and is often forgetful, verbal instructions may not be the most effective communication approach. Educational objective:The most important nursing intervention in caring for a child with attention-deficit hyperactivity disorder is providing a structured, consistent, and organized environment. A written schedule of activities will remind the child what to expect at any given time.

The nurse is planning a client care conference with the parents of a 3-year-old with newly diagnosed type 1 diabetes mellitus. What is the priority outcome for the caregivers? A. Demonstrating adequate coping skills B. Knowing how to keep blood sugars stable C. Understanding how to perform meal planning D. Understanding the need for periodic follow-up visits

Correct Answer: B. Knowing how to keep blood sugars stable Management of type 1 diabetes mellitus requires understanding of blood sugar regulation. If the child becomes hypoglycemic or hyperglycemic, complications could develop. The priority for caregivers should be to focus on the child's safety. Managing the child's blood sugars should be the initial goal. Incorrect Answers: [A. Demonstrating adequate coping skills] Dealing with a new diagnosis will require time. Although acquiring coping skills is important, this is more of a long-term goal. [C. Understanding how to perform meal planning] Consistent menus, appropriate eating times, and adequate intake based on age are all important parts of meal planning. However, checking the child's blood sugars and keeping these stable with the correct insulin dose is the priority. [D. Understanding the need for periodic follow-up visits] Frequent follow-up visits are important to prevent long-term complications of diabetes. However, preventing hypoglycemia and hyperglycemia at home is the priority. Educational objective:Initial teaching of the parents of a child with newly diagnosed type 1 diabetes should focus on basic safety and survival skills, including proper insulin administration and adequate monitoring of blood sugars. Information should be introduced slowly, repeated often, and given based on the child's developmental age.

The nurse is assessing a 4-week-old infant during a routine office visit. Which assessment finding is most likely to alert the nurse to the presence of right hip developmental dysplasia? A. Decreased right hip adduction B. Presence of extra gluteal folds on right side C. Right leg longer than the left leg D. Right pelvic tilt with lordosis

Correct Answer: B. Presence of extra gluteal folds on right side Developmental dysplasia of the hip (DDH) is a set of hip abnormalities ranging from mild dysplasia of the hip joint to full dislocation of the femoral head. Because it is much easier to treat during infancy, DDH screening is a standard assessment for newborns and infants. Manifestations in infants age <2-3 months include: 1. The presence of extra inguinal or thigh folds 2. Laxity of the hip joint on the affected side. Hip laxity/instability is tested through the Barlow and Ortolani maneuvers. However, these tests must only be performed by an experienced health care provider to avoid further hip injury. If DDH is not treated, these signs disappear after age 2-3 months due to the development of muscle contractures. Incorrect Answer: [A. Decreased right hip adduction] Limited hip abduction occurs as contractures develop, particularly once the infant is age >3 months. [C. Right leg longer than the left leg] In children with one-sided DDH, the affected leg may be shorter than the opposite leg. However, this is also apparent after age 3 months. [D. Right pelvic tilt with lordosis] If DDH is not corrected in infancy, additional manifestations develop when the child learns to walk. These signs include a notable limp, walking on the toes, and a positive Trendelenburg sign (pelvis tilts down on unaffected side when standing on the affected leg). In the case of bilateral DDH, the child may also develop a waddling gait and severe lordosis. Educational objective:Screening for developmental dysplasia of the hip is a standard part of infant assessment. Manifestations in infants age <2-3 months include the presence of extra inguinal or thigh folds and laxity of the hip joint on the affected side. After age 3 months, limited hip abduction and limb shortening on the affected side are evident. A pelvic tilt is noted once the child learns to walk.

The nurse cares for a 4-year-old who is on long-term, strict bed rest. Which toy is most appropriate to provide diversion and minimize developmental delays? A. Board games B. Puppets C. Soap bubbles D. Stacking and nesting toys

Correct Answer: B. Puppets Play is an integral part of a child's mastery of emotional, social, and physical development. When a child is hospitalized, play can also serve as a diversion and a way to express stress and anxiety. Preschoolers enjoy play that enables them to imitate others and be dramatic. They have rich imaginations and enjoy make-believe. Their play often centers on imitating adult behaviors by playing dress up and using housekeeping toys, telephones, medical kits, dolls, and puppets. Quiet play appropriate for the preschooler includes finger paints, crayons, illustrated books, puzzles with large pieces, and clay. Through playing with objects such as dolls or puppets, preschoolers can often process fears and anxieties that are difficult for them to express. Incorrect Answer: [A. Board games] Board games are appropriate for children of school age, when play becomes more complex and competitive. [C. Soap bubbles] Soap bubbles are appropriate for toddlers, who learn from tactile play and environmental exploration. [D. Stacking and nesting toys] Stacking and nesting toys are appropriate for toddlers who are developing fine motor skills. Educational objective:Play serves as an important part of children's emotional, social, and physical development. It is important that they be provided with toys that can help them achieve developmental tasks. Appropriate toys for preschoolers are those that encourage imitation of adults, such as dolls, puppets, imaginative toys, dress-up clothing, medical kits, cars, and planes.

A nurse is discussing parallel play with the parent of a 2-year-old. Which statement by the parent indicates understanding of the discussion? A. "I encourage working in a group to build towers with large blocks." B. "I have a chalk board available to teach the alphabet and numbers." C. "I set out a basket of various balls in the backyard when other children come to play." D. "I try to organize games that involve a team approach."

Correct Answer: C. "I set out a basket of various balls in the backyard when other children come to play." Parallel play is typical behavior of a toddler and involves activities focused on improving motor skills, imitative efforts, and the use of multiple senses. Toddlers play alongside, rather than with, other children. Having a variety of different balls for a group of children allows each child to be present with others and participate as they desire. Other examples of parallel play activities include pushing and pulling large toys; smearing paint; playing with dolls or toy cars; and digging in a sandbox. Incorrect Answer: [A. "I encourage working in a group to build towers with large blocks."] Working in groups is an appropriate play activity for children in the preschooler period. [B. "I have a chalk board available to teach the alphabet and numbers."] The classroom approach does not promote parallel play. Using large chalk to draw allows the child creative expression in an unstructured manner. [D. "I try to organize games that involve a team approach."] A toddler is challenged by the concept of team games, which requires attention to the group's effort. Educational objective:Toddlers engage in parallel play, which involves playing alongside, not with, other children. Activities such as playing with dolls or toy cars, pushing and pulling large toys, smearing paint, and digging in a sandbox encourage parallel play.

The practical nurse (PN) is collaborating with the registered nurse to conduct a developmental assessment of a 7-month-old client during a well-child visit. Which statement by the infant's parent should cause the PN concern? A. "I get embarrassed if my child screams when approached by unfamiliar people." B. "I thought my child would be sitting without needing their hands for support by now." C. "I wonder when my child will put their pacifier to their mouth without my help." D. "It seems odd that my child says 'mama' and 'dada' to strangers."

Correct Answer: C. "I wonder when my child will put their pacifier to their mouth without my help." Developmental milestones mark the achievement of expected patterns of growth and development by a specific age and are assessed at routine well-child visits. Although each child's growth and development are unique, follow-up with a health care provider is necessary for suspected delays. Infants should develop certain fine motor skills (eg, grasp) such as using their hands to bring objects to their mouth by age 4-5 months and purposefully grasping objects by age 5 months. If, by age 7 months, an infant does not use their hands to bring a pacifier or other objects (eg, toys) to their mouth, then further assessment is required. Incorrect Answers: [A. "I get embarrassed if my child screams when approached by unfamiliar people."] Stranger anxiety begins around age 6-8 months and demonstrates age-appropriate social development. Some infants cry loudly whereas others become quiet and stare fearfully at strangers. [B. "I thought my child would be sitting without needing their hands for support by now."] Sitting alone while using the hands for support (ie, tripod sitting) is expected for a 7-month-old client. This demonstrates age-appropriate gross motor development. Sitting alone without support occurs by age 8-9 months. [D. "It seems odd that my child says 'mama' and 'dada' to strangers."] By age 6-7 months, the infant may imitate sounds (eg, "mama," "dada") without knowing the meaning of words. This demonstrates age-appropriate vocal development. Comprehension of some words occurs around age 10 months. Educational objective:Infants should develop certain fine motor skills (eg, grasp) such as using their hands to bring objects to their mouth by age 4-5 months. If a delay is suspected in this developmental milestone, further assessment by the health care provider is necessary.

The clinic nurse is interviewing the parents of a 6-month-old client about the infant's diet. Which statement by the parents is most concerning? A. "Because apples are healthy, we make apple pie and feed small, soft bites to our baby." B. "If our baby refuses to finish foods, we continue to offer small bites, so food isn't wasted." C. "Infant oatmeal sweetened with fresh honey is our baby's favorite breakfast." D. "We found that the food in TV dinners can be easily pureed and is convenient."

Correct Answer: C. "Infant oatmeal sweetened with fresh honey is our baby's favorite breakfast." Clostridium botulinum spores in honey or soil can colonize an infant's immature gastrointestinal system and release a toxin that causes botulism, a rare but serious illness. The toxin attacks the neuromuscular system, causing progressive muscle paralysis that can potentially lead to respiratory failure and death. Initial manifestations may include constipation, generalized weakness, difficulty feeding, and decreased gag reflex. Iron-fortified infant cereals (eg, oatmeal) mixed with formula or breastmilk are appropriate for infants >6 months; however, honey (especially raw or wild) is not recommended for infants age <12 months due to the risk of botulism. Incorrect Answers: [A. "Because apples are healthy, we make apple pie and feed small, soft bites to our baby."] Although apple pie adds excessive amounts of fat and sugar to the infant's diet, this is not the priority over honey, which can be life-threatening. [B. "If our baby refuses to finish foods, we continue to offer small bites, so food isn't wasted."] Small portions (<1 tablespoon) of solid food are appropriate for infants. Continuing to feed an infant who acts disinterested in food (eg, turns away) can contribute to future obesity. The nurse should explore this behavior further; however, the priority is to address the danger of feeding an infant honey. [D. "We found that the food in TV dinners can be easily pureed and is convenient."] TV dinners and various canned foods have high sodium and sugar content and therefore are not the best sources of nutrition for an infant. However, TV dinners are not immediately life threatening. Educational objective:Clostridium botulinum spores in honey can colonize an infant's (age <12 months) immature gastrointestinal system and release a toxin that causes botulism, a rare but potentially life-threatening illness.

The mother of a 6-year-old child with cystic fibrosis (CF) has received instruction on the use of pancreatic enzymes. Which statement made by the mother indicates a need for further teaching? A. "I need to monitor the total amount of this medication that I give to my child every day." B. "I should give this medication with or just before my child has a meal or snack." C. "It is okay for my child to chew this medication." D. "It is okay to open the capsule and sprinkle the medicine on a tablespoon of applesauce."

Correct Answer: C. "It is okay for my child to chew this medication." In CF, unusually thick mucus obstructs the pancreatic ducts, preventing pancreatic enzymes (amylase, trypsin, and lipase) from reaching the small intestine. The result is malabsorption of carbohydrates, fats, and proteins; the inability to absorb fat-soluble vitamins (A, D, E, and K) is of particular concern. Gastrointestinal signs and symptoms of CF include flatulence, abdominal cramping, ongoing diarrhea, and/or steatorrhea. Nutritional therapy includes the administration pancreatic enzyme supplements with or just before every meal or snack. These enzymes are enteric-coated beads designed to dissolve only in an alkaline environment similar to that of the small intestine. They must not be mixed with a substance that would cause them to dissolve prior to reaching the jejunum. Capsule contents may be sprinkled on applesauce, yogurt, or acidic, soft, room-temperature foods with pH <4.5. Capsules should be swallowed whole and not crushed or chewed; chewing the capsules could cause irritation of the oral mucosa. Excessive intake of pancreatic enzymes can result in fibrosing colonopathy. This is a true statement; some children have difficulty taking a whole capsule. Capsule contents can be sprinkled in acidic substances such as applesauce. Capsules should not be taken with milk as they can cause it to curdle. Educational objective:Pancreatic enzyme supplements are used to aid the absorption of carbohydrates, fats, and proteins in a child with CF. They are taken with or just before every meal (not as needed); should be swallowed whole or sprinkled on an acidic food; and should not be crushed or chewed. They should not be taken with milk. Excessive intake could result in fibrosing colonopathy.

A 5-year-old child is receiving morphine sulfate for pain. Which statement by the caregiver indicates that further teaching is necessary? A. "I will call the nurse if my child begins to act aggressively." B. "I'm concerned that my child thinks the pain is punishment." C. "My child is playing and so does not need pain medication." D. "The FACES pain scale seems to be working very well."

Correct Answer: C. "My child is playing and so does not need pain medication." The child who is playing or sleeping might still be experiencing pain but is using distraction as a coping mechanism. This statement by the caregiver indicates that further teaching is needed. Incorrect Answers: [A. "I will call the nurse if my child begins to act aggressively."] Preschool-age children may become physically or verbally aggressive when in pain. [B. "I'm concerned that my child thinks the pain is punishment."] The preschool-age child experiences magical thinking and might feel that pain is a punishment for wrongdoing. [D. "The FACES pain scale seems to be working very well."] Age-appropriate pain scales can be used to assess pain in children. The FACES pain rating scale consists of 6 cartoon faces with expressions from no pain to worst pain. Educational objective:A child's expression of pain varies based on developmental stage and past experiences with pain. The nurse should use age-appropriate pain scales. A child who is asleep or playing may be experiencing pain.

The parents of a 4-year-old tell the nurse that the child won't go to sleep at night due to fear of tigers living under the bed. Which response by the nurse is most helpful? A. "Have you recently visited the zoo? Maybe the tigers looked scary." B. "If you agree with your child, the fears could continue through this developmental stage." C. "Night fears are common at this age. Look under the bed with your child." D. "This is very unusual. Maybe the child saw something scary on TV."

Correct Answer: C. "Night fears are common at this age. Look under the bed with your child." Preschool children (age 3-5) are magical thinkers. Night fears are common during this period, and distinguishing between reality and fantasy is difficult. It is appropriate for parents to acknowledge the child's fears. A preschooler would be comforted and fears would be allayed if the parents looked under the bed and reassured the child that no tigers were there. Incorrect Answers: [A. "Have you recently visited the zoo? Maybe the tigers looked scary."] This reply does not educate the parents about normal growth and development. It is not a therapeutic response. [B. "If you agree with your child, the fears could continue through this developmental stage."] Fantasy fears are normal during the preschool years. They are not common during other developmental periods. [D. "This is very unusual. Maybe the child saw something scary on TV."] The parents should be told that magical thinking is common during the preschool period. This is not an accurate or therapeutic response. Educational objective:Magical thinking is common during the preschool period. It is not unusual for a child to have an imaginary friend, and parents should be taught that this is a normal part of development. Magical thinking satisfies children's questions about the world they live in.

The nurse has been providing care for the past month to a 7-year-old client recently diagnosed with type 1 diabetes mellitus. Initially, the family seemed devastated about the diagnosis and the client's parent stated, "Our lives will never be the same." Which statement made by the parent indicates that nursing interventions and education have been effective? A. "Our child will not be able to participate in any sporting events." B. "Our whole family will have to make sacrifices to deal with this disease." C. "We are working to manage this disease so that it cannot control our child's life." D. "We have set aside a place in the pantry for our child's special foods."

Correct Answer: C. "We are working to manage this disease so that it cannot control our child's life." Parents experience a variety of emotions when a child is diagnosed with a chronic illness (eg, diabetes mellitus). Reactions include shock, denial, helplessness, anger, fear, anxiety, and often guilt about perceived contribution or failure to prevent the development of the disease. Parents' emotional response, adaptation, and coping strategies impact the child's perception of self and ability to manage the disease. In providing diabetes education, the nurse should emphasize that with planning and preparation, diabetes can be managed and controlled and the child can resume regular day-to-day activities and have an independent life. Incorrect Answers: [A. "Our child will not be able to participate in any sporting events."] Clients with diabetes can participate in a wide variety of sports and should continue pursuing age-appropriate physical activities. [B. "Our whole family will have to make sacrifices to deal with this disease."] The diagnosis and management of diabetes in a child can affect the whole family; however, the word "sacrifice" suggests that the parent is feeling victimized by the disease. [D. "We have set aside a place in the pantry for our child's special foods."] Nutritional management of diabetes does not require special foods. Nutrition education should emphasize healthy food choices, consistent amounts of carbohydrates, and a balance of food choices, with insulin and exercise for blood glucose control. Educational objective:The diagnosis of a chronic illness (eg, diabetes) in a child will have an impact on the entire family. When parents see themselves and the child as capable of being independent and in control of the disease, there is an increased likelihood that the disease will be managed and controlled and the child can have an independent life.

A 10-year-old is implementing behavioral strategies to manage nocturnal enuresis. The client tells the nurse, "I want to go to sleep-away camp during the summer, but if I have an 'accident,' I'm afraid that other kids will tease me." What is the best response by the nurse? A. "Don't worry. Your problem will be resolved by then." B. "It would be better if you thought about going to day camp instead." C. "We can ask your health care provider about a medication trial that may help." D. "You could always wear a pull-up just in case."

Correct Answer: C. "We can ask your health care provider about a medication trial that may help." Pharmacological interventions are often used as second-line treatment for nocturnal enuresis in children age >5 years; this is done when there has been little or no response to behavioral approaches and/or when short-term improvement of enuresis is desired for attending sleepovers or overnight camp. A trial run is usually done at least 6 weeks before camp to determine the appropriate drug dose and effectiveness. However, there is a high risk of relapse once the drug is discontinued. Medications used to treat nocturnal enuresis include the following: 1. Desmopressin reduces urine production during sleep. 2. Tricyclic antidepressants such as imipramine, amitriptyline, and desipramine improve functional bladder capacity. Incorrect Answers: [A. "Don't worry. Your problem will be resolved by then."] This statement gives the client false reassurance. Although nocturnal enuresis resolves eventually, there is no guaranteed time frame. [B. "It would be better if you thought about going to day camp instead."] This response ignores the child's desire to go to overnight camp and dismisses any possibility of helpful treatment. [D. "You could always wear a pull-up just in case."] Wearing a pull-up could embarrass the child at overnight camp. Educational objective:Pharmacological interventions such as desmopressin and tricyclic antidepressants are often used for nocturnal enuresis treatment in children age >5 years when there has been little or no response to behavioral approaches and/or when short-term improvement of enuresis is desired for attending sleepovers or overnight camp.

A distraught parent informs the nurse of bleeding in a 1-day-old girl. What is an appropriate response by the nurse after finding a small amount of bloody mucus in the newborn's diaper? A. "Laboratory work will need to be completed to determine your newborn's hormone levels." B. "The health care provider will prescribe a dose of medication to stop the bleeding." C. "We will continue to monitor the amount, color, and consistency of the drainage." D. "What visitors have been present since the baby was born?"

Correct Answer: C. "We will continue to monitor the amount, color, and consistency of the drainage." Mammary gland enlargement, non-purulent vaginal discharge (leukorrhea), and mild uterine withdrawal bleeding (pseudomenstruation) are benign transient findings commonly seen in newborns; these are physiologic responses to transplacental maternal estrogen exposure. Reassurance should be provided. Monitoring the amount, color, and consistency is the appropriate action. Incorrect Answer: [A. "Laboratory work will need to be completed to determine your newborn's hormone levels."] The blood-tinged mucus will cease within a few days after birth when hormone levels return to normal. No additional workup or medications are indicated. [B. "The health care provider will prescribe a dose of medication to stop the bleeding."] The blood-tinged mucus will cease within a few days after birth when hormone levels return to normal. No additional workup or medications are indicated. [D. "What visitors have been present since the baby was born?"] Pseudomenstruation is a physiological process and is not caused by trauma or abuse. Educational objective:Mammary gland enlargement, non-purulent vaginal discharge (leukorrhea), and mild uterine withdrawal bleeding (pseudomenstruation) are benign transient findings commonly seen in newborns; they are physiologic responses to transplacental maternal estrogen exposure. Reassurance should be provided.

The clinic nurse is caring for several clients during well-child visits. The nurse should recognize which client as being the most at risk for anemia? A. 1-month-old infant born at term gestation who exclusively breastfeeds B. 2-month-old infant born at preterm gestation who exclusively receives iron-fortified formula C. 3-month-old infant born at preterm gestation who is exclusively bottle-fed with breastmilk D. 6-month-old infant born at term gestation who breastfeeds and eats iron-fortified infant cereal

Correct Answer: C. 3-month-old infant born at preterm gestation who is exclusively bottle-fed with breastmilk Iron deficiency during infancy causes reduced hemoglobin production, resulting in anemia, decreased immune function, and delayed growth and development. During gestation, the fetus stores iron received from the mother; the amount of iron stored is dependent on the length of gestation. After birth, iron stores are progressively depleted and nutritional sources of iron are eventually required. Infants born at preterm gestation have less time in utero to accumulate iron. Preterm infants typically deplete iron stores by age 2-3 months and require additional iron supplementation (eg, oral iron drops, iron-fortified formula). Therefore, a 3-month-old infant born at preterm gestation who is exclusively receiving breastmilk is most at risk for anemia. Incorrect Answers: [A. 1-month-old infant born at term gestation who exclusively breastfeeds] Infants born at term gestation have sufficient iron stores for the first 4-6 months of life. However, infants receiving exclusively breastmilk require iron supplementation (eg, oral iron drops) around age 4 months until food sources of iron (eg, iron-fortified infant cereal) are adequate around age 6 months. [B. 2-month-old infant born at preterm gestation who exclusively receives iron-fortified formula] Although this client is at risk for anemia due to preterm gestation, the risk decreases due to intake of iron-fortified formula. The iron content of most infant formulas is adequate for the first 12 months of life. [D. 6-month-old infant born at term gestation who breastfeeds and eats iron-fortified infant cereal] Infants born at term gestation have sufficient iron stores for the first 4-6 months of life. However, infants receiving exclusively breastmilk require iron supplementation (eg, oral iron drops) around age 4 months until food sources of iron (eg, iron-fortified infant cereal) are adequate around age 6 months. Educational objective:During gestation, the amount of iron a fetus stores is dependent on the length of gestation. Infants born at preterm gestation have lower iron stores at birth and are at an increased risk for iron-deficiency anemia. Iron supplementation (eg, oral iron drops, iron-fortified formula) is usually needed by preterm infants at an earlier age (2-3 months).

The nurse is reinforcing teaching about how to use a metered-dose inhaler to a 9-year-old with asthma. Place the nurse's instructions in the appropriate order. All options must be used. 1. Exhale completely 2. Deliver one puff of medication into spacer 3. Place lips tightly around the mouth piece 4. Rinse mouth 5. Shake the inhaler and attach it to spacer 6. Take a slow deep breath and hold it for 10 seconds A. 5, 3, 1, 2, 6, 4 B. 5, 2, 1, 3, 6, 4 C. 5, 1, 3, 2, 6, 4 D. 1, 5, 2, 3, 6, 4

Correct Answer: C. 5, 1, 3, 2, 6, 4 The proper method of delivering a dose via metered-dose inhaler (MDI) includes the following: 1. First shake the MDI and attach it to the spacer 2. Exhale completely to optimize medication inhalation 3. Place lips tightly around the mouthpiece 4. Deliver a single puff of medication into spacer 5. Take a slow deep breath and hold it for 10 seconds to allow for effective medication distribution 6. Rinse mouth with water to remove any leftover medication from oral mucous membranes. Spit out the water to ensure no medication is swallowed Educational objective:Any child under age 12 with asthma should use a spacer with a metered-dose inhaler (MDI) to ensure that the entire dose is inhaled. The child should shake the MDI, attach it to the spacer, exhale completely, place lips tightly around the mouthpiece, deliver a single puff of medication, take a slow deep breath and hold it for 10 seconds, and rinse the mouth with water following dose intake.

The practical nurse is collecting data on 4 infants in the pediatric unit. Which assessment finding would the practical nurse report to the registered nurse? A. 3-week-old whose anterior fontanelle bulges slightly with crying B. 4-week-old whose posterior fontanelle is flat and soft C. 6-month-old with birth weight of 7 lb 3 oz (3.3 kg) who now weighs 12 lb (5.4 kg) D. 12-month-old with birth weight of 6 lb 4 oz (2.8 kg) who now weighs 20 lb (9.1 kg)

Correct Answer: C. 6-month-old with birth weight of 7 lb 3 oz (3.3 kg) who now weighs 12 lb (5.4 kg) Infant growth is fast paced during the first year of life, with birth weight doubling by age 6 months and tripling by age 12 months. In addition, birth length increases by approximately 50% during the first year. An infant who does not meet expected length/weight milestones should be reported to the registered nurse for further assessment. Incorrect Answers: [A. 3-week-old whose anterior fontanelle bulges slightly with crying] At birth, the infant has non-ossified membranes called fontanelles; these "soft spots" lie between the bones of the cranium. The anterior and posterior fontanelles are soft, non-fused, and the most noticeable. Fontanelles should be flat, but slight pulsations visible in the anterior fontanelle are normal, as is temporary bulging when the infant cries, coughs, or is lying down. The posterior fontanelle fuses by age 2 months, and the anterior fontanelle fuses by age 18 months. [B. 4-week-old whose posterior fontanelle is flat and soft] At birth, the infant has non-ossified membranes called fontanelles; these "soft spots" lie between the bones of the cranium. The anterior and posterior fontanelles are soft, non-fused, and the most noticeable. Fontanelles should be flat, but slight pulsations visible in the anterior fontanelle are normal, as is temporary bulging when the infant cries, coughs, or is lying down. The posterior fontanelle fuses by age 2 months, and the anterior fontanelle fuses by age 18 months. [D. 12-month-old with birth weight of 6 lb 4 oz (2.8 kg) who now weighs 20 lb (9.1 kg)] This assessment shows tripling of the birth weight by age 12 months, a normal finding. Educational objective:Infants should double in birth weight by age 6 months and triple in birth weight by age 12 months. An infant who does not meet expected length or weight milestones should be reported to the registered nurse for further assessment. Fontanelles should be flat, but slight pulsation or temporary bulging of the anterior fontanelle when the infant cries, coughs, or is lying down is considered normal.

A 15-year-old client with type 1 diabetes mellitus is admitted to the hospital with a blood glucose of 460 mg/dL (25.6 mmol/L). Based on this information, the nurse understands that which factor is contributing to this client's noncompliant behavior? A. Client has limited understanding of the disease process B. Client is depressed and wants to die C. Client's psychosocial developmental stage D. Lack of supervision by the client's caregivers

Correct Answer: C. Client's psychosocial developmental stage Certain behaviors are common in the adolescent period, ages 11 (early adolescence) to 20 (late adolescence). Teenagers engage in risk-taking behaviors and want to be just like their peers. Adolescents with chronic disease may have difficulty managing their illness due to a false sense of security and the belief that they are invincible. Incorrect Answers: [A. Client has limited understanding of the disease process] An adolescent is fully able to understand disease management, including risks of noncompliance, but may choose to ignore the issue out of a desire to be like peers. [B. Client is depressed and wants to die] Although this client may not currently be managing the disease well, there is no indication that the child is suicidal. [D. Lack of supervision by the client's caregivers] It is unrealistic to expect the parents of an adolescent with diabetes mellitus to monitor the child's diet. Teenagers have developed their own code of behavior and need independence. Educational objective:Adolescence in psychosocial development is marked by risk-taking behaviors, a sense of invincibility, the need for independence, and a strong connection to peers.

The nurse is caring for an infant with suspected meningitis and preparing to assist with a lumbar puncture. What is the appropriate nursing intervention? A. Administer oxygen via nasal cannula for client comfort and safety B. Clean area with povidone iodine in a circular motion moving outward C. Hold the child with the head and knees tucked in and the back rounded out D. Monitor and record vital signs every 15 minutes throughout the procedure

Correct Answer: C. Hold the child with the head and knees tucked in and the back rounded out The optimal position for access during a lumbar puncture is to have the client's head and knees tucked in and the back rounded out. This provides the most room for the health care provider (HCP) to perform the procedure and allows for a good hold to keep the client still. A lumbar puncture is a sensitive procedure, and it is important to keep the child from moving during needle insertion. Incorrect Answer: [A. Administer oxygen via nasal cannula for client comfort and safety] Unless the client has improper air exchange, oxygen administration is not needed. The nasal cannula will most likely bother the child and lead to unnecessary movement during needle placement. [B. Clean area with povidone iodine in a circular motion moving outward] The HCP performing the lumbar puncture will feel the spine for correct needle placement and then sterilize and prepare the chosen area for needle insertion. [D. Monitor and record vital signs every 15 minutes throughout the procedure] Unless the client is unstable, there is no need to record vital signs every 15 minutes. The client should be awake and alert, and the procedure should be fairly short in duration. Educational objective:Performing a lumbar puncture on a child is a very sensitive procedure that requires accuracy. The correct position and ability to hold the child still are important to achieve the best result and minimize the risk for complications.

The practical nurse monitoring a 3-year-old finds dyspnea, high fever, irritability, and open-mouthed drooling with leaning forward. The parents report that the symptoms started rather abruptly. The client has not received age-appropriate vaccinations. Which set of actions should the practical nurse anticipate? A. 20-gauge needle insertion at the mid-axillary line for pleural aspiration B. 4 L oxygen at 100% per nasal cannula with bilevel positive airway pressure ventilation standing by C. Intubation in the operating room with a prepared tracheotomy kit standing by D. Nebulized racemic epinephrine with a pediatric anesthesiologist standing by

Correct Answer: C. Intubation in the operating room with a prepared tracheotomy kit standing by Epiglottitis should be considered first in a 3- to 7-year-old with acute respiratory distress, toxic appearance (eg, sitting up, leaning forward, drooling), stridor, and high-grade fever. Tachycardia and tachypnea are also present. The complications of epiglottitis are serious and include sudden airway obstruction. Epiglottitis is a pediatric emergency and should be managed with endotracheal intubation. However, intubating such clients is difficult, and as a result, preparation for possible tracheostomy is also standard. Incorrect Answers: [A. 20-gauge needle insertion at the mid-axillary line for pleural aspiration] This is a recommended therapy for spontaneous tension pneumothorax, which is demonstrated by tracheal deviation, absent lung sounds, and severe abrupt hypotension and dyspnea. [B. 4 L oxygen at 100% per nasal cannula with bilevel positive airway pressure ventilation standing by] Neither oxygenation nor bilevel positive airway pressure is acceptable in acute epiglottitis as the trachea can close completely due to edema. [D. Nebulized racemic epinephrine with a pediatric anesthesiologist standing by] This is the appropriate therapy for croup, not epiglottitis. Croup presents with a characteristic hacking cough, which is absent in epiglottitis. Educational objective:When assessing a client with symptoms suggestive of epiglottitis (eg, acutely ill, drooling, leaning forward, dyspnea), the nurse should prepare for an emergency airway.

The practical nurse is assisting the registered nurse in performing well-child examinations in a pediatric clinic. Which finding requires further evaluation? A. Bilateral bowlegs (genu varum) in a 15-month-old B. Chest rounded with the anteroposterior diameter equal to the lateral diameter in an infant C. Lateral curvature to the spine noted on examination of a 10-year-old girl D. Presence of an S3 heart sound in a 2-year-old

Correct Answer: C. Lateral curvature to the spine noted on examination of a 10-year-old girl The findings in this client indicate scoliosis, one of the most commonly diagnosed spinal deformities characterized by lateral curvature of the spine and spinal rotation. Although scoliosis may result from congenital or pathologic conditions, it is most often idiopathic. The condition is commonly first noticed during periods of rapid growth, particularly during early adolescence in girls. Screenings may occur in schools or at well-child office visits for girls age 10-12 years and for boys age 13-14 years. Early detection and prompt treatment may reduce the need for surgical intervention. Incorrect Answers: [A. Bilateral bowlegs (genu varum) in a 15-month-old] Genu varum (bowlegs), the lateral bowing of the legs, is common in toddlers as they learn to walk. The condition resolves 18-24 months after they develop strength in their legs and lower back. After 2 years, normal alignment will again progress to valgus deformity until age 4 years and then will return to normal adult alignment by age 7 years. All of this is a normal physiologic alignment. [B. Chest rounded with the anteroposterior diameter equal to the lateral diameter in an infant] A rounded, nearly circular chest shape with the front-to-back (anteroposterior) diameter approximately equal to the side-to-side (lateral) diameter is an expected finding in a healthy infant. The chest is more oval and the lateral diameter is greater than the anteroposterior diameter by age 2 years. [D. Presence of an S3 heart sound in a 2-year-old] An S3 heart sound, reflecting rapid filling of the left ventricle, is considered normal when heard in children. S3 is a dull, low-pitched sound heard in diastole immediately after S2 but heard louder in the mitral or apical area, which distinguishes it from a split S2 that is best heard in the pulmonic area. Educational objective:An S3 heart sound is a normal finding in children. Bowlegs are common until age 18-24 months. Scoliosis is always abnormal, and its early detection and prompt treatment may reduce the need for surgical intervention.

The nurse is reviewing a nutritional plan for a 6-month-old who has recently been started on solid foods. Which of the following recommendations has the highest priority in the plan? A. Canned baby food is more expensive than food prepared at home B. Finger foods can be introduced before the child has teeth C. New foods should be introduced at least 5-7 days apart D. Rice cereal can be mixed with cow's milk to increase nutritional intake

Correct Answer: C. New foods should be introduced at least 5-7 days apart The introduction of solid foods generally occurs at 4-6 months. The process usually starts with a form of iron-fortified infant cereal, such as rice or oatmeal. Cereal can be mixed with breast milk, formula, or water. When introducing new foods, it is important to allow 5-7 days between foods to observe for any allergies to a particular food. Allergic responses often worsen with subsequent exposure, so it is a priority to identify food triggers as soon as possible. Incorrect Answers: [A. Canned baby food is more expensive than food prepared at home] A mashed portion of soft fruits or fully cooked vegetables made at home is less expensive than commercially prepared baby food. Carrots, peas, and bananas are examples of early foods that are simple to prepare. However, this is not the highest priority. [B. Finger foods can be introduced before the child has teeth] When an infant reaches age 6-8 months, pureed fruits and vegetables are introduced to provide needed vitamins. After introducing purees, it is also appropriate to begin offering simple finger foods, such as teething crackers and small pieces of fruit, soft vegetables, or cheese. These foods help children develop motor skills and learn to chew, even before they have teeth. [D. Rice cereal can be mixed with cow's milk to increase nutritional intake] Cow's milk is not introduced until after the first year because it lacks crucial vitamins and minerals for appropriate growth and is also more difficult for an infant to digest. Educational objective:Solid foods are introduced at age 4-6 months, beginning with iron-fortified cereal and progressing to soft fruits and vegetables. 5 to 7 days should elapse before a new food is introduced to observe for allergies. Simple finger foods may be introduced at age 6-9 months. Cow's milk should not be introduced until after age 1 year.

The nurse is caring for an infant with osteogenesis imperfecta admitted with a new fracture. The client also has old fractures in multiple stages of healing but no bruising, abrasions, or redness of the skin. Which nursing intervention should be included in the plan of care? A. During diaper changes, carefully lift the infant by the ankles B. Lift from under the arms when picking up the infant C. Obtain blood pressure manually to avoid cuff over-tightening D. Request a social work consultation to assess for child abuse

Correct Answer: C. Obtain blood pressure manually to avoid cuff over-tightening Osteogenesis imperfecta (OI) (brittle bone disease) is a rare genetic condition resulting in impaired synthesis of collagen by osteoblasts. Collagen allows bone to be somewhat flexible while still maintaining strength. Impaired collagen causes bones to be frail and easily fractured. Clinical manifestations can range from mild defects to lethal disease in utero. OI is usually transmitted by autosomal dominant inheritance. The nurse's priority for a client with OI is careful handling to minimize additional fractures. Care of the infant with OI includes: · Checking blood pressure manually to avoid cuff over-tightening, which may occur with automatic blood pressure cuffs · Lifting the infant by slipping a hand under the broadest areas of the body (eg, back, buttocks) so the pressure is distributed · Repositioning the infant frequently using supportive devices and gel padding to avoid molding of the soft bones of the skull Incorrect Answers: [A. During diaper changes, carefully lift the infant by the ankles] Lifting by the ankles or under the arms puts too much pressure on the delicate bones (eg, legs, ribcage). [B. Lift from under the arms when picking up the infant] Lifting by the ankles or under the arms puts too much pressure on the delicate bones (eg, legs, ribcage). [D. Request a social work consultation to assess for child abuse] Nonaccidental traumas with fractures (eg, child abuse) are usually associated with soft-tissue injury (eg, bruising, abrasions, redness) from the force of an external source. Educational objective:Osteogenesis imperfecta (brittle bone disease) is a rare genetic condition resulting in fragile bones and frequent fractures. The nurse should use careful handling (eg, checking blood pressure manually, distributing pressure when lifting the infant, using supportive devices) to minimize additional fractures and prevent molding of soft bones (eg, skull).

A nurse is caring for a 2-year-old with a new diagnosis of strabismus. Which intervention should the nurse anticipate? A. Eye drops in the abnormal eye B. Measurement of intraocular pressure (IOP) C. Patching the stronger eye D. Correction with laser surgery

Correct Answer: C. Patching the stronger eye Strabismus (crossed eyes) is a disorder involving misalignment of the eyes caused by a congenital defect or acquired weakness of an eye muscle. One eye may appear deviated inward (esotropia) or outward (exotropia). When the visual axes are not in alignment, the brain perceives 2 images (diplopia) and suppresses the weaker image to compensate. If left untreated by age 4-6, permanent reduction or loss of visual acuity in the affected eye (amblyopia) can occur. Initial treatments vary depending on the underlying cause. One common treatment is to strengthen the muscles of the weaker eye by wearing a patch over the stronger eye or using special corrective lenses. If nonsurgical methods are unsuccessful, surgical intervention to shorten or reposition an eye muscle for more effective movement may be required. Incorrect Answers: [A. Eye drops in the abnormal eye] The use of eye drops in the abnormal eye is not an effective treatment for strabismus. Some uncommon treatments of strabismus may include drops in the normal/stronger eye to blur the vision and increase use of the weaker eye. Eye drops are more commonly used to treat glaucoma. [B. Measurement of intraocular pressure (IOP)] Monitoring of IOP would be necessary in a client with glaucoma. Strabismus is not associated with abnormal IOP. [D. Correction with laser surgery] Surgical repair of strabismus involves changes to the muscles controlling the eye and does not utilize a laser. Laser surgery is an appropriate treatment for refractive errors, such as myopia, hyperopia, or astigmatism. Educational objective:Strabismus is a disorder involving misalignment of the eyes (eg, one eye deviated inward or outward) caused by a congenital or acquired defect of an eye muscle. Treatment of strabismus may include wearing a patch over the stronger eye to develop strength in the weaker eye.

A nurse is planning to test the visual acuity of a 7-year-old. Which is the best way to test visual acuity in this child? A. Have the child focus on a bright object and follow the target B. Have the child view a set of cards one at a time C. Position the child at a distance of 10 ft (3 m) from a chart D. Shine a light into the child's eyes at a distance of 16 in (40.6 cm)

Correct Answer: C. Position the child at a distance of 10 ft (3 m) from a chart Visual acuity testing in children ages 6 and older is generally assessed by use of the Snellen letter chart. The child is positioned 10 ft (3 m) from the chart and asked to read the letters, beginning with the lines of large text to small text. Standard testing for visual acuity is at 20 ft (6 m); however, the American Academy of Pediatrics recommends testing at 10 ft as it is easier to maintain the child's attention and provides a more accurate result. If the child wears glasses, they remain in place. Both eyes should remain open while one eye at a time is covered to read the chart. The child must identify 4 of 6 letters in each line before moving to the next. A referral to an ophthalmologist is made if a child is unable to identify 4 correct letters on the 10/15 line (equivalent to 20/30 vision) with either eye. Incorrect Answers: [A. Have the child focus on a bright object and follow the target] Following a target, usually a bright-colored object or a human face, is a method of testing visual acuity and fixation in infants. If visual fixation and following are not present by age 3-4 months, referral to a formal ophthalmic examination is needed. [B. Have the child view a set of cards one at a time] Viewing a set of cards one at a time is a test of color vision deficits, not visual acuity. [D. Shine a light into the child's eyes at a distance of 16 in (40.6 cm)] The corneal light reflex is tested by shining a light held 16 in (40.6 cm) from the child's eyes. Although this is not the best option, it can be used to test vision in newborns. The nurse observes blink response, alertness, and following the light to the middle. Educational objective:Distance visual acuity of children age 6 or older is best assessed by asking the child to read letters from the Snellen letter chart using one eye at a time. The child should be able to identify 4 out of 6 letters on the 10/15 line (equivalent to 20/30 vision) with both eyes. In infancy, visual fixation should be present by age 3-4 months and is assessed by following a target.

A 2-year-old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect? A. Black, sticky stools B. Greasy, foul-smelling stools C. Stools mixed with blood and mucus D. Thin, "ribbon-like" stools

Correct Answer: C. Stools mixed with blood and mucus Intussusception is an intestinal obstruction that occurs when a segment of the bowel folds (ie, telescopes) into another segment. Pressure gradually increases within the bowel, causing ischemia and leakage of blood and mucus into the lumen, which produces the characteristic stool mixed with blood and mucus (ie, red, "currant jelly"). Initially, some infants may have only general symptoms (eg, irritability, diarrhea, lethargy). Subsequently, episodes of sudden abdominal pain (cramping), drawing the knees up to the chest, and inconsolable crying are seen. After an episode, the infant may vomit and then appear otherwise normal. Assessment may show a sausage-shaped abdominal mass. Incorrect Answer: [A. Black, sticky stools ] Melena (dark red or black, sticky stool) is an indication of an upper gastrointestinal (UGI) bleed. Gastritis is a common cause of UGI bleeding in infants and toddlers. [B. Greasy, foul-smelling stools] Oily or bulky, foul-smelling stool is an indication of excess fat in the stool (steatorrhea) from malabsorption. This is characteristic of pancreatic insufficiency, cystic fibrosis, or celiac disease. [D. Thin, "ribbon-like" stools] Thin, ribbon-like stool is characteristic of Hirschsprung disease (congenital aganglionic megacolon). Bowel obstruction is caused by failure of the internal sphincter to relax. Educational objective:The classic symptom triad of intussusception is abdominal pain, "currant jelly" stools, and a sausage-shaped abdominal mass. However, it is more common for clients to have episodes of sudden abdominal pain, inconsolable crying, and vomiting followed by periods of normal behavior.

The parent of a newborn is concerned about the possibility of the child developing hip dysplasia. Which intervention should the nurse encourage to help reduce the risk in this newborn? A. Choose an infant carrier with a narrow seat B. Place 2 diapers on the infant at all times C. Swaddle the infant with hips flexed and abducted D. Use an infant swing that keeps both legs straight

Correct Answer: C. Swaddle the infant with hips flexed and abducted Developmental dysplasia of the hip (DDH) is a range of various hip abnormalities that may be present at birth or develop during the first few years of life. There are many risk factors, including breech birth, large infant size, and family history. Although all cases cannot be prevented, several interventions have been shown to help reduce the risk of DDH development. Key measures include: · Proper swaddling technique - infants should be swaddled with their hips bent up (flexion) and out (abduction), allowing room for hip movement · Choosing infant carriers or car seats with wide bases - infant seats should allow for proper hip positioning in an abducted manner · Avoiding any positioning device, seat, or carrier that causes hip extension with the knees straight and together Incorrect Answers [A. Choose an infant carrier with a narrow seat] Narrow infant carriers prevent proper hip abduction, putting a strain on the hip ligaments and possibly leading to DDH. [B. Place 2 diapers on the infant at all times] Double/triple diapering is no longer recommended as a preventive measure for DDH. This practice can cause extension of the hip, leading to abnormal development. [D. Use an infant swing that keeps both legs straight] Infant swings, bouncers, wraps, and other similar items can cause the legs to be positioned straight and together, which can increase the risk for DDH. Educational objective:DDH is a range of hip abnormalities that may be present at birth or develop in early childhood. Preventive measures include proper swaddling with hips bent up and out, and avoiding seats or carriers that hold the legs straight and together.

The nurse is reinforcing health promotion education to the parents of a toddler. Which statement by a parent requires the nurse to clarify teaching? A. "I will offer my child options rather than asking yes or no questions." B. "I will wait at least 15 minutes after a play period to offer a meal to my child." C. "If my child is having a tantrum, I will have them sit in a quiet area for a short time-out." D. "If my child refuses a meal, I will have them stay at the table until they eat half the food."

Correct Answer: D. "If my child refuses a meal, I will have them stay at the table until they eat half the food." Physiologic anorexia (ie, decreased nutritional need and appetite) occurs when the very high metabolic demands of infancy slow down to keep pace with moderate growth during toddlerhood. During this phase, toddlers are increasingly picky about their food choices and eating schedules. Parents sometimes fear the child is not consuming enough calories, but over several days intake usually meets nutritional and energy needs. Parents should avoid forcing food or pressuring the toddler to eat more, which can lead to poor eating habits in the future. Strategies to promote intake for toddlers include: · Offering 2 or 3 high-quality food choices · Keeping food portions small (1-2 tablespoons per serving) · Exposing the child to new foods repeatedly · Avoiding distractions (eg, television, toys) during meals/snacks Incorrect Answers: [A. "I will offer my child options rather than asking yes or no questions."] Parents can help the toddler gain a sense of control by providing options (eg, corn or peas) rather than asking yes or no questions. [B. "I will wait at least 15 minutes after a play period to offer a meal to my child."] Toddlers may have difficulty sitting still at the table immediately after physical activity. Offering a 15-minute period to calm down promotes better eating habits. [C. "If my child is having a tantrum, I will have them sit in a quiet area for a short time-out."] Tantrums are common as toddlers seek more independence. Parents can consider using time-outs in a quiet, controlled environment to help the child calm down. Educational objective:Toddlers may develop a physiologic decrease in appetite due to reduced nutritional and metabolic demands. The nurse should reassure parents that intake over several days usually meets nutritional and energy needs and encourage parents not to force or pressure the toddler to eat more.

The nurse assists with a community teaching program for parents and caregivers of infants. Which statement by a participant indicates that teaching has been successful? A. "After age 6 months, it is safe to use honey to sweeten my infant's formula." B. "I should wait until my infant is 1 year old to introduce egg products." C. "I will switch my 1-year-old to low-fat milk instead of commercial formula." D. "My infant should be able to pick up small finger foods by age 10 months."

Correct Answer: D. "My infant should be able to pick up small finger foods by age 10 months." The pincer grasp, a thumb to forefinger movement, develops at age 8-10 months. This is the time to start offering small finger foods, such as crackers or cut-up pieces of nutritious foods. Caregivers should inform their health care provider if the infant does not achieve this significant milestone in fine motor development. Incorrect Answers: [A. "After age 6 months, it is safe to use honey to sweeten my infant's formula."] Formula should never be sweetened. Honey (especially raw or wild) should not be offered to children age <12 months because their immature gut systems are susceptible to Clostridium botulinum (botulism) infection. [B. "I should wait until my infant is 1 year old to introduce egg products."] Common allergenic foods (eg, eggs, fish, peanut products) may be introduced along with other foods starting at age 4-6 months. Previous guidelines recommended delaying introduction of these foods until age 12 months. However, recent evidence suggests that delaying introduction of these foods may actually increase the risk for food allergy. [C. "I will switch my 1-year-old to low-fat milk instead of commercial formula."] Infants should be transitioned to whole milk, not low-fat milk, at age 12 months. Due to rapid growth, a child's brain requires the nutrition from the fat found in whole milk. Educational objective:The pincer grasp should be present by age 10 months. Offering small finger foods allows the infant to develop fine motor skills. The child will also enjoy the ability to self-feed and explore a variety of nutritious foods.

The clinic nurse is asked by the mother of a 15-month-old, "I am worried about my child's thumb sucking and its effects on tooth alignment. What should I do?" What is the nurse's best response? A. "As long as your child's thumb sucking stops by age 2-3 years when all of the primary teeth have erupted, there is little concern." B. "Because your child already has teeth, it is important to implement a plan to stop the thumb sucking as soon as possible." C. "Newer research shows that thumb sucking has little effect on a child's teeth." D. "The risk for misaligned teeth occurs when thumb sucking persists after eruption of permanent teeth."

Correct Answer: D. "The risk for misaligned teeth occurs when thumb sucking persists after eruption of permanent teeth." Rooting and sucking are a part of an infant's natural reflexes. Nonnutritive sucking assists in helping the infant to feel secure. Some parents become very concerned about their infants sucking fingers, thumbs, or a pacifier and try to stop the behavior. As a rule, if thumb sucking stops before the permanent teeth begin to erupt, misalignment of the teeth and malocclusion can be avoided. Parents should be taught that teasing and punishing a child for using a pacifier or sucking the thumb is not an effective method for getting the child to stop. This can increase the child's anxiety and cause the child to increase the behavior. Incorrect Answers: [A. "As long as your child's thumb sucking stops by age 2-3 years when all of the primary teeth have erupted, there is little concern."] These options are incorrect. Use of a pacifier or thumb sucking prior to eruption of the permanent teeth does not tend to cause dental issues such as teeth misalignment or malocclusion. [B. "Because your child already has teeth, it is important to implement a plan to stop the thumb sucking as soon as possible."] These options are incorrect. Use of a pacifier or thumb sucking prior to eruption of the permanent teeth does not tend to cause dental issues such as teeth misalignment or malocclusion. [C. "Newer research shows that thumb sucking has little effect on a child's teeth."] These options are incorrect. Use of a pacifier or thumb sucking prior to eruption of the permanent teeth does not tend to cause dental issues such as teeth misalignment or malocclusion. Educational objective:The risk of teeth misalignment and malocclusion occurs when a child uses a pacifier or sucks the thumb after the eruption of the permanent teeth.

The clinic nurse reviews teaching provided to the parent of a child being considered for growth hormone replacement therapy at home. Which statement by the parent indicates that teaching has been effective? A. "Treatment will be considered a success when my child grows at a rate equal to peers." B. "Treatment will be required throughout my child's life." C. "Treatment will begin when my child becomes an adolescent." D. "Treatment will require a daily injection under my child's skin."

Correct Answer: D. "Treatment will require a daily injection under my child's skin." A child who demonstrates a slow growth pattern will undergo diagnostic evaluation to determine the cause. If the cause is found to be growth hormone deficiency, the child may undergo growth hormone replacement therapy. The biosynthetic hormone is administered via subcutaneous injection on a daily basis. Despite replacement therapy, the child may still have a final height less than "normal." Treatment is most successful when diagnosis and replacement therapy begin early in the child's life. When to stop therapy is decided by the client, family, and provider. However, growth less than 1 inch (2.5 cm) per year and bone age of 14 years in girls and 16 years in boys are the criteria often used to stop therapy. Incorrect Answers: [A. "Treatment will be considered a success when my child grows at a rate equal to peers." ] Growth hormone replacement does not guarantee that a child will grow at a rate equal to peers. Treated children often remain shorter than their peers. [B. "Treatment will be required throughout my child's life."] Replacement therapy is not continued throughout a child's life. It is stopped when bone growth begins to cease or when the child, parents, and provider make the decision. [C. "Treatment will begin when my child becomes an adolescent."] Replacement therapy is most successful when treatment begins early, as soon as growth delays are noted. Educational objective:Growth hormone replacement is an option for children who are not growing according to accepted standards. The treatment should begin as soon as delays are noted and continue until bone growth begins to cease despite replacement therapy. Replacement is administered via subcutaneous injections.

The nurse is reinforcing education to the caregivers of a 9-year-old client diagnosed with scarlet fever. The client has a history of type 1 diabetes mellitus. Which statement by the caregivers indicates that further teaching is needed? A. "We will encourage extra fluid intake while our child is sick." B. "We will increase the frequency of blood glucose checks." C. "We will monitor our child's urine for ketones with each void." D. "We will not administer insulin if our child is unable to eat."

Correct Answer: D. "We will not administer insulin if our child is unable to eat." An acute illness (eg, scarlet fever) in clients with type 1 diabetes may trigger the release of stress hormones, which leads to higher blood glucose and ketone levels (sometimes leading to ketoacidosis). Clients with type 1 diabetes do not produce any insulin (unlike those with type 2 diabetes), so clients should not skip administration of external insulin even if not eating. Insulin therapy should be continued as prescribed during an acute illness. Additional sick-day management includes: · Increasing frequency of blood glucose level checks (every 1-4 hours) · Increasing or decreasing the dose of insulin as needed based on blood glucose levels · Maintaining adequate hydration · Testing for urinary ketones frequently Incorrect Answers: [A. "We will encourage extra fluid intake while our child is sick."] Stress hormones released during illness cause increased insulin resistance and lead the body to break down fat for energy. Ketones are produced when fat is broken down, which can lead to diabetic ketoacidosis (DKA). The client's urine should be monitored frequently for ketones while the client is sick. Fluids are encouraged to clear ketones from the system and prevent dehydration. [B. "We will increase the frequency of blood glucose checks."] Blood glucose should be assessed frequently while the client is ill due to the potentially unpredictable and rapidly changing levels caused by illness and/or fasting. [C. "We will monitor our child's urine for ketones with each void."] Stress hormones released during illness cause increased insulin resistance and lead the body to break down fat for energy. Ketones are produced when fat is broken down, which can lead to diabetic ketoacidosis (DKA). The client's urine should be monitored frequently for ketones while the client is sick. Fluids are encouraged to clear ketones from the system and prevent dehydration. Educational objective:Clients with type 1 diabetes should not discontinue insulin usage during an illness. Encouraging fluids and monitoring glucose and ketone levels are priorities for this client.

The nurse is discussing child safety with the parents of a 12-month-old who is just beginning to walk. Which statement by the parents indicates a need for further instruction? A. "Our swimming pool is fenced in with a lock on the gate." B. "We have installed childproof gates at the top and bottom of our stairs." C. "We need to lower the mattress in our child's crib." D. "When we can't be watching, we put our child in a mobile child walker."

Correct Answer: D. "When we can't be watching, we put our child in a mobile child walker." Due to the relatively high incidence of injuries associated with child walkers, the American Academy of Pediatrics has recommended a ban on the manufacture and sale of mobile infant walkers. Accidents associated with child walkers include: · Rolling down stairs (the most common cause of injury) · Burns - children can reach high in a walker, enabling them to grab hot pot handles, reach heaters and fireplaces, or grab a hot cup of liquid off a counter or table · Drowning - a child can fall into a bathtub or pool while in a mobile walker · Poisoning - the child can reach higher objects Even if a parent is close by and watching a child in a walker, an accident may not be preventable. Children can move quickly and the parent or caregiver may not be able to respond quickly enough. Safer alternatives to mobile baby walkers include stationary walkers (no wheels) and play areas. If parents or caregivers insist on using a baby walker, they should be advised to choose one that meets the American Society for Testing and Materials safety standards. Walkers with braking mechanisms stop if at least one wheel drops off the riding surface. Incorrect Answers: [A. "Our swimming pool is fenced in with a lock on the gate."] This is an appropriate action; swimming pools should be surrounded by fences with childproof locks to prevent accidental drowning. Wading pools and all water containers should be emptied after each use. [B. "We have installed childproof gates at the top and bottom of our stairs."] This is an appropriate action; childproof gates should be installed on stairs and at the entrances to rooms that could pose danger to a child. [D. "When we can't be watching, we put our child in a mobile child walker."] This is an appropriate action; as children grow taller and can stand, they may be able to crawl over the crib rails and fall. Educational objective:Mobile baby walkers are associated with injuries such as falls and drowning as they can easily tip over. Children can also reach higher places while in a baby walker, enabling them to pull hot objects and dangerous substances off counters and tables.

A 2-month-old infant has been admitted to the hospital with suspected shaken baby syndrome (abusive head trauma). In reviewing the infant's chart, the nurse expects to encounter which of these clinical findings? A. A reported history of recent trauma B. Abdominal bruising C. External signs of trauma D. Irritability and vomiting

Correct Answer: D. Irritability and vomiting Shaken baby syndrome (SBS) is a type of abusive head injury and is defined by the Centers for Disease Control and Prevention (CDC) as severe physical child abuse resulting from violent shaking of an infant by the arms, legs, or shoulders. The impact of the shaking causes bleeding within the brain or the eyes. It is not uncommon for the diagnosis of SBS to be missed as the clinical findings are often vague and nonspecific—vomiting, irritability, lethargy, inability to suck or eat, seizures, and inconsolable crying. Usually, there are no external signs of trauma except for occasional small bruises on the chest or upper arms where the child was held during the shaking episode. The most common reasons that caregivers seek medical attention for children with SBS are breathing difficulty, apnea, seizures, and lifelessness. Caregivers typically do not offer a history of trauma nor do they report the episodes of shaking. By contrast, children who have sustained unintentional head injury are typically brought for treatment out of concern by their caregivers even when the children are asymptomatic. Incorrect Answers: [A. A reported history of recent trauma] Typically, a history of physical trauma is not reported by the parent or caregiver. [B. Abdominal bruising] Abdominal bruising is not an expected clinical finding of SBS. [C. External signs of trauma] External signs of trauma are usually absent on physical examination of an infant with SBS. Minimal bruising on the extremities or chest may be present. Educational objective:Shaken baby syndrome is a form of child physical abuse resulting from violent shaking of an infant by the extremities or shoulder that causes bleeding within the brain and/or eyes. The clinical findings of shaken baby syndrome are nonspecific and include lethargy, vomiting, seizures, irritability, inability to eat, and inconsolable crying. Multiple and severe shaking episodes can result in breathing difficulty and lifelessness. Caregivers typically do not report a history of trauma.

A 9-year-old with type 1 diabetes takes insulin glargine and NPH regularly. While at school, the client becomes shaky, diaphoretic, and pale. What is the most appropriate action by the nurse? A. Administer scheduled dose of NPH insulin B. Give emergency glucagon IM injection C. Give peanut butter and crackers D. Provide 4 oz (120 mL) of a regular soft drink

Correct Answer: D. Provide 4 oz (120 mL) of a regular soft drink Clients experiencing hypoglycemia may develop shakiness, palpitations, sweating, pallor, and altered mental status (eg, difficulty speaking, confusion). If manifestations of hypoglycemia are present, the nurse should check the client's blood glucose (BG) level immediately. A BG of <70 mg/dL (3.9 mmol/L) requires treatment; however, if glucose testing is not readily available, the client should be treated based on symptoms. Hypoglycemia treatment in a conscious client is administration of 15 g of a quick-acting carbohydrate. After treatment, the nurse should recheck BG every 15 minutes, repeating treatment if it remains low. Quick-acting carbohydrate options include: · 4 oz (120 mL) of a regular soft drink or fruit juice · 8 oz (240 mL) of low-fat milk · 1 tablespoon (15 mL) of honey or syrup · 6 hard candies · Commercial dextrose products Incorrect Answers: [A. Administer scheduled dose of NPH insulin] The nurse should hold the client's scheduled NPH insulin until the client's BG is normal and symptoms resolve. [B. Give emergency glucagon IM injection] An emergency glucagon IM injection is indicated if the client is somnolent, unconscious, seizing, or unable to swallow. [C. Give peanut butter and crackers] After the client's BG improves, the client should eat a meal. However, if the next meal is more than an hour away, the nurse should give the client a serving of carbohydrate (eg, crackers) plus protein or fat (eg, peanut butter, cheese) to maintain glucose levels. Educational objective:Clients with diabetes mellitus should be monitored for signs of hypoglycemia (eg, shakiness, sweating, pallor, alterations in mental status). Conscious clients experiencing hypoglycemia should receive a snack of 15 g of a quick-acting carbohydrate.

A 4-year-old admitted with Wilms tumor is scheduled for a right nephrectomy in the morning. Which nursing action is a priority pre-operatively? A. Assessment of the child's emotional maturity level B. Auscultating for adventitious breath sounds C. Monitoring blood pressure closely D. Reinforcing instructions not to palpate the abdomen

Correct Answer: D. Reinforcing instructions not to palpate the abdomen Wilms tumor (nephroblastoma) is a kidney tumor that usually occurs in children age <5. Most often it involves only one kidney, and the prognosis is good if the tumor has not metastasized. An unusual contour in the child's abdomen is suggestive of Wilms tumor and confirmatory diagnosis is made by ultrasound. Once the diagnosis is suspected or confirmed, the abdomen should not be palpated, as this can disrupt the encapsulated tumor. It is important to post the sign "DO NOT PALPATE ABDOMEN" at the bedside. It is also essential that the child be handled carefully during bathing. Incorrect Answers: [A. Assessment of the child's emotional maturity level] Assessment of a child's development level and emotional maturity will help determine the appropriate approach to use during the many painful procedures that the child will undergo in rapid succession. However, this assessment is not a priority. [B. Auscultating for adventitious breath sounds] If the tumor has metastasized, adventitious sounds may be present. Auscultating for them is not a priority. [C. Monitoring blood pressure closely] Some clients may have hypertension due to excess production of renin, and this will require monitoring. However, it is not as important as ensuring that the abdomen is not palpated. Educational objective:Wilms tumor is discovered when caregivers note an unusual bulging/swelling on one side of a child's abdomen. The abdomen should not be palpated once diagnosis is suspected or confirmed as this can disrupt the tumor and cause dissemination of tumor cells.

A 1-year-old child who goes to day care is recovering from an episode of otitis media. Which intervention is most important for the nurse to reinforce to the parents in order to prevent recurrence? A. Exclusive breastfeeding B. Not sending the child to day care C. Preventing water from entering the ear D. Smoking cessation by the parents

Correct Answer: D. Smoking cessation by the parents Otitis media (OM) is the inflammation or infection of the middle ear resulting from dysfunction of the eustachian tube. OM typically occurs in infants and children under age 2, sometimes following a respiratory tract infection. The eustachian tubes in infants and young children are short, straight, and fairly horizontal, which results in ineffective drainage and protection from respiratory secretions. Infants with exposure to tobacco smoke are at risk for OM due to the resulting respiratory inflammation. OM risk is also higher with activities such as using a pacifier or drinking from a bottle when lying down as these allow fluid to pool in the mouth and then reach the eustachian tubes. Key preventive measures include eliminating exposure to smoke, obtaining routine immunizations to prevent infection, and reducing or eliminating use of a pacifier after age 6 months. Incorrect Answers: [A. Exclusive breastfeeding] Breast-fed infants have a decreased risk for OM, possibly due to the semivertical position used when breastfeeding, which reduces reflux to the eustachian tubes. Exclusive breastfeeding is recommended for the first 6 months. However, this client is age 1 and should be receiving a varied, healthy intake of solid food at this time. [B. Not sending the child to day care] Day care attendance is a significant risk factor to the development of OM. However, the recommendation to avoid day care is usually not practical as many parents must work outside of the home. [C. Preventing water from entering the ear] Excess water in the ears from bathing or swimming can alter the protective environment of the external ear and contribute to otitis externa, known as swimmer's ear; however, this does not contribute to OM. Educational objective:Otitis media, inflammation of the middle ear, commonly occurs in children under age 2. Key interventions for prevention include avoiding exposure to tobacco smoke, obtaining routine immunizations, and discontinuing use of a pacifier after age 6 months.

A newborn had a bowel resection with temporary colostomy for Hirschsprung disease. The practical nurse should alert the supervising registered nurse about which postoperative finding? A. Moderate amount of blood-tinged mucus from the stoma on postoperative day 2 B. Small amount of non-formed stool in the colostomy bag on postoperative day 6 C. Stoma bleeds a small amount during colostomy bag change on postoperative day 3 D. Stoma is gray-tinged at the edges but pink at the center on postoperative day 5

Correct Answer: D. Stoma is gray-tinged at the edges but pink at the center on postoperative day 5 In Hirschsprung disease, a portion of the colon has no innervation and must be removed. Some children require a temporary colostomy. The stoma created from the surgery should remain beefy red in the immediate postoperative period. Any paleness or graying of the stoma indicates decreased blood supply to that area. Incorrect Answers: [A. Moderate amount of blood-tinged mucus from the stoma on postoperative day 2] Blood-tinged mucus would be expected the first few days after surgery due to irritation of the intestinal mucosa during the procedure. [B. Small amount of non-formed stool in the colostomy bag on postoperative day 6] By postoperative day 6, non-formed stool would be expected from the colostomy due to removal of part of the fluid-absorbing portion of the large intestine. [C. Stoma bleeds a small amount during colostomy bag change on postoperative day 3] It is not uncommon for a stoma to bleed a small amount with manipulation in the postoperative period. Educational objective:The colostomy stoma should be beefy red in the immediate postoperative period. Any discoloration of the stoma could indicate decreased blood supply to the area; the nurse should notify the supervising registered nurse.

A nurse in a clinic is talking with a parent about the onset of puberty in boys. What is the first sign of pubertal change that occurs? A. Appearance of upper lip hair B. Increase in height C. Presence of axillary hair D. Testicular enlargement

Correct Answer: D. Testicular enlargement Testicular enlargement, including scrotal changes, is the first manifestation of puberty and sexual maturation. This typically occurs at age 9½-14. It is followed by the appearance of pubic, axillary, facial, and body hair. The penis increases in size and the voice changes. Some boys also experience an increase in breast size. Growth spurt changes of increased height and weight may not be apparent until mid-puberty. Educational objective:Sexual maturation in boys begins with an increase in testicular size, followed by changes in the scrotum, appearance of pubic, axillary, facial, and body hair, and voice changes.

The parent of an 8-year-old client asks the nurse for guidance on how to help the client cope with the recent death of the other parent. When developing a response to the parent, the nurse considers that a school-aged child is most likely to do what? A. React anxiously to altered daily routines B. Realize that death eventually affects everyone C. Think about the religious or spiritual aspects of death D. Understand that death is permanent but be curious about it

Correct Answer: D. Understand that death is permanent but be curious about it Understanding a child's perception of illness and death can empower caregivers (eg, parents) to support the child during the loss of a loved one. A child's developmental stage as well as the caregiver's view of death and relationship with the child will influence coping during bereavement. The nurse should educate the parent of an 8-year-old client about how to assist with coping based on the knowledge that school-aged children (age 6-12 years) most likely have both a curiosity and fear about the implications of death (eg, process of dying, funeral services) and understand that death is permanent. Therefore, it is important for the parents to be honest during discussions about death, talk about the lost loved one, and provide anticipatory guidance to reduce fears. Incorrect Answers: [A. React anxiously to altered daily routines] Infants (age 1-12 months) and toddlers (age 12-36 months) mostly react to separation from caregivers, both temporary and permanent, because it affects daily routines. [B. Realize that death eventually affects everyone] A child will most likely be aware that death affects everyone and also perceive it as evil by age 10-12 years. [C. Think about the religious or spiritual aspects of death] Adolescents are most likely to think about the religious and spiritual aspects of death, although this may occur earlier for some children. Educational objective:The nurse should understand how children perceive illness and death within each age group to provide guidance for caregivers. School-aged clients most likely understand the concrete finality of death and are curious and fearful about its implications (eg, process of dying, funeral services).

The nurse in a clinic is caring for an 8-month-old with a new diagnosis of bronchiolitis due to respiratory syncytial virus (RSV). Which instructions can the nurse anticipate reviewing with the parent? A. Administering a cough suppressant and antihistamine B. Prophylactic treatment of family members C. Temporary cessation of breastfeeding D. Use of saline drops and a bulb syringe to suction nares

Correct Answer: D. Use of saline drops and a bulb syringe to suction nares Bronchiolitis is a common viral illness of childhood that is usually caused by RSV. It typically begins with viral upper respiratory symptoms (eg, rhinorrhea, congestion) that progress to lower respiratory tract symptoms such as tachypnea, cough, and wheezing. Bronchiolitis is a self-limited illness and supportive care is the mainstay of treatment. Most children can be managed in the home environment. Breastfeeding should be continued and additional fluids offered if there is a risk of dehydration due to frequent coughing and vomiting (Option 3). Parents should be instructed to use saline nose drops and then suction the nares with a bulb syringe to remove secretions prior to feedings and at bedtime. Incorrect Answers: [A. Administering a cough suppressant and antihistamine] Medications such as cough suppressants, antihistamines, bronchodilators (eg, albuterol), and corticosteroids have not been found to be effective and are not recommended. [B. Prophylactic treatment of family members] Prophylactic treatment of family members is recommended for pertussis infection but not for RSV bronchiolitis. [C. Temporary cessation of breastfeeding] Breastfeeding should be continued and additional fluids offered if there is a risk of dehydration due to frequent coughing and vomiting. Educational objective:Bronchiolitis is a common viral illness of childhood that is usually caused by RSV. The focus of home care is on monitoring respiratory status and periodic nasal suctioning using saline nose drops to ease breathing. Additional fluids should be offered.

Which assessment findings of an 18-month-old cause the nurse to be concerned about delayed development? A. Cannot climb steps alone, pulls a toy, turns the pages of a book B. Is bottlefed, can use a spoon, creeps down stairs C. Throws a ball, is able to point to 2 or 3 body parts, cannot draw a picture D. Uses 2 words, cannot hold a cup, can seat self in a small chair

Correct Answer: D. Uses 2 words, cannot hold a cup, can seat self in a small chair An 18-month-old should have a vocabulary of ≥10 words and be able to hold and drink from a cup. Lack of age-appropriate vocabulary and fine motor function is concerning. In addition, such delays in communication and language development and fine motor skills may be more apparent at age 18 months than at earlier ages. Either finding should prompt the nurse that further evaluation is needed. Incorrect Answers: [A. Cannot climb steps alone, pulls a toy, turns the pages of a book] An 18-month-old can climb stairs with assistance, use a pull-toy, and turn the pages of a book. [B. Is bottlefed, can use a spoon, creeps down stairs] An 18-month-old can hold and clumsily use a spoon and creep down stairs and may continue to be bottle-fed at times. [C. Throws a ball, is able to point to 2 or 3 body parts, cannot draw a picture] An 18-month-old is able to throw a ball, can point to body parts, and might be able to scribble but not draw a picture. Educational objective:An 18-month-old should have a vocabulary of ≥10 words and be able to perform fine motor functions (eg, use a spoon, hold and drink from a cup).

A nurse is caring for a child who is receiving oxygen at 2 L/min by nasal cannula and observes the current oxygen saturation and pulse plethysmographic waveform on the pulse oximeter. Which intervention should be the nurse's initial action? [Pictured: Plethysmograph depicting Motion Artifact] A. Auscultate the child's lung fields B. Have the child take slow, deep breaths C. Increase the oxygen flow rate to 3 L/min D. Verify the position and integrity of the finger probe

Correct Answer: D. Verify the position and integrity of the finger probe The first action of the nursing process is assessment. The nurse should first evaluate the accuracy of the reading by evaluating the pulse plethysmographic waveform. Waveforms that are irregular or erratic may contain artifact caused by a loose, misapplied, or damaged pulse oximeter or by client movement (Option 4). After ensuring that the probe has been properly applied and positioned to provide an accurate reading, the nurse should perform a thorough physical assessment and intervene as appropriate. Incorrect Answers: [A. Auscultate the child's lung fields] Auscultation of the lungs would be the next appropriate action to perform if pulse oximetry readings are deemed accurate. [B. Have the child take slow, deep breaths] If the reading is deemed accurate after further assessment, the nurse should assist the client into the high Fowler position and encourage slow, deep breaths to promote ventilation. The nurse should increase the oxygen flow rate and notify the health care provider if the client's oxygen saturation does not improve with nursing interventions. [C. Increase the oxygen flow rate to 3 L/min] If the reading is deemed accurate after further assessment, the nurse should assist the client into the high Fowler position and encourage slow, deep breaths to promote ventilation. The nurse should increase the oxygen flow rate and notify the health care provider if the client's oxygen saturation does not improve with nursing interventions. Educational objective:When a low oxygen saturation with apparent artifact in the pulse plethysmographic waveform is observed, the nurse should discern the accuracy of the reading to prevent unnecessary treatment. If the pulse oximeter reading is accurate, the nurse should perform a thorough physical assessment and intervene as appropriate.

A 14-year-old is scheduled for surgery to treat scoliosis. The child will be hospitalized for about a week and then discharged home to recuperate for 3-4 weeks before returning to school. What is the best activity the nurse can recommend to promote age-specific growth and development during this time? A. Attending selected after-school events and social activities B. Keeping up with schoolwork C. Reading teen magazines D. Visits from friends

Correct Answer: D. Visits from friends During adolescence, being with a peer group is part of the process of achieving individual identity, the most important developmental task at this age. An adolescent's friends have more influence than parents, teachers, or any other adults. Social relationships and activities help to provide a sense of belonging, acceptance, and approval. Having face-to-face visits and spending time with friends will help counteract feelings of isolation and loneliness during the client's recuperative period. In addition, the client is at risk for body image disturbance related to the scoliosis and surgery. The client may be particularly sensitive about body image and needs understanding and acceptance from peers. Incorrect Answers: [A. Attending selected after-school events and social activities] The client can attend school functions or social activities with friends when off all pain medication and when the spine has healed sufficiently. [B. Keeping up with schoolwork] It is important for the client to keep up with schoolwork, but it is not a priority for recovery. [C. Reading teen magazines] Reading teen magazines can be a diversionary activity and may help distract the client from any pain, but it is not a priority. Educational objective:Friends play a significant role in the adolescent's quest for identity and provide a source of support, belonging, and understanding. Interacting with friends during recuperation after surgery is important to help counteract feelings of loneliness and isolation.

The practical nurse is performing a physical examination with the registered nurse on a 2-year-old with cold symptoms and a fever at home of 101.7 F (38.7 C). Which interventions will enhance the child's cooperation during the examination? Select all that apply. A. Allow the child to play with the stethoscope B. Begin with the child in the parent's lap C. Interact with the parent in a friendly manner D. Play with the child using a finger puppet E. Start by taking the child's vital signs

Correct Answers: A, B, C, and D Always complete the assessment by performing the least invasive parts first and then progressing to the most invasive. By first establishing a rapport with the parent, the nurse will elicit the child's trust and cooperation. Playing with the child will help the child relax and perceive the nurse as less of a threat. Examining the child while in the parent's lap and explaining procedures in simple terms will provide a sense of security for the child. Measuring the child's height and weight should be performed next. Auscultation of the heart and lungs should then be performed. Allowing the child to play with the equipment first will make this part of the assessment easier. Praising the child throughout the assessment will enhance cooperation. Incorrect Answer: [E. Start by taking the child's vital signs] Taking vital signs can be difficult as a blood pressure cuff can be perceived as painful; once the child is upset, it becomes difficult to continue with the assessment. A temperature of 101.7 F (38.7 C) is not serious in a child, especially if there are signs and symptoms of an upper respiratory infection. Educational objective:Performing a physical assessment in a toddler can be challenging. The nurse should establish a rapport with the parent and then attempt to gain the child's trust. Playing with the child and allowing the child to sit on the parent's lap can make the experience easier on the nurse, parent, and child. The nurse should always perform the least invasive procedures first, explain them in simple terms, and praise the child throughout the assessment.

The nurse is reviewing the plan of care for a 4-year-old client who will receive daily dressing changes for an infected leg wound. Which of the following interventions should the nurse include in the plan of care for a preschool-age child? Select all that apply. A. Allow the child's parents to stay during the procedure B. Emphasize that dressing changes are not punishment for misbehavior C. Encourage the child to voice questions and concerns about the procedure D. Have the child place bandages on a doll when reinforcing education E. Introduce the child to other clients with the same health condition

Correct Answers: A, B, C, and D Planning care during pediatric hospitalization requires the nurse to consider the child's stage of psychosocial and cognitive development. For the preschool-age child (3-5 years), developing a sense of initiative (ie, start and accomplish tasks, learn new things) is a primary psychosocial need, and cognitive development is marked by preoperational thinking (ie, egocentrism, poor causality, continuing language development). During preprocedural education, the nurse should: · Promote a sense of security and reduce fear by allowing the parents to stay with the child during the procedure · Address misconceptions related to preoperational thinking (ie, state that the procedure is not punishment for misbehavior) · Foster initiative by encouraging the child to ask questions, voice concerns, and participate during dressing changes · Enhance the child's learning ability and confirm the child's understanding of the procedure by allowing the child to imitate the procedure using a doll or toy equipment Incorrect Answer: [E. Introduce the child to other clients with the same health condition] Peer support from other clients undergoing similar procedures is a coping technique that is more appropriate for adolescents. Educational objective:Interventions that meet the psychosocial (ie, sense of initiative) and cognitive (ie, preoperational thinking) needs of preschool-age children during preprocedural education include allowing parents to remain with the client during the procedure, emphasizing that the procedure is not punishment, encouraging the child to ask questions, and utilizing toys to communicate about the procedure.

Which assessment findings should the nurse anticipate in a child with suspected acute otitis media (AOM)? Select all that apply. A. Frequent pulling on the affected ear B. Refusal to eat C. Restlessness and irritability D. Retracted tympanic membranes E. Severe pain with pressure on the tragus

Correct Answers: A, B, and C AOM is an infection of the middle ear resulting from dysfunction of the Eustachian tube. OM typically occurs in infants and children age <2, often following a respiratory tract infection. Clinical manifestations of AOM include high fever (up to 104 F [40 C]), ear pain, irritability/restlessness, loss of appetite, and pulling on the affected ear. In AOM, the tympanic membrane will typically be bulging and very red. If the tympanic membrane ruptures from the buildup of fluid, the client will experience immediate pain relief and a gradually decreasing fever; purulent drainage may be observed in the external ear canal. Incorrect Answer: [D. Retracted tympanic membranes] Retracted tympanic membranes occur when there is negative pressure in the middle ear, which can occur with a blocked Eustachian tube or as a complication of chronic infections. In acute otitis media, pus/fluid inside the ear produces bulging and red membranes. [E. Severe pain with pressure on the tragus] Severe pain experienced with direct pressure on the tragus or with pulling on the pinna is a manifestation of otitis externa, an infection of the outer ear. The pain associated with AOM is not affected by manipulation of the outer ear. Educational objective:Clinical manifestations of AOM include high fever; ear pain; irritability; pulling on the affected ear; and bulging, red tympanic membranes.

A nurse is caring for a 1-month-old client who is being evaluated for congenital hypothyroidism. The nurse should recognize which of the following as clinical manifestations of hypothyroidism in infants? Select all that apply. A. Difficult to awaken B. Dry skin C. Frequent, loose stools D. Hoarse cry E. Tachycardia

Correct Answers: A, B, and D Congenital hypothyroidism occurs when abnormal development of the thyroid gland causes complete or decreased secretion of thyroid hormone (TH). Untreated hypothyroidism can cause severe intellectual disability in infants if undetected. Screening occurs after birth for all infants in the United States and Canada to prevent disability and encourage early treatment (ie, levothyroxine). TH plays an important role in growth, development, and regulation of many bodily functions (eg, heat production, muscle tone, skin function, cardiac function, metabolism). Clinical manifestations in affected infants reflect the pathophysiology of decreased TH and may include: · Difficulty awakening, lethargy, or hyporeflexia due to alterations in central nervous system function · Dry skin due to alterations in skin function · Hoarse cry caused by swelling of the vocal cords due to fluid retention · Constipation due to slowed metabolism · Bradycardia due to the effect of TH on cardiac function Incorrect Answers: [C. Frequent, loose stools] Hyperthyroidism (Graves disease) is an autoimmune condition related to increased production of TH. Neonatal Graves disease is uncommon and usually occurs secondary to maternal hyperthyroidism. Tachycardia and increased bowel motility (frequent or loose stools) are features of hyperthyroidism and are related to an increase in metabolic processes. [E. Tachycardia] Hyperthyroidism (Graves disease) is an autoimmune condition related to increased production of TH. Neonatal Graves disease is uncommon and usually occurs secondary to maternal hyperthyroidism. Tachycardia and increased bowel motility (frequent or loose stools) are features of hyperthyroidism and are related to an increase in metabolic processes. Educational objective:Congenital hypothyroidism is a partial or complete loss of thyroid function that affects growth, development, and regulation of bodily functions. Clinical manifestations in affected infants may include dry skin, hoarse cry, or difficulty awakening beginning a few months after birth. If untreated, intellectual disability may occur.

A nurse is discussing the fine motor abilities of a 10-month-old infant with the infant's parent. Which are developmentally appropriate skills for an infant of this age? Select all that apply. A. Grasps a small doll by the arm B. Stacks 3 wooden blocks C. Transfers small objects from hand to hand D. Turns single pages in a book E. Uses a basic pincer grasp

Correct Answers: A, B, and E Fine motor skills of infants develop around the ability to grasp and pick up objects. By 3 months, infants will reflexively grasp a rattle placed in their hand. At 5 months, they are able to voluntarily clasp it with their palm. Around 7 months, infants are able to transfer an object from one hand to the other. By 8-10 months, infants have replaced the palmar grasp with a crude pincer grasp (use of thumb, index, and other fingers) to pick up round oat cereal and other finger foods. By 11 months, this develops into a neat pincer grasp (use of thumb and index finger). Incorrect Answers: [C. Transfers small objects from hand to hand] By 12 months, infants may attempt to turn multiple book pages at once, and they also begin attempts to stack 2 blocks. These skills require finer muscle control than is expected of a 10-month-old. [D. Turns single pages in a book] By 12 months, infants may attempt to turn multiple book pages at once, and they also begin attempts to stack 2 blocks. These skills require finer muscle control than is expected of a 10-month-old. Educational objective:Fine motor skills of infants develop around the ability to grasp objects. Voluntary grasping with the palm begins around 5 months, followed by the ability to transfer an object between hands by 7 months and the development of a crude pincer grasp (using the thumb, index, and other fingers) around 8-10 months.

The parents of a 2-year-old client ask how they can help their child cope with hospitalization. Which of the following suggestions should the nurse give the parents? Select all that apply. A. Follow as many home routines as possible B. Organize a visit from a playgroup friend C. Sleep in the child's hospital room at night D. Take child on regular visits to the playroom E. Tell the child they did not cause the illness

Correct Answers: A, C, and D Hospitalization for toddlers (ie, 12-36 months) is particularly difficult due to separation anxiety and a limited ability to cope with stress. Toddlers thrive on home rituals and routines, which bring stability and reassurance. Hospitalization can severely disrupt these routines, triggering frustration and temper tantrums. Caregivers should maintain as many home routines as possible (eg, sleeping, eating) to help the child cope with unfamiliar hospital surroundings and procedures. Parents should also stay with the child as much as possible, including overnight (ie, rooming-in), to provide consistency and alleviate separation anxiety. Play, an important part of a child's emotional and social well-being, is an effective coping mechanism for children of all ages to deal with the stress of being away from home. The playroom is a safe place for children to act out their fears and anxieties related to illness and hospitalization. Incorrect Answers: [B. Organize a visit from a playgroup friend] A visit from friends is not likely to provide much comfort to a toddler and may actually cause additional stress. Adolescents, who are driven by peer interaction, would be more likely to benefit from this strategy. [E. Tell the child they did not cause the illness] Preschool-aged children (3-5 years) have egocentric and magical thinking, which may cause them to think that their illness is due to something they have done or thought. Toddlers do not think this way. Educational objective:Coping mechanisms used by hospitalized toddlers include following homes rituals and routines, having parents stay with the child (including overnight), and using the playroom for relief of anxiety and fear.

The nurse is reinforcing education to a group of parents about ways to decrease the risk of sudden infant death syndrome. Which of the following recommendations should the nurse suggest? Select all that apply. A. Breastfeeding the infant B. Cosleeping with the infant in the parent's bed C. Giving the infant a pacifier at bedtime D. Maintaining a smoke-free environment E. Placing the infant to sleep in a side-lying position

Correct Answers: A, C, and D Sudden infant death syndrome (SIDS) is the unexpected, unexplained death of an infant age <1 year, occurring most frequently in those age <6 months during sleep/naps. The nurse should reinforce teaching with parents regarding placement of the infant during sleep (ie, on their back, on a firm surface, without loose or soft items) to prevent suffocation. The nurse may also encourage pacifier use during sleep, which is protective against SIDS. Environmental factors such as smoking may also increase the infant's risk for SIDS; therefore, parents should maintain a smoke-free environment. In addition, breastfeeding helps to keep infants healthy and is protective against SIDS. Incorrect Answers: [B. Cosleeping with the infant in the parent's bed] Parents should avoid cosleeping with their infant (ie, bed sharing) because it increases the infant's risk for suffocation and falls. Encouraging room sharing without bed sharing is appropriate, however. [E. Placing the infant to sleep in a side-lying position] Due to the infant's body shape (ie, barrel chest; flat, uncurved spine), side-lying positions facilitate rolling over to a prone position. Instead, the nurse may recommend supervised time during the day for the infant to lay on the stomach while awake (ie, tummy time) to promote muscle development and prevent positional plagiocephaly. Educational objective:Sudden infant death syndrome (SIDS) is the unexpected, unexplained death of an infant age <1 year. To reduce the incidence of SIDS, the nurse should reinforce education with parents about avoiding cosleeping and prone/side-lying sleeping positions; encouraging a smoke-free environment; using safe sleep practices (eg, pacifier during sleep); and breastfeeding.

A home health nurse is managing care for an adolescent client with cystic fibrosis. Which of the following potential complications should the nurse consider when developing a nursing care plan? Select all that apply. A. Chronic hypoxemia B. Diabetes insipidus C. Frequent respiratory infections D. Obesity E. Vitamin deficiencies

Correct Answers: A, C, and E Cystic fibrosis (CF) is an inherited disorder (autosomal recessive) characterized by thickened secretions due to impaired chloride and sodium channel regulation that causes exocrine gland dysfunction. Management of a client with CF should primarily address potential complications related to the following body systems: · Pulmonary: Alterations in respiratory secretions (ie, thick sputum) make it difficult to clear the airway and can result in frequent respiratory infections and sinusitis. Frequent infections and inflammation damage lung tissue and may lead to chronic hypoxemia. · Gastrointestinal: Thickened secretions obstruct the release of pancreatic enzymes, causing malabsorption of fat-soluble vitamins (eg, A, E, D, K) and other nutritional deficiencies. High-protein, high-calorie foods and supplemental enzymes with meals are necessary. · Reproductive: Thickened reproductive secretions (eg, seminal fluid, cervical mucus) or the absence of the vas deferens in men contributes to CF-related infertility. Incorrect Answers: [B. Diabetes insipidus] Diabetes mellitus, not diabetes insipidus, is a potential complication for clients with CF due to pathologic pancreatic changes (eg, fibrosis). [D. Obesity] Due to impaired gastrointestinal absorption, weight loss and failure to thrive are more common and a greater concern than obesity. Educational objective:Cystic fibrosis is an inherited disorder that results in impaired exocrine gland function and is characterized by thickened secretions that affect the pulmonary, gastrointestinal, and reproductive systems. When planning care, the nurse should monitor for priority concerns, including development of respiratory infections, chronic hypoxemia, nutritional deficiencies, and abnormal growth (failure to thrive).

A nurse is speaking with the parent of a toddler who believes the child has a hearing deficit. Which findings support this suspected diagnosis? Select all that apply. A. Behavior appears withdrawn B. Intelligible speech began at age 12 months C. Monotone speech D. Seems attentive, nods, and smiles when given directions E. Speaks with loud voice

Correct Answers: A, C, and E Hearing impairment in children may be related to family history, an infection, use of certain medications, or a congenital disorder. Toddlers with hearing deficits may appear shy, timid, or withdrawn, often avoiding social interaction. They may seem extremely inattentive when given directions and appear "dreamy." Speech is usually monotone, difficult to understand, and loud. Increased use of gestures and facial expressions is also common. Incorrect Answers: [B. Intelligible speech began at age 12 months] Children typically begin to use well-formed syllables such as "mama" and "dada" by approximately age 7 months. A referral for a hearing test should be made if there is an absence of well-formed syllables by age 11 months or intelligible speech is not present by 24 months. [D. Seems attentive, nods, and smiles when given directions] Lack of attentiveness and appropriate response when given a direction is characteristic of a toddler who has a hearing impairment. Educational objective:Hearing impairment in infants delays development of intelligible speech. As these infants become toddlers, they often have a loud voice and monotone speech that is difficult to understand. They appear shy, timid, and inattentive.

The nurse assessing a 2-year-old should expect the child to be able to perform which actions? Select all that apply. A. Build a tower with blocks B. Draw a square C. Hop on one foot D. Say own name E. Walk without help

Correct Answers: A, D, and E Nurses play an important role in identifying appropriate growth and development in all clients. Children who do not meet key developmental milestones for their age should be reported to the health care provider (HCP) to determine the need for further testing. Developmental milestones that a 2-year-old toddler should meet include: · Motor skills: Walks alone, builds block towers, draws lines, kicks a ball · Language: Knows 300+ words, uses 2- to 3-word phrases, states name · Cognitive/social skills: Engages in parallel play, imitates others, exerts independence Incorrect Answers: [B. Draw a square] Normally, a child will develop the ability to draw or copy a square later during the preschool years (age 3-5). [C. Hop on one foot] A 2-year-old client will not yet demonstrate the balance required for this activity. The ability to hop and stand on one foot for 5-10 seconds develops during the preschool years (age 3-6). Educational objective:Developmental assessment findings in 2-year-old clients include the ability to build block towers, say their own name, and walk without assistance. The nurse should notify the HCP if a child is not meeting age-appropriate developmental milestones so the child can be referred for further testing.

The nurse is reinforcing education about home care to the parent of a 10-year-old with cystic fibrosis. Which of the following statements by the parent indicates that teaching has been effective? Select all that apply. A. "Chest physiotherapy is administered only if respiratory symptoms worsen." B. "I will give my child pancreatic enzymes with all meals and snacks." C. "I will increase my child's salt intake during hot weather." D. "Our child will need a high-carbohydrate, high-protein diet." E. "We will limit our child's participation in sports activities."

Correct Answers: B, C, and D In clients with cystic fibrosis (CF), a defective protein responsible for transporting sodium and chloride causes exocrine gland secretions to be thicker and stickier than normal. Viscous respiratory secretions accumulate, resulting in impaired airway clearance and a chronic cough. Clients eventually develop chronic lung disease, which predisposes them to recurrent respiratory infections. Pancreatic enzyme secretion, needed for digestion and absorption of nutrients, is also impaired because thick secretions block pancreatic ducts. Therefore, the client needs supplemental enzymes with all meals and snacks. The client also requires multiple vitamins and a diet high in carbohydrates, protein, and fat to help meet nutritional requirements for growth. Sweat gland abnormalities prevent sodium and chloride reabsorption, causing increased salt loss, dehydration, and hyponatremia during times of significant perspiration. Therefore, parents should increase the child's salt intake and fluids during hot weather, exercise, or fever. Incorrect Answers: [A. "Chest physiotherapy is administered only if respiratory symptoms worsen."] Regardless of symptoms, clients should incorporate chest physiotherapy (eg, percussion, vibration, postural drainage) into their daily routine to improve mucus clearance and lung function. [E. "We will limit our child's participation in sports activities."] The parents should encourage physical activity as tolerated because it helps to thin secretions and remove them from airways and improves muscle strength and lung capacity. Educational objective:Cystic fibrosis causes increased viscosity of exocrine gland secretions. Clients require pancreatic enzyme supplements with all meals and snacks; a diet high in carbohydrates, protein, and fat; and increased salt intake during times of significant perspiration. Clients should also incorporate chest physiotherapy and exercise into their daily routine.

A 2-month-old recently diagnosed with developmental dysplasia of the hip is beginning treatment with a Pavlik harness. Which instructions should the nurse reinforce to the parents? Select all that apply. A. "Apply lotion under the straps to protect the skin." B. "Dress the child in a shirt and knee socks under the straps." C. "Lightly massage the skin under the straps daily." D. "Place the diaper under the straps." E. "Remove the harness during diaper changes."

Correct Answers: B, C, and D. Developmental dysplasia of the hip (DDH) is instability or dislocation of the hip joint that may be present at birth or develop during the first few years of life. Nonsurgical treatment methods, such as a harness or cast, are most successful when initiated during the first 6 months of life. After this time, surgery is frequently required. A Pavlik harness, the most common tool used in treating early DDH, maintains the infant's hips in a slightly flexed and abducted position, allowing for proper hip development. Pavlik harnesses are typically worn for about 3-5 months or until the hip joint is stable. The straps are adjusted periodically by the health care provider to account for infant growth. Instructions on care for the infant wearing a Pavlik harness are as follows: · Regularly assess skin for redness or breakdown under the straps · Dress the child in a shirt and knee socks under the harness to protect the skin · Avoid lotions and powders to prevent irritation and excess moisture · Lightly massage the skin under the straps every day to promote circulation · Only apply 1 diaper at a time as wearing ≥2 diapers (previous treatment practice) increases risk of incorrect hip placement · Apply diapers underneath the straps to keep harness clean and dry The Pavlik harness is usually worn all the time, particularly during the first few weeks of treatment. Some providers may allow the harness to be removed for a short bath once a day, but it should be left in place for all other care activities, including diaper changes. Educational objective:The Pavlik harness maintains the infant's hips in a slightly flexed and abducted position to allow for proper joint development. Care of the infant with a harness includes dressing the child in a shirt and knee socks, keeping the skin dry, regularly assessing for skin breakdown, massaging the skin to promote circulation, and applying diapers under the straps.

The practical nurse is assisting the registered nurse during a physical assessment of a 10-year-old with abdominal discomfort. Which actions does the practical nurse anticipate during the assessment? Select all that apply. A. Ask the accompanying parent to rate and describe the client's pain B. Ask the client to describe the most concerning symptom C. Conduct a head-to-toe examination in a manner similar to an adult examination D. Explain the outcome of the examination to the parent without the client present E. Honor the client's request to be examined without a parent present

Correct Answers: B, C, and E Factors to consider during the physical assessment of school-age children (age 6-12) include the following: · Clients (even those as young as age 3) can tell and/or show the examiner where they hurt or how they feel in their own terms · Clients are capable of understanding and assisting in their physical examination. In fact, school-age clients are usually quite interested in medical equipment and how it works. · Clients develop modesty during this period and some do not want a parent, especially of the opposite sex, in the room with them during a physical examination. This request should be honored. · A head-to-toe sequence is appropriate for this age group. Incorrect Answer: [A. Ask the accompanying parent to rate and describe the client's pain] Pain is the fifth vital sign; its rating and description provide subjective data. School-age children can describe and rate pain accurately. [D. Explain the outcome of the examination to the parent without the client present] If the nurse or parent will not explain the results of the examination, the school-age child may think there is something seriously wrong. Educational objective:When performing a physical examination on a child, it is imperative that the examiner proceed according to developmental age so that the child will be more comfortable and cooperative during the examination.

The nurse is reviewing the medical record of a 4-year-old client with failure to thrive. Which of the following risk factors likely contribute to the client's condition? Select all that apply. A. Child is the youngest of four children in the home B. One parent is incarcerated for spousal abuse C. One parent was diagnosed with anorexia nervosa prior to having children D. One parent works a full-time job outside the home E. Parents are concerned about not having enough money to buy food

Correct Answers: B, C, and E Failure to thrive (FTT) describes a client with poor growth due to inadequate caloric intake, inadequate food absorption, or excess caloric expenditure. In children, a weight that is <80% of ideal weight for height, weight that is below the 3rd to 5th percentile on growth charts, or persistent decrease in growth over time on growth charts support the diagnosis of FTT. Causes of FTT are typically multifactorial but may be related to certain medical conditions (eg, low birth weight, prematurity, congenital anomalies) or influenced by psychosocial risk factors, including: · Domestic violence in the home and/or history of child neglect or abuse · Caregiver or child with negative attitudes toward food (eg, fear of obesity, anorexia, food restriction) · Poverty or food insecurity (which is the greatest risk factor) · Disordered feeding behaviors (eg, unstructured mealtimes) Incorrect Answer: [A. Child is the youngest of four children in the home] Children are not at risk for FTT based on birth order or number of siblings. [D. One parent works a full-time job outside the home] Children with a parent who works outside the home do not have an increased risk for FTT. Educational objective:Failure to thrive (FTT) describes a client with poor growth due to inadequate caloric intake, inadequate food absorption, or excess caloric expenditure. In children, psychosocial risk factors for FTT include lack of structured mealtimes, domestic violence, negative attitudes toward food, and poverty.

The nurse is evaluating a parent's understanding of home care management for a 2-week-old client after initial cast placement for treatment of congenital clubfoot. Which of the following statements by the parent indicate a correct understanding? Select all that apply. A. "Cradling my baby in my arms may cause stress and damage to the cast." B. "I will check my baby's toes several times a day to ensure that they are pink and warm." C. "My baby should alternate between sleeping on the stomach and back." D. "My baby will need to have a new cast applied weekly for 5-8 weeks." E. "When I bathe or diaper my baby, I will be sure to keep the cast dry."

Correct Answers: B, D, and E Clubfoot (ie, talipes equinovarus) is a congenital bone deformity and soft tissue contracture manifested by one or both feet being turned inward. The health care provider typically begins management of the deformity soon after birth by manipulation and stretching of the affected foot and placing a long-leg cast. Weekly recasting over 5-8 weeks (ie, Ponseti method) is necessary to gradually reposition the foot. To maintain the correction after successful casting, the client commonly wears custom shoes secured to a bar brace. To prevent recurrence, long-term follow-up continues until the child attains skeletal maturity. The nurse should teach parents about cast care, which includes monitoring the client's circulation (eg, toes pink and warm) and keeping the cast dry during diapering and bathing to prevent skin irritation or infection. Incorrect Answers: [A. "Cradling my baby in my arms may cause stress and damage to the cast."] Parents should continue to cradle and hold their infants to encourage bonding and attachment. [C. "My baby should alternate between sleeping on the stomach and back."] Parents should place infants to sleep in the supine position. Placing an infant on the stomach to sleep increases the risk for sudden infant death syndrome. Educational objective:Clients with clubfoot typically receive manipulation and stretching of the affected foot and serial casting soon after birth to correct the deformity. The nurse should instruct parents about cast care, which includes monitoring for adequate circulation (eg, toes pink and warm) and keeping the cast dry.

The pediatric nurse cares for a 16-year-old client who is scheduled for an appendectomy in the morning. Which of the following interventions are appropriate to support the client's psychosocial needs? Select all that apply. A. Create a strict daily schedule for the client while hospitalized B. Encourage the client to have peers visit while hospitalized C. Ensure parental presence during any client procedure D. Include the client as an active participant when planning care E. Support the client in discussing concerns about body image changes

Correct Answers: B, D, and E Pediatric clients are at increased risk for impaired psychosocial integrity during stressful experiences (eg, hospitalization, surgical procedures, medical treatment) and require developmentally appropriate care based on their age to assist with managing stress. Unaddressed or ineffectively managed developmental needs may lead to or worsen the client's anxiety, disobedient behavior, and/or social withdrawal. Developmentally appropriate nursing care for an adolescent client includes: · Encouraging interaction with peers (eg, hospital visits, internet communication), which supports the developmental need for social connection and support and reduces stress and anxiety · Involving the client in care planning to address the developmental needs for control and independence · Assisting the client to discuss emotions or fears related to treatment (eg, changes in body image, disability, possibility of death) to improve coping, support the developmental need for understanding, and decrease anxiety Incorrect Answers: [A. Create a strict daily schedule for the client while hospitalized] Strict scheduling by the nurse reduces the adolescent's perception of control and independence, which may increase stress. Adolescents should be allowed to determine their daily schedule when possible. [C. Ensure parental presence during any client procedure] Loss of privacy (eg, forced parental presence) can increase anxiety in the adolescent client. Adolescents should be asked if they want parents present for procedures and what level of parental involvement they prefer. Educational objective:Nursing care for the hospitalized adolescent client needs to be developmentally appropriate and promote the elimination of stressors. The nurse should encourage adolescent clients to interact with peers, discuss emotions or fears about treatments, and involve the client in decision-making regarding the plan of care.

A nurse is performing an assessment of a 12-month-old child. Which of the following findings would the nurse expect? Select all that apply. A. Approaches strangers with ease B. Birth weight is tripled C. Can skip and hop on one foot D. Fully developed pincer grasp E. Sits from a standing position

Correct Answers: B, D, and E The first 12 months of life are characterized by rapid growth and development. By age 12 months, the child's birth weight should be about tripled. A 12-month-old child should have mastered the gross motor skill of sitting down from a standing position without assistance. The pincer grasp (ie, use of the thumb and forefingers to pick up objects) is an important fine motor skill that should also be fully developed by this age. Incorrect Answers: [A. Approaches strangers with ease] Stranger anxiety is well developed by age 8 months and continues into the toddler years. At age 12 months, the child typically prefers the parents and exhibits fear when separated. [C. Can skip and hop on one foot] The gross motor skills of skipping and hopping on one foot do not usually occur until around age 4. Educational objective:Assessment findings of a 12-month-old child should include a weight that is approximately triple the birth weight. Expected motor skills include the ability to sit from a standing position without assistance and to use a fully developed pincer grasp.

The nurse is caring for a 7-year-old client diagnosed with nephrotic syndrome who will be discharged soon. Which statement by the parent indicates the need for further teaching? A. "I'll provide a healthy diet without added salt for my child." B. "I'll organize playdates to keep my child's spirits up during relapses." C. "I'll restrict my child's fluids if I notice swelling or rapid weight gain." D. "I'll test for protein in my child's urine every day."

Correct Answers: B. "I'll organize playdates to keep my child's spirits up during relapses." Nephrotic syndrome, an autoimmune disease, affects children age 2-7 and is characterized by increased permeability of the glomerulus to proteins (eg, albumin, immunoglobulins, natural anticoagulants). Loss of albumin in urine leads to hypoalbuminemia; this causes decreased plasma oncotic pressure, which allows fluid to leak out of the vascular spaces. Reduced plasma volume (hypovolemia) activates kidneys to retain salt and water (via the renin-angiotensin-aldosterone system). Clients experience generalized edema, weight gain, loss of appetite (from ascites), and decreased urine output. The loss of immunoglobulins causes increased susceptibility to infection. Caregivers should minimize the risk of infection during relapses (eg, limiting visitors). Treatment typically includes: · Corticosteroids and other immunosuppressants (eg, cyclosporine) · Loss of appetite management (eg, making foods fun and attractive) · Infection prevention (eg, limiting social interaction until the child is in remission) Incorrect Answers: [A. "I'll provide a healthy diet without added salt for my child."] A regular diet without added salt is prescribed to prevent edema while in remission. More stringent sodium restrictions are necessary when symptoms are present. [C. "I'll restrict my child's fluids if I notice swelling or rapid weight gain."] Fluid restriction is needed in cases of edema or rapid weight gain. [D. "I'll test for protein in my child's urine every day."] There is a high risk for recurrence after recovery, and relapses may occur several times per year. The parent/caregiver should test daily for proteinuria, weigh the child weekly, and keep a diary of results. Educational objective:Nephrotic syndrome is characterized by massive proteinuria, edema, and hypoalbuminemia. Home management includes a low-sodium diet with attractive foods; infection prevention; fluid restriction for severe edema; and monitoring of weight gain and proteinuria to detect relapse.

The summer camp nurse and parent of a 9-year-old with juvenile idiopathic arthritis (JIA) are discussing appropriate physical activities for the child. Which of the following activities should be included? Select all that apply. A. Dodgeball B. Reading a book C. Stationary bicycling D. Swimming E. Yoga

Correct Answers: C, D, and E Children with JIA are at high risk for becoming deconditioned due to decreased muscle strength and endurance and overall capacity for exercise. They tend to tire quickly even when the disease is in remission. Both aerobic and anaerobic exercise can help minimize this risk, and resistance training can increase muscle strength and endurance. Exercise may also have a positive effect on low bone density, a secondary condition often associated with JIA. In general, low-impact, weight-bearing, and non-weight-bearing exercises that involve range of motion and stretching to preserve joint mobility and strengthen muscles are best. High-impact activities and those that cause overtiring and joint pain should be avoided. Swimming is often considered the ideal activity for children with JIA as it allows for exercising a large number of joints with minimal gravitational pull. Other recommended activities include riding a stationary bike, throwing or kicking a ball, low-impact aerobic dancing, walking, and yoga. Incorrect Answers: [A. Dodgeball] Playing dodgeball places the child at risk for joint or other injury. [B. Reading a book ] Reading a book does not provide physical activity. Educational objective:Exercise and physical activity for the child with JIA are important to prevent joint deformity and maintain muscle strength and endurance. The best activities are those that are low impact; these can be weight bearing or non-weight bearing. Examples include swimming, riding a stationary bike, throwing or kicking a ball, and yoga.

The nurse monitors a child who has been treated for an acute asthma exacerbation. Which finding is the best indicator that treatment has been effective? A. Episodes of spasmodic coughing have decreased B. No wheezes are audible on chest auscultation C. Oxygen saturation has increased from 88% to 93% D. Peak expiratory flow rate has dropped from 212 L/min to 127 L/min

Correct Answers: C. Oxygen saturation has increased from 88% to 93% Asthma is a chronic condition characterized by inflammation, swelling, and narrowing of the airways in the lungs. The client having an acute attack will experience chest tightness, wheezing, uncontrollable coughing, rapid respirations, retractions, and anxiety and panic. Treatment of an acute attack can include nebulized breathing treatment with a short-acting beta-agonist medication such as albuterol, and oral or IV corticosteroids. Oxygen saturation is the best indicator of treatment effectiveness as it reflects gas exchange. Incorrect Answer: [A. Episodes of spasmodic coughing have decreased] Decreased coughing may indicate improvement, but it is more subjective than measurement of oxygen saturation. In addition, it may be a sign of client exhaustion and worsening asthma. [B. No wheezes are audible on chest auscultation] The absence of wheezes may indicate resolution of the attack or progression of airway swelling to the point of little air flowing through the lungs. [D. Peak expiratory flow rate has dropped from 212 L/min to 127 L/min] Peak expiratory flow rate, by measuring how much air a person can exhale, indicates the amount of airway obstruction. Following treatment for an acute asthma attack, an increase, not a decrease, in peak expiratory flow would be expected. Educational objective:Improvements in oxygen saturation and peak expiratory flow are the best indicators of treatment effectiveness during an acute asthma attack.

The nurse is caring for a 10-year-old diagnosed with osteomyelitis. What is the best activity the nurse can suggest to promote age-specific growth and development during hospitalization? A. Fantasy play with puppets B. Invite friends to come visit C. Provide missed schoolwork D. Watch favorite movies

Correct Answers: C. Provide missed schoolwork According to Erikson's stages of psychosocial development, school-age children deal with the conflict of industry versus inferiority. Attaining a sense of industry (competence) is the most significant developmental goal for children age 6-12. Parents should therefore be encouraged to provide a hospitalized child with missed school work on a regular basis. This will help the child keep up with school demands, learn new skills, cope with the stressors of hospitalization, and avoid a sense of inferiority. Incorrect Answers: [A. Fantasy play with puppets] Fantasy play with puppets is more appropriate for a preschool-age child as imaginary play and magical thinking peak during this stage of development. [B. Invite friends to come visit] Although school-age children enjoy spending time with friends, peer relationships are significantly more important during the adolescent period. [D. Watch favorite movies] Watching television is a good diversion for all hospitalized children, but it does not promote age-specific growth and development. Educational objective:According to Erikson's stages of psychosocial development, school-age children deal with the conflict of industry versus inferiority. During this stage, unlike other developmental stages, learning is a priority and completing school work provides a sense of accomplishment and satisfaction. It is therefore important that parents provide hospitalized school-age children with missed school work on a regular basis.

The summer camp nurse and parent of a 9-year-old with juvenile idiopathic arthritis (JIA) are discussing appropriate physical activities for the child. Which of the following activities should be included? Select all that apply. A. Dodgeball B. Reading a book C. Stationary bicycling D. Stationary bicycling E. Swimming F. Yoga

Correct Answers: D, E, and F Children with JIA are at high risk for becoming deconditioned due to decreased muscle strength and endurance and overall capacity for exercise. They tend to tire quickly even when the disease is in remission. Both aerobic and anaerobic exercise can help minimize this risk, and resistance training can increase muscle strength and endurance. Exercise may also have a positive effect on low bone density, a secondary condition often associated with JIA. In general, low-impact, weight-bearing, and non-weight-bearing exercises that involve range of motion and stretching to preserve joint mobility and strengthen muscles are best. High-impact activities and those that cause overtiring and joint pain should be avoided. Swimming is often considered the ideal activity for children with JIA as it allows for exercising a large number of joints with minimal gravitational pull. Other recommended activities include riding a stationary bike, throwing or kicking a ball, low-impact aerobic dancing, walking, and yoga. Incorrect Answers: [A. Dodgeball] Playing dodgeball places the child at risk for joint or other injury. [B. Reading a book] Reading a book does not provide physical activity. Educational objective:Exercise and physical activity for the child with JIA are important to prevent joint deformity and maintain muscle strength and endurance. The best activities are those that are low impact; these can be weight bearing or non-weight bearing. Examples include swimming, riding a stationary bike, throwing or kicking a ball, and yoga.

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bow legged

The nurse in a clinic is obtaining a developmental history of an 18-month-old during a well-child visit. Which activities should the child be expected to perform? Select all that apply. A. Goes up stairs while holding a hand B. Knows approximately 350 words C. Runs without falling D. Stacks 6 blocks in a tower E. Turns 2 pages in a book at a time

Correct Answer: A and E A toddler's development centers on both fine and gross motor skills. By 18 months, the toddler should be able to manage stairs while holding a hand and turn 2 or 3 pages in a book. The direction of development is toward improving locomotion skills. Incorrect Answers: [B. Knows approximately 350 words] A 24-month-old should be able to build a tower of 6 or 7 blocks, run without falling, and have a vocabulary containing over 300 words. [C. Runs without falling] A 24-month-old should be able to build a tower of 6 or 7 blocks, run without falling, and have a vocabulary containing over 300 words. [D. Stacks 6 blocks in a tower] A 24-month-old should be able to build a tower of 6 or 7 blocks, run without falling, and have a vocabulary containing over 300 words. Educational objective:An 18-month-old typically is developing both fine and gross motor skills, which include going up stairs while holding a hand and turning 2 or 3 pages in a book.

The nurse assists with a staff education conference about appropriate nonpharmacological pain-management interventions for newborns and infants. Which of the following strategies should be included in the presentation? Select all that apply. A. Administer an oral sucrose solution to a newborn during a circumcision procedure B. Apply a cold pack to a newborn's heel 30 minutes before performing a heel stick C. Assist the parent to hold a newborn skin-to-skin during an immunization injection D. Offer a pacifier to an infant while performing venipuncture E. Swaddle an infant while leaving one arm unwrapped during an IV dressing change

Correct Answer: A, C, D, and E Painful procedures (eg, capillary heel sticks, immunizations) are frequently required to provide optimal care but may cause considerable stress or alterations in a client's status (eg, vital sign changes, instability) without proper management. Nonpharmacological pain management is a method for stopping or reducing the sensation of pain and may eliminate or decrease the need for pharmacological intervention. Appropriate nonpharmacological pain-management interventions for infants and newborns include: · Offering concentrated sucrose, if prescribed, which is associated with reduced indicators of pain (eg, presence and duration of crying, grimacing) · Assisting the parent to hold the infant skin-to-skin (kangaroo care), which provides sensory stimulation that is calming and reduces indicators of pain · Offering nonnutritive sucking interventions (eg, pacifiers), which help calm the infant during painful procedures · Swaddling the infant, which provides a sense of comfort and security and reduces the heart rate and incidences of crying Incorrect Answer: [B. Apply a cold pack to a newborn's heel 30 minutes before performing a heel stick] Before a heel stick is performed, a warm (not cold) pack should be applied to help facilitate blood flow to the area. Although a cold pack is a nonpharmacological pain-management technique, it causes vasoconstriction and impedes blood flow, which may result in a need to apply pressure to obtain blood or to perform multiple heel sticks. Educational objective:Nurses performing painful procedures (eg, capillary heel sticks) should implement pain-management techniques to promote the client's comfort and stability. Appropriate nonpharmacological interventions for newborns and infants include concentrated sucrose solutions, skin-to-skin contact, nonnutritive sucking (eg, pacifiers), and swaddling.

A 12-month-old client has a high blood lead level of 18 mcg/dL. The nurse is reinforcing teaching about lead poisoning to the parents. Which statements made by a parent indicate that teaching has been successful? Select all that apply. A. "I should have our home inspected for the source of lead." B. "I will vacuum our hard-surface floors daily." C. "I will wash my child's hands often, especially before eating." D. "We should use hot water from the tap for cooking." E. "We will have to return for a follow-up lead level."

Correct Answer: A, C, and E Lead poisoning occurs from repeated lead exposure, either via ingestion of lead-based paints (eg, walls, toys), glazes (eg, pottery), or water from lead pipes or via inhalation of contaminated dust or soil found around older homes. Elevated blood lead levels (BLLs) impair neural, blood, and renal development. A BLL screening is recommended at ages 1-2 or up to age 6 if the child was not previously screened. Clients with elevated BLLs (≥5 mcg/dL) require follow-up blood work to ensure that levels decrease. Chelation therapy may be required if levels remain elevated. The priority intervention for clients with elevated BLLs is preventing continued exposure. The home environment should be inspected for lead sources. Pediatric and pregnant clients should not live in homes being renovated until work is complete. Handwashing, especially before eating, is important for removing lead residue. Incorrect Answer: [B. "I will vacuum our hard-surface floors daily."] Vacuuming spreads lead dust in the air, which increases inhalation exposure. Hard surfaces should be wet-dusted or mopped at least weekly. [D. "We should use hot water from the tap for cooking."] Hot water dissolves lead from older pipes; therefore, cold water should be used for consumption if lead plumbing is present. Taps should be flushed for several minutes to clear out contaminated water before use. Educational objective:Pediatric clients are at risk for lead poisoning from environmental exposure in the home (eg, paint, dust, plumbing). Clients with elevated blood lead levels require monitoring. Lead sources in the home should be removed or mitigated (eg, handwashing, wet dusting/mopping) to prevent further exposure.

A nurse preceptor on a pediatric unit is reviewing interventions with a student nurse who will be caring for a toddler. What are appropriate activities to minimize the effect of hospitalization on a toddler? Select all that apply. A. Integrate preferred snack foods in the day's routine B. Explain the body changes that may occur C. Plan quiet play prior to usual nap time D. Post a daily schedule by the child's bed E. Provide 1 or 2 options when choosing toys

Correct Answer: A, C, and E Toddlers (age 1-3) display an egocentric approach as they strive for autonomy. They attempt to control their experiences through intense emotional displays, such as temper tantrums or forceful negative responses (eg, "no!"). Hospitalization causes loss of a toddler's usual routines and rituals, often resulting in regressive behavior. The toddler may also be frequently separated from the parents, leading to separation anxiety. Nursing care activities should be similar to the toddler's home routines and include providing preferred snacks and anticipating nap time. The toddler should be given options rather than asked yes/no questions to limit any potential negative responses. It is also important to encourage participation and parental presence whenever possible. Incorrect Answer: [B. Explain the body changes that may occur] This is an appropriate activity when working with adolescents as they are often very concerned with outward changes that may occur as a result of illness or surgery. [D. Post a daily schedule by the child's bed] This is an appropriate activity when working with school-age children after they have grasped the concept of time. Toddlers have not yet reached this level of cognition. Educational objective:Toddlers react to the experience of hospitalization with a display of intense emotions, regressive behaviors, and manifestations of separation anxiety. Nursing care should focus on integrating a toddler's home routines into planned activities.

A client with a ventriculoperitoneal shunt has a dazed appearance and grunting and has not responded to the caregiver for 10 minutes. Status epilepticus is suspected. Which nursing intervention should be performed first? A. Administer rectal diazepam B. Assess for neck stiffness and Brudzinski sign C. Draw blood for laboratory studies D. Transport the client to CT for assessment of shunt malfunction

Correct Answer: A. Administer rectal diazepam This client is in status epilepticus, a serious and life-threatening emergency in which a client has been seizing for 5 minutes or longer. Grunting and a dazed appearance are 2 common signs. A client with hydrocephalus (abnormal collection of cerebrospinal fluid in the head) and a ventriculoperitoneal (VP) shunt is at a higher risk for seizures. Stopping seizure activity is the first nursing priority. IV benzodiazepines (diazepam or lorazepam) are used acutely to control seizures. However, rectal diazepam is often prescribed when the IV form is unavailable or problematic. Parents often get prescriptions for rectal diazepam and are advised to administer a dose before bringing a child to the emergency department. Incorrect Answer: [B. Assess for neck stiffness and Brudzinski sign] Stopping the status epilepticus is a priority over determining its cause through a neurologic assessment. Quickly obtaining the oxygen saturation level and managing the airway are priority assessments. [C. Draw blood for laboratory studies] Blood draw is needed for laboratory studies but is not a priority over stopping the seizure. [D. Transport the client to CT for assessment of shunt malfunction] A VP shunt drains excess fluid in the brain down to the abdomen, where it is absorbed by the body. A CT scan can accurately assess shunt malfunction. Any malfunction would need to be treated promptly to prevent future seizures and damage. Finding the cause of the seizure is important and should be done as soon as seizing has stopped. Educational objective:Status epilepticus is a serious condition that could result in brain damage and death. Quickly stopping the seizure is the first nursing priority as long as there is an adequate airway and the client is breathing. IV or rectal benzodiazepines (lorazepam or diazepam) are used to rapidly control seizures.

A newborn is being evaluated for possible esophageal atresia with tracheoesophageal fistula. Which finding is the nurse most likely to observe? A. Choking and cyanosis during feeding B. Concave (scaphoid) abdomen C. Diminished lung sounds D. Projectile vomiting after feeding

Correct Answer: A. Choking and cyanosis during feeding Esophageal atresia (EA) and tracheoesophageal fistula (TEF) consist of a variety of congenital malformations that occur when the esophagus and trachea do not properly separate or develop. In the most common form of EA/TEF, the upper esophagus ends in a blind pouch and the lower esophagus connects to the primary bronchus or the trachea through a small fistula. EA/TEF can usually be corrected with surgery. Clinical manifestations of EA/TEF include frothy saliva, coughing, choking, and drooling. Clients may also develop apnea and cyanosis during feeding. Aspiration is the greatest risk for clients with EA/TEF, and newborns who demonstrate signs of the condition are immediately placed on nothing by mouth (NPO) status. Incorrect Answers: [B. Concave (scaphoid) abdomen] A newborn with EA/TEF may have a distended abdomen due to the buildup of air in the stomach via the fistula from the trachea to the lower esophagus. A concave (ie, scaphoid) abdomen is associated with a congenital diaphragmatic hernia due to the migration of abdominal organs to the thoracic space. [C. Diminished lung sounds] Diminished lung sounds are not an ordinary sign of EA/TEF unless aspiration pneumonia develops. These may be an indication of a diaphragmatic hernia or pneumothorax. [D. Projectile vomiting after feeding] A newborn with EA/TEF may experience apnea, choking, and cyanosis due to aspiration of fluid while eating. Projectile vomiting after feeding is a classic manifestation of hypertrophic pyloric stenosis. Educational objective:Clinical manifestations of EA/TEF include frothy saliva, coughing, choking, drooling, and a distended abdomen. Clients may also develop apnea and cyanosis while feeding. These findings must be reported to the health care provider for further evaluation.

A nurse is caring for a 3-month-old infant who has bacterial meningitis. Which clinical findings support this diagnosis? Select all that apply. A. Depressed anterior fontanelle B. Frequent seizures C. High-pitched cry D. Poor feeding E. Presence of Babinski sign F. Vomiting

Correct Answer: B, C, D, and F Bacterial meningitis is an inflammation of the meninges in the brain and spinal cord that is caused by specific types of bacteria, including group B streptococcal, meningococcal, or pneumococcal pathogens. Clinical manifestations of bacterial meningitis in infant age <2 include: · Fever or possible hypothermia · Irritability, frequent seizures · High-pitched cry · Poor feeding and vomiting · Nuchal rigidity · Bulging fontanelle possible but not always present One of the most common acute complications of bacterial meningitis in children is hydrocephalus. Long-term complications include hearing loss, learning disabilities, and brain damage. Due to the severity of potential complications, prompt identification and immediate treatment are vital for any client with suspected bacterial meningitis. Incorrect Answers: [A. Depressed anterior fontanelle] Infants with bacterial meningitis may have bulging fontanelles due to an increase in intracranial pressure. Depressed fontanelles indicate severe dehydration. [E. Presence of Babinski sign] The Babinski reflex can be present up to 1-2 years and is a normal expected finding; it does not indicate meningitis. Educational objective:Bacterial meningitis is inflammation of the meninges in the brain and spinal cord caused by bacterial infection. Key characteristics of bacterial meningitis in infants under age 2 include frequent seizures, a high-pitched cry, poor feeding, nuchal rigidity, and possible bulging fontanelles.

The school nurse creates a cafeteria menu for a newly enrolled child with celiac disease. Which lunches would be appropriate for this child? Select all that apply. A. Beef barley soup with mixed vegetables and French bread B. Grilled chicken, baked potato, and strawberry yogurt C. Mexican corn tacos with ground beef and cheese D. Peanut butter and jelly on rice cakes with an oatmeal cookie E. Rice noodles with chicken and broccoli

Correct Answer: B, C, and E Celiac disease (celiac sprue) is an autoimmune disorder in which the body is unable to process gluten, a protein found in most grains. Gluten consumption will damage the villi of the small intestine; this results in malabsorption of fats (steatorrhea, foul-smelling stools) and other nutrients, which can lead to malnutrition and failure to thrive. The child will need to adhere to a gluten-free diet for life. Rice, corn, and potatoes are gluten free and are allowed in the diet. A child with celiac disease cannot eat barley, rye, oats, or wheat (mnemonic - BROW). Incorrect Answer: [A. Beef barley soup with mixed vegetables and French bread] A child with celiac disease cannot consume barley or French bread as both contain gluten. [D. Peanut butter and jelly on rice cakes with an oatmeal cookie] Peanut butter and jelly on rice cakes are permitted but not the oatmeal cookie. Educational objective:Celiac disease is an autoimmune disorder in which an individual cannot tolerate gluten, a protein found in barley, rye, oats, and wheat (BROW). Rice, corn, and potatoes are allowed in the diet and can be used as grain substitutes. Affected individuals must adhere to a gluten-free diet for life.

The nurse is collecting data on a 2-day-old infant with suspected Hirschsprung disease. Which findings should the nurse anticipate? Select all that apply. A. Bright red bleeding from anus B. Distended abdomen C. Has not passed stool (meconium) D. Nonbilious vomiting E. Refuses to feed

Correct Answer: B, C, and E In Hirschsprung disease, or congenital aganglionic megacolon, a child is born with a lack of specialized nerve cells in some sections of the distal large intestine; this renders the internal anal sphincter unable to relax. As a result, there is no peristalsis and stool is not passed. Newborns exhibit symptoms of distal intestinal obstruction (eg, distended abdomen, difficulty feeding, vomiting green bile) and do not pass meconium within the expected 24-48 hours. In less severe cases of the disease, the diagnosis may not be made until the child is older. Clinical manifestations include chronic constipation that is not psychogenic in nature and ribbon- or pellet-like stools. Incorrect Answer: [A. Bright red bleeding from anus] Bright red rectal bleeding could be a symptom of Meckel diverticulum, a remnant of the umbilical cord that should have disintegrated at 8 weeks in utero but became an outpouch in the small intestine. Rectal bleeding is not seen with Hirschsprung disease. [D. Nonbilious vomiting] Nonbilious vomiting is seen in conditions in which the pathology is proximal to the pylorus (eg, hypertrophic pyloric stenosis). Bilious (green) vomiting is seen in conditions in which the pathology is distal to the duodenum as the common bile duct drains at the duodenum. Educational objective:Hirschsprung disease is caused by a lack of specialized nerve cells in portions of the distal large intestine; this renders the internal sphincter unable to relax. An infant with Hirschsprung disease will not pass meconium but will have a distended abdomen and bilious emesis.

The nurse is monitoring a 12-month-old diagnosed with intussusception. Which findings should the nurse expect? Select all that apply. A. Palpable olive-shaped mass in epigastrium B. Palpable sausage-shaped mass in upper right quadrant C. Projectile vomiting containing blood D. Screaming and drawing the knees up to the chest E. Stool mixed with blood and mucus

Correct Answer: B, D, and E Intussusception is a common obstructive disorder in infancy that occurs when one segment of the bowel telescopes into another. The classic clinical triad is intermittent, severe, crampy abdominal pain; a palpable "sausage-shaped" mass on the right side of the abdomen; and "currant jelly" stools. Other manifestations include inconsolable crying, drawing the knees up to the chest during episodes of pain, and vomiting. The child may appear normal and comfortable between episodes. Incorrect Answer: [A. Palpable olive-shaped mass in epigastrium] Infants with infantile hypertrophic pyloric stenosis often present with excessive hunger (frequent feeder), a palpable olive-shaped mass in the epigastrium to the right of the umbilicus, and projectile vomiting (can be up to 3 feet). [C. Projectile vomiting containing blood] Projectile vomiting (without blood) is seen with pyloric stenosis and elevated intracranial pressure. Bloody vomiting is seen with gastric ulcers and variceal bleed. Intussusception causes non-projectile vomiting that is usually non-bloody, but stools mixed with mucus and blood are seen. Educational objective:The classic clinical triad of intussusception is intermittent, severe, crampy abdominal pain; a palpable sausage-shaped mass on the right side of the abdomen; and currant jelly stools.

The clinic nurse supervises a graduate nurse who is reinforcing teaching about home management to the parents of a 2-year-old with acute diarrhea. The nurse would need to intervene when the graduate nurse reinforces which instruction? A. "Do not give your child antidiarrheal medications." B. "Follow the bananas, rice, applesauce, and toast diet for the next few days." C. "Record the number of wet diapers and return to the clinic if you notice a decrease." D. "Use a skin barrier cream such as zinc oxide in the diaper area until diarrhea subsides."

Correct Answer: B. "Follow the bananas, rice, applesauce, and toast diet for the next few days." During bouts of acute diarrhea and dehydration, treatment focuses on maintaining adequate fluid and electrolyte balance. The first-line treatment is oral rehydration therapy, which involves using oral rehydration solutions (ORS) to increase reabsorption of water and sodium. Even if the diarrhea is accompanied by vomiting, ORS should still be offered in small amounts at frequent intervals. Continuing the child's normal diet (solid foods) is encouraged as it shortens the duration and severity of diarrhea. The BRAT (bananas, rice, applesauce, and toast) diet is not recommended as it does not provide sufficient protein or energy. Incorrect Answer: [A. "Do not give your child antidiarrheal medications."] Use of antidiarrheal medications is discouraged as these have little effect in controlling the condition and may actually be harmful by prolonging some bacterial infections and causing fatal paralytic ileus in children. [C. "Record the number of wet diapers and return to the clinic if you notice a decrease."] Parents should be taught to monitor their child for signs of dehydration by checking the amount of fluid intake, number of wet diapers, presence of sunken eyes, and condition of the mucous membranes. [D. "Use a skin barrier cream such as zinc oxide in the diaper area until diarrhea subsides."] Protecting the perineal skin from breakdown during bouts of diarrhea can be accomplished by using skin barrier creams (eg, petrolatum, zinc oxide). Educational objective:When a child has acute diarrhea, the priority is to monitor for dehydration. Treatment is accomplished with oral rehydration solutions and early reintroduction of the child's normal diet (usual foods).

The nurse is reinforcing teaching on behavioral strategies to treat fecal incontinence due to functional constipation to the parent of a 6-year-old. Which statement by the parent indicates a need for further teaching? A. "I will give my child a picture book to look at during toilet time." B. "I will give my child a reward for each bowel movement made while sitting on the toilet." C. "I will keep a log of my child's bowel movements, laxative use, and episodes of soiling." D. "I will schedule regular toilet sitting time for my child."

Correct Answer: B. "I will give my child a reward for each bowel movement made while sitting on the toilet." Fecal incontinence (ie, encopresis, soiling) refers to the repeated passage of stool in inappropriate places by children age ≥4 years. In more than 80% of cases, it is due to functional constipation (retentive type); in about 20% of cases, it may be caused by psychosocial triggers (nonretentive type). Management of fecal incontinence/constipation includes 3 primary components: Disimpaction followed by prolonged laxative therapy, dietary changes (increased fiber and fluid intake), and behavior modification. Behavioral strategies are used to promote and restore regular toileting habits and to gain the child's cooperation and participation in the treatment program. Behavioral interventions include the following: · Regularly schedule toilet sitting times 5-10 minutes after meals for 10-15 minutes. · Provide a quiet activity for the child during toilet sitting, which will help pass the time and make the experience more "enjoyable". · Initiate a reward system to boost the child's participation in the treatment program; the reward would be given for effort, not for success of evacuation in the toilet (children with retentive encopresis have dysfunctional anal sphincters and little control over bowel movements; it would not be effective to give a reward for something over which the child has no control). · Keep a diary or log of toilet sitting times, stooling, medications, and episodes of soiling to evaluate the success of the treatment. Educational objective:A reward system is a behavioral strategy used in the treatment of functional incontinence (due to constipation). The reward is given to encourage the child's involvement in the treatment to restore normal bowel function. Rewards are given for the child's effort and participation, not for having bowel movements while sitting on the toilet.

A child is scheduled to have an electroencephalogram (EEG). Which statement by the parent indicates understanding of the teaching? A. "I will let my child drink cocoa as usual the morning of the procedure." B. "I will wash my child's hair using shampoo the morning of the procedure." C. "My child may have scalp tenderness where the electrodes were applied." D. "My child will not remember the procedure."

Correct Answer: B. "I will wash my child's hair using shampoo the morning of the procedure." An electroencephalogram (EEG) is a diagnostic procedure used to evaluate the presence of abnormal electrical discharges in the brain, which may result in a seizure disorder. The EEG can be done in a variety of ways, such as with the child asleep or awake with or without stimulation. Teaching for the parents includes the following: 1. Hair should be washed to remove oils and hair care products, and accessories such as ribbons or barrettes should be removed. Hair may need to be washed after the procedure to remove electrode gel. 2. Avoid caffeine, stimulants, and central nervous system depressants prior to the test. 3. The test is not painful, and no analgesia is required. Incorrect Answer: [A. "I will let my child drink cocoa as usual the morning of the procedure."] Food and liquids are not restricted prior to an EEG except for caffeinated beverages. Cocoa contains caffeine. [C. "My child may have scalp tenderness where the electrodes were applied."] This test (EEG) is not painful as it only records brain electrical activity. Electrode gel is nonirritating to the skin. [D. "My child will not remember the procedure."] A routine EEG is not performed under sedation, and so the child should remember the procedure. Educational objective:An EEG is used to diagnose the presence of a seizure disorder. Electrodes are secured to the scalp to observe for abnormal electrical discharges in the brain. Preprocedure teaching includes avoiding stimulants and CNS depressants and washing the hair.

A newborn has a large myelomeningocele. What nursing intervention is priority? A. Assess the anus for muscle tone B. Cover the area with a sterile, moist dressing C. Measure the occipital frontal circumference D. Place the newborn supine with the head of the bed elevated

Correct Answer: B. Cover the area with a sterile, moist dressing Myelomeningocele occurs when the neural tube fails to fuse properly during fetal development. An outpouching of spinal fluid, spinal cord, and nerves covered by only a thin membrane occurs, typically in the lumbar area. The newborn is at high risk for infection at this area. A priority nursing intervention is to cover the area with a sterile, moist dressing to decrease the risk of infection until surgical repair can occur. Incorrect Answers: [A. Assess the anus for muscle tone] Assessing for an anal wink will assist in the assessment of the level of neurologic deficit but is not a priority intervention. [C. Measure the occipital frontal circumference] Myelomeningocele may decrease the absorption of cerebrospinal fluid, which would place the newborn at risk for hydrocephalus from the excess cerebrospinal fluid. An occipital frontal circumference is needed as a baseline measurement but is not a priority. [D. Place the newborn supine with the head of the bed elevated] The newborn would be placed in the prone position (with face turned to the side) to prevent rupture of the myelomeningocele. Educational objective:The newborn with a myelomeningocele is at risk for infection. Covering the myelomeningocele with a sterile, moist dressing is indicated to decrease the risk of infection at the site. The infant should be placed on the abdomen (prone) with the face turned to the side.

The nurse is observing the parent feed a 3-month-old diagnosed with gastroesophageal reflux. Which action by the parent indicates that further teaching is necessary? A. The parent does not push the infant to finish the bottle B. The parent engages the infant in active play after the feeding C. The parent interrupts the feeding to burp the infant D. The parent supports the infant upright during the feeding

Correct Answer: B. The parent engages the infant in active play after the feeding Gastroesophageal reflux (GER) is attributed to an immature lower esophageal sphincter. It is common in infants age ≤3 months and results in spitting up after feeds. If an infant is gaining weight and meeting developmental milestones, treatment is aimed at controlling the symptoms. Because infants with GER are at risk for aspiration and apnea, caregivers should be instructed in cardiopulmonary resuscitation. For at least 30 minutes after feeding, these infants should not be rocked or agitated by active play but should be kept calm and upright. Incorrect Answers: [A. The parent does not push the infant to finish the bottle] Infants with GER should be offered small frequent feedings and not be pushed to complete a feeding when demonstrating satiety. [C. The parent interrupts the feeding to burp the infant] To minimize reflux, the feedings should be interrupted after every 1-2 ounces for burping the infant as waiting until the feeding is complete will increase the chance of regurgitation. [D. The parent supports the infant upright during the feeding] Maintaining the infant in an upright position during and after feedings will minimize spitting up. Infants should not be placed in a car seat after feedings as this can increase intra-abdominal pressure, causing reflux. An infant's head should be elevated 30 degrees when placed in an infant seat. Educational objective:Infants with gastroesophageal reflux should be offered small frequent feeds, burped frequently during the feeding, and kept in an upright position during and after the feeding.

The nurse is reinforcing teaching to the parents of a 6-month-old child who has been given a new prescription for a liquid iron supplement. Which statements by the parents indicate a need for further teaching? Select all that apply. A. "Our child might become constipated while taking this medication." B. "Our child's stools might become black and tarry." C. "We can give the dose with milk to prevent gastric irritation." D. "We will administer the dose into the back of our child's cheek." E. "We will administer the dose with meals to increase absorption."

Correct Answer: C and E At birth, a newborn has enough iron (received during the last trimester of pregnancy) to last until approximately age 4 months. After this age, formula-fed infants usually receive adequate iron intake from iron-fortified formula, whereas breastfed infants may require supplementation until they begin eating iron-rich foods. Iron supplements should be given on an empty stomach between meals for best absorption. If gastric irritation occurs, iron may be given with meals; however, this decreases absorption. If the child is old enough, supplements with citrus fruit juice should be offered as an abundance of vitamin C increases absorption. Milk products and antacids should be avoided for 2 hours following oral iron administration as these will decrease absorption. Incorrect Answers: [A. "Our child might become constipated while taking this medication."] Iron supplements may cause constipation and black or dark green, tarry stools; therefore, parents should be taught not to be alarmed if these expected findings occur. [B. "Our child's stools might become black and tarry."] Iron supplements may cause constipation and black or dark green, tarry stools; therefore, parents should be taught not to be alarmed if these expected findings occur. [D. "We will administer the dose into the back of our child's cheek."] Liquid iron supplements can stain teeth; to reduce this risk, parents should use a medicine dropper to administer the dose at the back of the infant's cheek. The dose may also be diluted with water or juice to prevent staining and improve flavor. An older child should use a straw to take the supplement and drink water or juice after each dose. Educational objective:Liquid iron supplements are best absorbed on an empty stomach. Consuming vitamin C with iron supplements increases iron absorption. Milk products and antacids should be avoided for 2 hours following oral iron administration. Iron may be given with meals to reduce gastric irritation; however, this will decrease absorption.

Which of the following statements made by the mother of a child recently diagnosed with celiac disease indicates a need for further teaching? A. "I will need to read the labels of all processed foods." B. "It is okay if my child eats rice, corn, and potatoes." C. "My child can have small amounts of foods containing wheat as long as she remains symptom free." D. "My child will need to be on a gluten-free diet for the rest of her life."

Correct Answer: C. "My child can have small amounts of foods containing wheat as long as she remains symptom free." The following are important principles to teach clients with celiac disease: 1. All gluten-containing products should be eliminated from the diet. These include wheat, barley, rye, and oats. 2. Rice, corn, and potatoes are gluten free and are allowed on the diet. 3. Deficient vitamins (mainly fat-soluble vitamins), iron, and folic acid should be replaced. 4. Processed foods (eg, chocolate candy, hot dogs) may contain "hidden" sources of gluten such as modified food starch, malt, and soy sauce. Food labels should indicate that the product is gluten free. 5. Clients will need to be on a gluten-free diet for the rest of their lives. Eliminating gluten from the diet reduces the risk of nutritional deficiencies and intestinal cancer (lymphoma). 6. Eating even small amounts of gluten will damage the intestinal villi although the client may have no clinical symptoms. All sources of gluten must be eliminated from the diet. Educational objective:All sources of gluten must be eliminated from the diet of a client with celiac disease; consuming small amounts, even in the absence of clinical symptoms, will increase the risk of damage to the intestinal villi. Clients can have foods containing rice, corn, and potatoes. They should read food labels and follow the diet for the rest of their lives.

A nurse is reinforcing teaching to the parent of a child who has a new diagnosis of absence seizures. Which statement by the parent indicates understanding of the teaching? A. "My child may experience incontinence." B. "My child may seem confused afterwards." C. "My child may stare and seem inattentive." D. "My child will notice unusual odors prior to the event."

Correct Answer: C. "My child may stare and seem inattentive." Absence seizures occur in children age 4-12 and usually disappear at puberty. Clinical manifestations include a brief loss of consciousness and an appearance of inattention or daydreaming (the absence attack) without loss of postural body tone. However, slight loss of tone may lead to dropping objects held in the hands. Most absence seizures last less than 10 seconds and often go unrecognized. Following an attack, behavior and awareness immediately return to normal. The child does not experience a postictal period but usually has no recollection that a seizure has occurred. A child may have multiple absence seizures each day. Treatment includes the use of anticonvulsant medication(s). Incorrect Answer: [A. "My child may experience incontinence."] Altered sensory perceptions (eg, awareness of odors, auras), postictal confusion, and incontinence are clinical manifestations of complex partial or tonic-clonic seizures. [B. "My child may seem confused afterwards."] Altered sensory perceptions (eg, awareness of odors, auras), postictal confusion, and incontinence are clinical manifestations of complex partial or tonic-clonic seizures. [D. "My child will notice unusual odors prior to the event."] Altered sensory perceptions (eg, awareness of odors, auras), postictal confusion, and incontinence are clinical manifestations of complex partial or tonic-clonic seizures. Educational objective:Absence seizures are characterized by a brief loss of consciousness and the appearance of inattention or daydreaming without loss of postural tone. Most absence seizures occur in children age 4-12, last less than 10 seconds, and may occur multiple times daily.

The parent of a 7-month-old reports that the child has been crying and vomiting with a distended belly for the past 4 hours. The infant is now lying quietly in the parent's arms with a pulse of 200/min and respirations of 60/min. Which of the following components of SBAR (situation, background, assessment, recommendation/read-back) communication is most important for the nurse to report? A. Client has been ill for approximately 4 hours B. Client has improved from apparent earlier distress C. Client is now lethargic with abnormal vital signs D. Does the health care provider want to order a laxative?

Correct Answer: C. Client is now lethargic with abnormal vital signs SBAR (situation, background, assessment, recommendation/read-back) is an established reporting format used to communicate with the health care provider (HCP). Use of SBAR ensures that the HCP receives the necessary information to make a clinical judgment regarding treatment or need for immediate assessment. In this situation, the client's presentation indicates worsening symptoms that require immediate intervention. The client's lethargy represents a declining level of consciousness. The client also has significantly abnormal vital signs (normal infant pulse rate is 110-160/min, respirations generally around 40/min). These are ominous signs that should be reported immediately. Incorrect Answers: [A. Client has been ill for approximately 4 hours] Although it is helpful to know that the change is fairly recent, it is most important to report the current concerning change in the client's clinical presentation and vital signs. [B. Client has improved from apparent earlier distress] Abnormal vital signs with a decreased level of consciousness are not improvements; rather, these findings indicate deterioration. [D. Does the health care provider want to order a laxative?] It would not be appropriate to assume and treat potential constipation in this client without further assessment and diagnostic procedures. The nurse needs to assess additional aspects, including bowel sounds, abdominal characteristics, and temperature. Vital signs this significantly abnormal would not be caused by constipation. Educational objective:SBAR (situation, background, assessment, recommendation/read-back) is used to transmit complete essential information to the health care provider. Any abnormal vital signs or current deterioration should be communicated immediately.

Prior to discharge of a child with a ventriculoperitoneal (VP) shunt, the nurse reinforces teaching to the caregiver about when to contact the health care provider. The caregiver shows understanding of the instructions by contacting the health care provider about which symptom? A. A temperature of 99 F (37.2 C) that occurs during the evening B. The child cannot recall items eaten for lunch the previous day C. The child vomits after awakening from a nap and again 1 hour later D. The VP shunt is palpated along the posterolateral portion of the skull

Correct Answer: C. The child vomits after awakening from a nap and again 1 hour later The caregiver of a child with a ventriculoperitoneal (VP) shunt must understand symptoms of increased intracranial pressure (ICP), which indicate shunt malfunction. Vomiting may be a sign of increased ICP and would require that the health care provider (HCP) be contacted. Incorrect Answers: [A. A temperature of 99 F (37.2 C) that occurs during the evening] Fever may indicate shunt infection, but a temperature of 99 F (37 C) remains within acceptable parameters. Contacting the HCP is not indicated. [B. The child cannot recall items eaten for lunch the previous day] Memory lapse or changes in mental status may indicate increased ICP. However, the inability to remember one meal would not indicate a change in mental status. [D. The VP shunt is palpated along the posterolateral portion of the skull] A VP shunt is tunneled under the scalp and can be palpated. Educational objective:Increased intracranial pressure may occur with ventriculoperitoneal shunt malfunction. The caregiver must recognize symptoms of vomiting, headaches, vision changes, and changes in mental status. Early intervention by the health care provider will decrease the risk of damage to brain tissue.

A 10-year-old weighs 99 lb (44.9 kg) and has a BMI of 24.8 kg/m2 (>95th percentile). The licensed practical nurse (LPN) is collaborating with the registered nurse (RN) to formulate a weight loss plan. Which is most important for the nurse to determine? A. Child's pattern of daily physical activity B. Family's eating habits C. Family's financial resources for purchasing healthy foods D. Family's readiness for change

Correct Answer: D. Family's readiness for change Before initiating a treatment plan for weight loss, it is most important to make certain that the child and family are ready for change. Attempting to engage the family and child in weight loss strategies and dietary changes before they are ready could easily result in frustration, treatment failure, and reluctance to try new approaches in the future. The nurse needs to explore the reasons and desire for weight loss by assessing: · Motivation and confidence · Willingness to change behaviors and food choices · Perceived importance of a weight loss treatment plan · Confidence in ability to take on healthier eating habits Incorrect Answer: [A. Child's pattern of daily physical activity] Physical activity is an important component of a weight loss treatment plan, but it is not the priority nursing assessment. [B. Family's eating habits] The family's eating habits will have a strong influence on the child's ability to make changes and need to be assessed. However, it is more important to assess the family's readiness for change. [C. Family's financial resources for purchasing healthy foods] Assessing the family's financial resources is important in planning education about healthy food choices, but it is not the priority nursing action. Educational objective:Before initiating a treatment program that requires a client and family to make major lifestyle and behavior changes, the nurse needs to assess readiness for change. Motivation and a desire for change are the keys to successful weight loss.

During the client interview for a developmentally normal 18-month-old, the parent expresses concern about the small amount of food the child consumes. What is the nurse's priority intervention? A. Check the child for parasitic infections B. Consult a pediatric nutritionist for suspected eating disorder C. Notify the health care provider D. Reinforce teaching about the toddler's nutritional needs

Correct Answer: D. Reinforce teaching about the toddler's nutritional needs Starting at approximately age 1 year, the very high metabolic demands of infancy slow down to keep pace with the moderate growth of toddlerhood. During this phase, toddlers are increasingly picky about their food choices and schedules. Although to the parents it may appear that the child is not consuming enough calories, intake over several days actually meets nutritional and energy needs. Parents should be educated concerning what constitutes a healthy diet for toddlers and which foods they are more likely to consume. Some effective strategies for dealing with a toddler during this stage of decreased appetite and pickiness include: · Set and enforce a schedule for all meals and snacks. · Offer the child 2 or 3 choices of food items. · Do not force the child to eat. · Keep food portions small (1-2 teaspoons per serving) and provide an additional serving after the first serving is consumed. · Expose the child repeatedly to new foods on several separate occasions. · Do not allow the child to watch TV and play games during meals or snacks. Incorrect Answer: [A. Check the child for parasitic infections] Parasitic infection can cause malnutrition (eg, failure to thrive). There is no indication that the child is suffering from any malnutrition. Therefore, an evaluation for parasites or referral to a nutritionist is not necessary. [B. Consult a pediatric nutritionist for suspected eating disorder] Parasitic infection can cause malnutrition (eg, failure to thrive). There is no indication that the child is suffering from any malnutrition. Therefore, an evaluation for parasites or referral to a nutritionist is not necessary. [C. Notify the health care provider] Evaluation of a toddler's nutritional status is a routine assessment and within the nurse's scope of practice. Educational objective:During toddlerhood, it is normal for a child to have a decreased appetite as the result of reduced metabolic needs. Parents should be taught to provide multiple food options, set a schedule for meals/snacks, and avoid watching TV or playing games during mealtime. Toddlers should not be forced to eat.

The nurse is reinforcing teaching to parents about childhood nutrition and feeding practices. The nurse recognizes that which snack is best for a toddler? A. ½ cup orange juice B. Dry, sweetened cereal C. Raw carrot sticks D. Slice of cheese

Correct Answer: D. Slice of cheese When choosing foods for a toddler (age 1-3 years), parents should consider the following factors: · Safety: Small, hard, sticky, or slippery foods (eg, hot dogs, whole grapes, nuts, raw carrot sticks, popcorn, peanut butter, hard candy, fruit snacks) pose a choking risk and should not be offered. · Nutrient density: Foods should contain valuable nutrients (eg, protein, vitamins) rather than just "empty calories" (eg, sugars). · Potential for foodborne illness: Children are at a higher risk for developing food-related infections, especially if given raw, unpasteurized foods (eg, partially cooked eggs, raw fish, raw bean sprouts). Healthy snacks for a toddler include pieces of cheese, whole-wheat crackers, banana slices, yogurt, cooked vegetables, and cottage cheese with thinly, sliced fruit. Incorrect Answers: [A. ½ cup orange juice] Although orange juice is a source of vitamin C, it contains a large amount of sugar and lacks fiber. Toddlers should have no more than 4-6 oz of 100% fruit juice per day. [B. Dry, sweetened cereal] Sweetened cereals, especially those marketed toward children, can be high in sugar and low in nutrients. [C. Raw carrot sticks ] Raw carrot sticks are hard and pose a choking risk. Parents should serve carrots and other hard vegetables grated or cooked. Educational objective:Food for young children should contain valuable nutrients and pose little risk of choking or foodborne infection. An example of a healthy snack for a toddler is a slice of cheese.

A nurse discovers a cyanotic newborn with excessive frothy mucus in the mouth. What should be the nurse's first action? A. Administer 100% oxygen B. Auscultate the lungs C. Place infant in knee-chest position D. Suction the infants mouth

Correct Answer: D. Suction the infants mouth The initial nursing action for a client experiencing cyanosis and excess oral secretions is suctioning the mouth (ie, oropharynx) to clear the airway. Excessive frothy mucus and cyanosis in a newborn could be due to esophageal atresia (EA) and tracheoesophageal fistula (TEF). If EA/TEF is suspected, the infant should be kept supine with the head elevated at least 30 degrees to prevent aspiration. A nasogastric tube should be inserted and connected to continuous or intermittent suction until surgical repair. Incorrect Answers: [A. Administer 100% oxygen] Oxygen cannot be delivered to the lungs if secretions obstruct the airway. Therefore, suctioning is a priority. [B. Auscultate the lungs] This infant is aspirating and in immediate distress, which should be addressed without delay. After suctioning the excess saliva and ensuring a clear airway, the nurse may perform further assessments. [C. Place infant in knee-chest position] This infant's cyanosis is a result of aspirating secretions and does not indicate a circulatory problem. The knee-chest position is appropriate to increase pulmonary blood flow in infants with a cyanotic heart defect (eg, tetralogy of Fallot). Educational objective:The initial nursing action for a client experiencing cyanosis and excess oral secretions is oropharyngeal suctioning to ensure airway patency.

The nurse is reinforcing discharge teaching for the parents of a 1-year-old with a newly diagnosed cow's milk allergy. Which nutrients normally provided by milk should be obtained from other sources? Select all that apply. A. Calcium B. Fiber C. Iron D. Vitamin D E. Vitamin K

Correct Answers: A and D Calcium and vitamin D are nutrients in cow's milk that are essential for proper bone development in children and adolescents. To obtain the recommended 500 mg of daily calcium (for ages 1-3 years), the parents should serve foods such as beans, dark green vegetables, and calcium-fortified cereals and juices. Vitamin D, which enhances the absorption of calcium, is synthesized in the skin by exposure to direct sunlight. Alternate dietary sources include fish oils, egg yolks, and vitamin D-fortified foods (eg, orange juice). Incorrect Answers: [B. Fiber] Fiber, which is important for digestive health, is found in only small amounts in cow's milk. Fiber-rich foods include whole grains, beans, and berries. [C. Iron] Cow's milk is not a significant source of iron. Dietary sources of iron include meats and spinach. [E. Vitamin K] Vitamin K is an important nutrient for coagulation. Vitamin K is produced by bacteria in the large intestine and is found in food sources such as dark green vegetables, fish, and eggs, not in cow's milk. Educational objective:Calcium and vitamin D are nutrients in cow's milk that are essential for proper bone development in children and should be obtained from other sources for clients with a cow's milk allergy. Alternate sources of calcium include beans, dark greens, and calcium-fortified cereal and juices. Vitamin D is synthesized in the skin when exposed to sunlight and can be obtained in foods such as fish, egg yolks, and vitamin D-fortified foods.

The nurse on a pediatric unit is caring for a preschooler who exhibits separation anxiety when the parents go to work. Which interventions should the nurse implement? Select all that apply. A. Encourage the parents to leave the child's favorite stuffed animal B. Establish a daily schedule similar to the child's home routine C. Give the child time to calm down alone when visibly upset D. Provide frequent opportunities for play and activity E. Remove visual reminders of the parents from the room

Correct Answers: A, B, and D Some of the first stressors faced by children from infancy through the preschool years are related to illness and hospitalization. Separation anxiety, also known as anaclitic depression, particularly affects children age 6-30 months. There are 3 stages of separation anxiety: protest, when the child refuses attention from others, screams for the parent to return, and cries inconsolably; despair, when the child is withdrawn, quiet, uninterested in activities or meals, and displays younger behavior (eg, use of pacifier, wetting the bed); and detachment, when the child suddenly appears happy and interested in building relationships. Nursing care of hospitalized clients experiencing separation anxiety focuses on maintaining a calm environment and a supportive demeanor to build trust between the nurse and the child, and encouraging connection with family and familiar environments, even when they are absent. Key interventions include: · Encouraging the parents to leave favorite toys, books, and pictures from home · Establishing a daily schedule that is similar to the child's home routine · Maintaining a close, calming presence when the child is visibly upset · Facilitating phone or video calls when parents are available · Providing opportunities for the child to play and participate in activities Incorrect Answers: [C. Give the child time to calm down alone when visibly upset] When the child is visibly upset, it is important to provide a calming presence and implement strategies to reduce the child's anxiety. Leaving the child alone at such times can further increase stress. [E. Remove visual reminders of the parents from the room] Providing pictures of the child's family is actually beneficial, as it reminds the child of something familiar and safe. Educational objective:Toddlers and preschool-age children experience separation anxiety in response to the stress of illness and hospitalization. Key nursing interventions to alleviate separation anxiety include encouraging the presence of favorite items, establishing a daily routine, providing opportunities for play, facilitating phone calls with the parents, and providing support when the child is upset.

The nurse is reinforcing education with the parents of a 2-year-old child about diet choices to promote growth. The family observes a strict vegan diet. Which of the following statements by the nurse are appropriate? Select all that apply. A. "Diets consisting of legumes as the only protein source are sufficient for growth." B. "It is important to feed your child fortified breads and cereals to help with iron intake." C. "Preparing meals with vegetables and fruits will ensure sufficient vitamin B12 intake." D. "Try to pair foods high in iron with foods high in vitamin C to aid iron absorption." E. "Your child may require calcium and vitamin D supplementation due to lack of dairy intake."

Correct Answers: B, D, and E With careful monitoring of nutritional intake, a vegan diet (ie, excluding all animal-derived products [eg, meat, dairy, eggs]) can be appropriate for clients in all age groups. Pediatric clients consuming a vegan diet are at increased risk for nutritional deficiencies (eg, protein, calories, calcium, vitamin D, iron, vitamin B12) due to rapid growth and development. Nurses educating clients about preventing nutritional deficiencies in vegan diets should include information about: · Iron: Plant sources of iron, which are in smaller quantities and difficult to absorb, should be supplemented with fortified cereals and breads to decrease risk of iron-deficient anemia · Vitamin C: Iron absorption is improved when dietary sources of iron and vitamin C are taken together · Calcium: Without animal sources of calcium (eg, dairy, eggs, fish), vegan diets require supplementation of calcium and vitamin D for bone health Incorrect Answers: [A. "Diets consisting of legumes as the only protein source are sufficient for growth."] Many plant-based proteins (eg, legumes, grains) do not individually contain all the essential amino acids to support growth and tissue repair; therefore, vegan clients will require further teaching on combinations of protein sources. [C. "Preparing meals with vegetables and fruits will ensure sufficient vitamin B12 intake."] Fruits and vegetables do not provide vitamin B12. The nurse should educate the parents on the need for multivitamins or fortified grains as quality vitamin B12 sources. Educational objective:Pediatric clients consuming a vegan diet are at risk for dietary deficiencies (eg, iron, protein, calories, vitamin B12, calcium, vitamin D). Parent education about supplementation and adequate food sources of these nutrients is necessary.

The nurse cares for an 11-lb (5-kg) infant admitted with dehydration and prepares to calculate intake and output over an 8-hour shift. Using the data in the exhibit, calculate the total output in milliliters for the 8-hour shift. Record your answer as a whole number. Click on the exhibit button for additional information. Intake and Output Record Emesis: 120 mL Wet Diaper 1: 50 g Wet Diaper 2: 52 g Wet Diaper 3: 46 g *Weight of a dry diaper = 30 g

Correct Answer: 178 mL To measure the urinary output of an infant in diapers, subtract the weight of the diaper when dry from its weight when wet. One (1) gram of weight is equal to one (1) milliliter of fluid. Adequate urinary output for an infant is 2 mL/kg/hr. Calculation: Urine output in diapers: Diaper 1: 50 - 30 = 20 g Diaper 2: 52 - 30 = 22 g Diaper 3: 46 - 30 = 16 g Total mg of urine: 58 g = 58 mL Total output: (Emesis) + (Urine) = 120 mL + 58 mL = 178 mL Educational objective:Urinary output for a child in diapers is calculated by subtracting the dry weight of the diaper from its weight when wet. One (1) gram of weight is equal to one (1) milliliter of fluid.

The clinic nurse is caring for a 3-year-old client. Which task, if not observed or reported by the parents as accomplished, will cause the nurse concern? A. Catches a ball at least 50% of the time B. Copies a square with a pencil or crayon C. Eats with a spoon D. Hops on one foot

Correct Answer: C. Eats with a spoon Things that most children can do by a certain age are considered developmental milestones. These include the following areas of development: social/emotional, language/communication, cognitive, and physical. Each child develops in a unique pattern, and ages are considered as general guidelines for assessing development. Normally, a toddler develops the ability to use a spoon by 18 months. Therefore, a 3-year-old should be able to eat with a spoon. Incorrect Answers: [A. Catches a ball at least 50% of the time] Catching a ball 50% of the time is a developmental expectation for a 4-year-old. [B. Copies a square with a pencil or crayon] A 4-year-old can copy or draw a square with a pencil or crayon. Copying shapes other than a circle is a developmental expectation for a 5-year-old. [D. Hops on one foot] Hopping on one foot is a developmental expectation for a 4-year-old. Educational objective:A 3-year-old should be able to eat with a spoon.

A child in the emergency department had a cast placed on the right arm for a nondisplaced fracture. The client is being discharged home with pain medications. Which statement by the parent indicates that additional teaching is required? A. "A tingling or burning sensation within the first 24-48 hours is not a concern." B. "An itching sensation under the cast for the first 24-48 hours is not a concern." C. "I will call the doctor if pain is severe despite medications for the first 24 hours." D. "My child should elevate the arm for the first 24-48 hours."

Correct Answer: A. "A tingling or burning sensation within the first 24-48 hours is not a concern." Parents of children with casts are taught to check for emergency signs of circulatory impairment, including changes in sensation and motor function, which could indicate early signs of compartment syndrome due to swelling within the confined space of the cast. However, some swelling is expected, so this symptom alone is not indicative of compartment syndrome. The 6 Ps of compartment syndrome include: 1. Pain: Increasing despite elevation, analgesics, and ice. Pain will also increase with passive stretching/movement. Increasing pain is an early sign and indicates muscle ischemia. 2. Pressure: Affected extremity or digits are firm and tense; skin is tight and appears shiny. 3. Paresthesia: Tingling, numbness, or burning sensation, which is also an early sign and indicates nerve ischemia. 4. Pallor: Skin appears pale; capillary refill is >3 seconds. These indicate poor perfusion. 5. Pulselessness: Pulse distal to injury or compartment is impalpable. Absent pulses are a late sign. 6. Paralysis: Loss of function or inability to move extremity or digits. Muscle weakness occurs before paralysis which is also a late sign and indicates dead muscle tissue. Incorrect Answers: [B. "An itching sensation under the cast for the first 24-48 hours is not a concern."] An itching sensation under the cast is expected, clients and parents are taught to avoid inserting anything into the cast to scratch the skin. Instead, they should use a hair dryer on the cold setting. [D. "My child should elevate the arm for the first 24-48 hours."] Arm elevation is indicated for the first 48 hours after cast placement to reduce edema. However, if compartment syndrome develops, the arm should be kept at torso level (not high or low). Educational objective:Compartment syndrome is a serious complication due to neurovascular compromise from swelling and increased pressure in a confined space. The characteristics (6 Ps) of compartment syndrome include: pain, pressure, paresthesia, pallor, pulselessness, and paralysis.

The nurse is caring for a hospitalized 6-month-old client. Which of the following interventions should the nurse implement to provide developmentally appropriate care for this client? Select all that apply. A. Adhere to the child's home routine when possible during hospitalization B. Encourage parents to bring the child's favorite toy from home C. Have the parents step out of the room during procedures D. Promote a quiet sleep environment with reduced stimuli E. Provide a parent's shirt for the child to hold during procedures

Correct Answer: A, B, D, and E Around 6 months of age, infants begin to experience separation anxiety. This anxiety may be heightened during hospitalization because of exposure to many unfamiliar stressors. Appropriate nursing care can play a significant role in reducing the infant's physiologic and psychologic stress. Key interventions include: · Adhering to the infant's home routine (eg, meal and sleep times) as closely as possible · Providing a favorite toy or pacifier · Encouraging caregivers to remain whenever possible during hospitalization · Providing a quiet sleep environment with reduced stimulation to promote restful sleep · Offering a familiar object (eg, caregiver's shirt, blanket, voice recording) during stressful situations The presence of parents or the primary caregiver during hospitalization reduces separation anxiety and decreases the infant's stress response. Therefore, caregivers should remain whenever possible throughout all the client's care (eg, procedures, medication administration, scans). Educational objective:To reduce separation anxiety in infants during hospitalization, the nurse should adhere to the infant's home routine, provide a favorite toy or pacifier, provide a quiet sleep environment, encourage the presence of the primary caregivers, and expose the infant to familiar objects during stressful situations.

The nurse is providing care to a 1-year-old recently diagnosed with failure to thrive. Which intervention is the priority nursing action for this child? A. Assess overall parenting skills B. Have the parent complete a 24-hour dietary intake C. Measure the child's height, weight, and head circumference D. Observe the child feeding

Correct Answers: D. Observe the child feeding Failure to thrive (FTT) is generally defined as weight less than 80% of ideal for age and/or depressed weight for length/height after correcting for gestational age, sex, and special medical conditions. The underlying cause of FTT is inadequate dietary intake, and contributing factors include a disturbance in feeding behavior and psychosocial factors. Observing the child feeding or when hungry will allow the nurse to identify potential factors contributing to insufficient intake. The nurse can observe the type of food being offered, the quantity of food consumed, how the child is held or positioned while being fed, the amount of time for feeding, the parent's response to the child's cues, the tone of the feeding, and the interaction between the child and parent. Incorrect Answer: [A. Assess overall parenting skills] Assessing parenting skills is not as important as evaluating the feeding experience and nutritional intake of the child. [B. Have the parent complete a 24-hour dietary intake] A 24-hour dietary intake survey is an assessment tool to obtain information regarding nutritional intake. However, because the child's intake would be reported by the parent, it may not be accurate and does not provide information about what occurs during feeding. [C. Measure the child's height, weight, and head circumference] This is an appropriate nursing action, but it provides no information about the factors contributing to the child's insufficient intake. Educational objective:Failure to thrive is generally defined as weight less than 80% of ideal for age and/or depressed weight for length/height after correcting for gestational age, sex, and special medical conditions. Observing the child being fed may provide information related to the cause of inadequate dietary intake, including disturbances in feeding behavior and psychosocial factors.

The school nurse is conducting an educational session for middle school teachers that is designed to heighten awareness of school bullying. The nurse recognizes that further instruction is needed when one of the teachers makes which comment? A. "Bullying is a normal part of childhood growth and development." B. "Children with physical disabilities are more vulnerable to bullying." C. "Most children who are victims of a school bully do not tell an adult about it." D. "The most common form of bullying is verbal aggression, such as insults and intimidation."

Correct Answer: A. "Bullying is a normal part of childhood growth and development." Despite increased media coverage, articles, and discussion about school bullying, myths and "old" attitudes toward school bullying persist. A number of parents and teachers continue to perceive bullying as a normal part of childhood, with the attitude of "kid will be kids." Some may even believe that bullying is "fun" and will help make those who are bullied stronger over time. These beliefs are one of the most common reasons why teachers and parents may ignore bullying behavior. The consequences of bullying are lasting harm and distress, including anxiety, depression, school adjustment problems, sleep difficulties, and even death. Incorrect Answers: [B. "Children with physical disabilities are more vulnerable to bullying."] This is a true statement. Children who bully often target those who seem different or are physically weak. Children with disabilities are easy targets. [C. "Most children who are victims of a school bully do not tell an adult about it."] This is a true statement. Most victims of bullying are afraid to tell an adult for fear that the bullying will get worse. They may also feel embarrassed that they appear to be a "weakling." [D. "The most common form of bullying is verbal aggression, such as insults and intimidation."] Bullying includes physical, verbal, and psychological aggression. Studies indicate that verbal abuse (eg, yelling obscenities, derogatory remarks, intimidation) is the most common type of bullying. Physical bullying tends to decrease from middle school to high school, but verbal bullying intensifies. Verbal attacks are more difficult to identify as they occur when adults are out of earshot. Educational objective:Bullying is not a part of normal childhood growth and development. It is abusive behavior that can have lasting and harmful physical and psychological effects on its victims.

The parent of a 2-year-old tells the nurse at the well-child clinic, "I am concerned because my child does not like to be cuddled, does not respond when called by name, and does not make eye contact when being fed." What is the priority question for the nurse to ask when completing the health history? A. "How many words can your child say?" B. "Is your child potty trained?" C. "What are your child's favorite foods?" D. "What kind of toys does your child like to play with?"

Correct Answer: A. "How many words can your child say?" The concerns presented by this child's parent are suggestive of a developmental delay and very possibly autism spectrum disorder (ASD). ASD is a complex neurodevelopmental disorder characterized by the onset of abnormal functioning before age 3. The 2 core symptoms of ASD are abnormalities in social interactions and communication (verbal and nonverbal), and patterns of behavior, interests, or activities that can be restricted and repetitive. Social skills, especially communication, are delayed more significantly than other developmental functioning and are the focus during client assessment. The vast majority of children diagnosed with ASD lack the acquisition of communication skills during the first 2 years of life. A healthy 2-year-old should have a vocabulary of about 300 words and should be able to string 2 or more words together in a meaningful phrase. Assessing this child's language abilities would be the priority. Incorrect Answers: [B. "Is your child potty trained?"] Assessing any 2-year-old's progress in toilet training is appropriate. However, it is not the priority assessment given the parent's concerns. [C. "What are your child's favorite foods?"] A nutrition assessment is part of every well-child visit, but it is not the priority in this situation. [D. "What kind of toys does your child like to play with?"] Although not the priority assessment, it would be important to ask the parent about the child's play activities. Children with ASD often have a restricted interest in and preoccupation with a single toy, exhibit repetitive behaviors when playing with the toy, and insist on the same play routine. Educational objective:The 2 core symptoms of autism spectrum disorder are abnormalities in social interactions and communication (verbal and nonverbal), and patterns of behavior, interests, or activities that can be restricted and repetitive. Social skills, especially communication, are delayed more significantly than other developmental functioning.