Pediatric Nursing - Growth and Development NGN EAQ

1400 Primary Care Provider 4-year-old client seen with parent today to discuss sleep disturbances that began approximately 3 weeks ago. Parent reports child is awakening late at night crying and acting scared. Child soothes fairly easily and then returns to sleep. Occurs several times per week. Parent reports consistent bedtime and bedtime routine without significant resistance. Sleeps approximately 12 hours per night with no daytime naps. No recent trauma or events. Child is well and otherwise in good health. General: Alert, interactive Ears: canals clear, tympanic membranes intact Nose: nares patent Mouth: moist mucous membranes, dentition intact Lungs: clear to auscultation to all lung fields Heart: regular rate and rhythm, no murmur Skin: warm, well perfused Neurological: speaks clearly, responsive to questions, symmetric movement of extremities, deep tendon reflexes 2+ bilaterally

Actions to Take: Limit media prior to bed and provide a transitional object Condition: Nightmare Parameters to Monitor: Event frequency and recollection of event Rationale: Nightmares, or scary dreams, typically take place in the latter half of the night and are often remembered by the child. The child may awaken during the nightmare, is aware of another's presence, and usually soothed back to sleep. In contrast, night terrors tend to occur soon after falling asleep, presenting as thrashing and bizarre behavior with the child unaware of another's presence. Children experiencing night terrors are not easily soothed but they will not have a memory of the event. Sleep depravation or "sleep debt" occurs when a child has less sleep than is recommended. This child usually has 12 hours of sleep, which is the recommended amount for a preschooler. Bedtime resistance often presents as curtain calls or resisting bedtime. There is no report of such resistance given that the child has a consistent routine and bedtime. Actions the nurse would take would be to limit media before bed, as it is alerting and may have scary or distressing content. The nurse would also encourage the parent to provide a transitional object, such as a favorite blanket or toy, to help the child self-soothe. The child already has an established bedtime routine. Intervention is recommended for nightmares, but not night terrors. Bed sharing is not routinely recommended at this age, unless a cultural practice. Parameters to monitor include the frequency of nightmares and whether the child can recall the nightmare; recollection may help with additional strategies to reassure or address the nightmares. There is no need to monitor for safety, as nightmares do not pose a threat to safety. The child's total sleep time is already at the recommended amount. T

3-year-old child brought into pediatrician office by parent for routine health and wellness visit. No significant PMH findings indicated in EHR. Immunizations up to date. Parent denies any signs of illness but reports that the child often bumps into doorways and furniture. The nurse reviews the electronic health record and documents visit-related care in the nursing progress notes. Implements provider orders and provides education as appropriate. While assessing a pediatric client, a nurse notices that the child is unable to focus on an object with both eyes simultaneously. Which other finding in the client will suggest strabismus? Select all that apply. One, some, or all responses may be correct.

Correct: Crossed appearance of eyes Red eye reflection in one eye Impaired extraocular muscles Tilting of head to look at something Squinting one eye to focus Rationale: Strabismus is a congenital condition in which both eyes do not focus on an object simultaneously, resulting in a crossed appearance of the eyes. Only one eye will display a red eye reflection when assessed with an ophthalmoscope. This condition is caused by impaired extraocular muscles. The pediatric client may demonstrate behaviors such as tilting their head or squinting one eye to look at something. Impaired near vision is associated with hyperopia or presbyopia, not strabismus. Elevated intraocular pressure results in glaucoma. Macular degeneration is caused by degeneration of the central retina.

6-month-old client brought to primary care provider for well-baby visit. Parent reports client is doing well and would like guidance on when to start solid foods. Presently, client's diet is breastfeeding and drinking expressed breast milk approximately every 3 hours with a 5-hour stretch between feedings overnight. Sleeps well otherwise. Many wet diapers and several seedy yellow stools daily. Attends daycare. Immunizations - due for 6-month vaccines, otherwise up to date. Musculoskeletal: No head lag evident when pulled from lying to sitting position. Sits with support. The nurse considers readiness for introduction of solid foods. Click to highlight the 3 assessments that the nurse would perform to assess readiness for introduction of solid foods.

Correct: Head control Extrusion reflex Swallow coordination Rationale: The nurse would assess the infant's head control, extrusion reflex, and suck coordination to determine whether the infant is ready for introduction of solid foods. Infants need good head control (minimal head lag) to safely introduce solid foods. Likewise, the extrusion reflex should have disappeared; if still present, the infant will reflexively spit out foods. Swallow coordination is also important as new food textures are introduced. Often, infants also begin tooth eruption around the same time, which will facilitate biting and chewing. The pincer grasp is not expected to develop until later infancy and is not a prerequisite to introduction of solid foods. Likewise, drinking from a straw would be expected in later infancy and is not a prerequisite to introduction of solid foods. The tonic neck reflex, where the infant extends an arm when their head is turned to the side, disappears by age 3-4 months and is not a prerequisite to introduction of solid foods.

2-month-old male infant brought into emergency department via personal vehicle by parent following a reported accident at home in which the client was dropped by a sibling that was carrying him. Client awake and crying. No significant findings in EHR. Immunizations up to date. On-call pediatrician paged. The nurse interviews the client's parent and reviews the electronic health record. Care is documented in the nursing progress notes. Diagnostics completed per provider orders. The nurse observes bleeding into the subgaleal compartment upon reviewing an infant's computerized tomography (CT) results. Which other finding would the nurse expect to assess? Select all that apply. One, some, or all responses may be correct.

Correct: Thrombocytopenia Pallor of skin Lowered hematocrit levels Hypotonia Tachypnea Rationale: Bleeding into the subgaleal compartment indicates subgaleal hemorrhage in an infant. Subgaleal hemorrhage is also associated with disseminated intravascular coagulation, which results in thrombocytopenia or decreased blood platelets in the body. The hemorrhage causes decreased circulating blood volume, which contributes to a pale color of the skin. An infant with subgaleal hemorrhage experiences destruction of red blood cells within the hematoma; therefore, the infant will have decreased hematocrit. Neurological symptoms associated with this type of bleeding include hypotonia and seizures. Tachypnea is a sign of the circulatory shock that will develop as the infant continues to lose blood. Subgaleal hemorrhage is characterized by tachycardia, not decreased heart rate or bradycardia. Subgaleal hemorrhage is characterized by hyperbilirubinemia because of degradation of red blood cells. An infant with subgaleal hemorrhage shows megacephaly, not decreased head circumference.

18-month-old female child brought into pediatrician office by parent for scheduled health and wellness visit. Vaccines up to date, due this visit: HepB (3rd dose), DTaP (4th dose), and Inactivated Poliovirus (3rd Dose). Parent denies any signs of illness but reports that the child sometimes has a bulge in the right groin area. The nurse reviews the electronic health record and documents visit-related care in the nursing progress notes. Implements provider orders and provides education as appropriate. The nurse is inspecting the abdomen of an 18-month-old child. Which method would the nurse adopt to inspect for inguinal hernia?

Correct: Visualize the inguinal sacral area for obvious bulging. Have the child blow a bubble. Get the child to laugh to raise the intra-abdominal pressure. Palpate the hernia sac for ovaries in a female client. Examine the client in both standing and supine positions. Rationale: The most common presenting symptom of an inguinal hernia is an obvious bulge in the inguinal sacral area. Typically, to locate an inguinal hernia, the nurse positions his or her finger at the proper site and asks the child to cough. However, if the child is too young to cough when asked to, such as at 18 months of age, the nurse can have the child blow a bubble or laugh to raise the intra-abdominal pressure sufficiently to demonstrate the presence of an inguinal hernia. It is not unusual to palpate an ovary in the hernia sac of a female infant. The area should be visualized both when the client is standing and in the supine position. In case of umbilical hernias, the nurse palpates the sac for abdominal contents and estimates the approximate size of the opening. In the case of a femoral hernia, it is felt or seen as a small mass on the anterior surface of the thigh just below the inguinal ligament in the femoral canal, the nurse would feel for a hernia by placing the index finger of the right hand on the child's right femoral pulse and the middle finger flat against the skin toward the midline. For a child who is old enough to cough when instructed, the nurse can slide the little finger into the external inguinal ring in the inguinoscrotal region of males or the inguinolabial region of females and ask the child to cough. If a hernia is present, it will hit the tip of the finger.

1-month-old infant brought into pediatrician office by parent for 2nd scheduled health and wellness visit. Initial HepB immunization administered at initial appointment, 2nd dose scheduled for this visit. Parent denies any signs of illness but reports that the infant only sleeps for short periods at a time. The nurse reviews the electronic health record and documents visit-related care in the nursing progress notes. Implements provider orders and provides education as appropriate. The nurse is assessing a 1-month-old's ears at a well-child visit. Which step is appropriate for performing the assessment in this client? Select all that apply. One, some, or all responses may be correct.

Correct: Observe for skin tags anterior to the ear. Manipulate the ear to straighten the curvature of the canal. Pull the pinna down and back to the 6 to 9 o'clock range. Perform auditory tests by placing electrodes on the child's head. Document any malformations of the ear. Inspect ears for position and rotation. Rationale: When inspecting the ear, attention should be paid to skin tags or small pits found anterior to the ear, which could possibly indicate renal abnormalities. The ear canal curves upward in infants. The nurse needs to pull the pinna down and back to the 6 to 9 o'clock range to straighten the canal for introducing the speculum. The auditory brainstem response (ABR) is used in newborns whereby activity in auditory nerve and brainstem pathways is measured by placing electrodes on the child's head. Malformations of the ears can indicate chromosomal abnormalities or congenital problems. Ears that are low or posteriorly rotated may be indicators of genetic diseases and require further evaluation. Restraint is needed for younger children because the ear examination upsets them; older children usually cooperate and do not need restraint. The nurse would not insert the speculum past the cartilaginous portion of the canal, usually a distance of 0.60 to 1.25 cm (0.23-0.5 inch) in older children. In neonates and young infants, the walls of the canal are pliable and floppy. The very small 2-mm speculum usually needs to be inserted deeper into the canal than in older children.

16-year-old male seen in pediatric office today for routine annual sports exam and physical. Labs and imaging completed one week earlier. Parent accompanies. PMH significant for exercise-induced asthma. Medications limited to albuterol inhaler. Denies current alcohol or tobacco use. The nurse reviews the electronic health record for pre-appointment labs and imaging, and documents visit-related care in the nursing progress notes. Provides education as appropriate. The nurse reviews the history to find an adolescent has a tattoo on the neck and piercings on the ear and eyebrow. During the next visit, the nurse finds a new tattoo on the right upper arm and another piercing on the nose. Which intervention will the nurse prioritize in this situation? Select all that apply. One, some, or all responses may be correct.

Correct: Screen the adolescent for human immunodeficiency virus (HIV). Schedule an appointment for administering the hepatitis vaccine. Rationale: Infection-causing viruses such as human immunodeficiency virus (HIV), and hepatitis C virus can be transmitted through body art needles from one person to another. The nurse would have the client tested for HIV and schedule an appointment for administering the hepatitis vaccine to ensure safety and reduce the risk of infection. Safety is the priority intervention over health promotion activities such as a proper diet plan, screening electrocardiogram, and exercise. It is important for adolescents to wear sunscreen and avoid sunburn to avoid increasing the risk of cancer, but this is not the priority for this client. Additional non-priority health promotion interventions associated with adolescents include adequate sleep and routine dental examinations.

6-month-old client brought to primary care provider for well-baby visit. Parent reports client is doing well and would like guidance on when to start solid foods. Presently, client's diet is breastfeeding and drinking expressed breast milk approximately every 3 hours with a 5-hour stretch between feedings overnight. Sleeps well otherwise. Many wet diapers and several seedy yellow stools daily. Attends daycare. Immunizations - due for 6-month vaccines, otherwise up to date. Musculoskeletal: No head lag evident when pulled from lying to sitting position. Sits with support. Which exam findings indicate that this patient is ready for introduction of solid foods? Select all that apply.

Correct: Sitting supported on exam table Central lower incisors erupted Extrusion reflex absent No head lag when pulled from lying to sitting Rationale: Exam findings that indicate readiness for introduction of solids include sitting unsupported, as this is a clue that the infant is able to sit during a feeding. Eruption of primary teeth are another sign of solid food readiness, as teeth facilitate biting and chewing. Absent extrusion reflex indicates that the infant will not immediately spit out any food introduced into their mouth. Likewise, absent head lag when pulled from lying to sitting indicates good head control, another prerequisite to introducing solid foods. Coughing during breastfeeding may indicate poorly coordinated sucking and swallowing, which may be a contraindication to introducing solid foods. A soft and round abdomen is an expected exam finding, but not an indicator of readiness for solid foods. Weight below the 5th percentile is a concern and may indicate inadequate caloric intake; however, introduction of solid foods is not expected to be a major source of calories but is primarily for taste and chewing experience. The primary source of calories is the infant's breastmilk and/or formula intake; therefore, the health care team would focus on dietary assessment and likely intervention to address client's weight.

9-month-old client brought to primary care provider for well-baby visit. Parent reports client is doing well but seeks advice on proper age-appropriate discipline. Parent reports that client has developed "naughty behavior" and is constantly dropping toys and other items off of highchair or when held. Client eats a variety of infant foods - infant cereal, fruits, vegetables, and strained meats. Primarily takes formula bottles during the day. Sleeps 10 hours overnight with two daytime naps. Many wet diapers and usually one soft brown stool daily. Attends daycare. Immunizations - due for 9-month vaccines, otherwise up to date. Development (observation by examiner): Sits independently, pulls to stand. Plays peek-a-boo with examiner. Seeks toy when covered with blanket. Crude pincer grasp to pick up toy. Vocalizes "hi," "bye," "doggie."

The nurse considers the parent's concern about "naughty behavior." Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse determines that the client is likely experiencing: Expected cognition. Rationale: The nurse would determine that this client is demonstrating expected cognition, which includes the development of object permanence as indicated by their delight in dropping items off of tables and when held and seeking a toy that is covered by a blanket; object permanence refers to the realization that objects continue to exist even when beyond the child's visual field. A crude pincer grasp is expected fine motor development at 9 months; therefore, the nurse would not determine the client has fine motor delay. Sitting steadily and pulling to a stand are expected gross motor milestones at 9 months; therefore, the nurse would not determine that the client has a gross motor delay. Use of several words besides "dada" or "mama" is expected at 11 months; therefore, this client is demonstrating advanced (not expected) communication. The client is demonstrating age-appropriate developmental milestones, not defiant behavior. The nurse would educate the parent with respect to this expected milestone.

9-month-old client brought to primary care provider for well-baby visit. Parent reports client is doing well but seeks advice on proper age-appropriate discipline. Parent reports that client has developed "naughty behavior" and is constantly dropping toys and other items off of highchair or when held. Client eats a variety of infant foods - infant cereal, fruits, vegetables, and strained meats. Primarily takes formula bottles during the day. Sleeps 10 hours overnight with two daytime naps. Many wet diapers and usually one soft brown stool daily. Attends daycare. Immunizations - due for 9-month vaccines, otherwise up to date. Development (observation by examiner): Sits independently, pulls to stand. Plays peek-a-boo with examiner. Seeks toy when covered with blanket. Crude pincer grasp to pick up toy. Vocalizes "hi," "bye," "doggie."

The nurse considers the parent's concern for naughty behavior when the client drops toys and other items from highchair or when held. Select the 3 actions that the nurse would recommend in response to the parent's concern. Correct: Support milestone attainment Encourage child to place objects in container Observe child work to get a toy that is out of reach Rationale: The client is demonstrating age-appropriate cognitive development; therefore, the nurse would encourage continued cognitive development milestone attainment, such as placing objects in and out of a container or placing a desired toy just out of reach to encourage the child to work for the toy. The client is demonstrating age-appropriate object permanence; therefore, the nurse would not counsel the family on discipline such as ignoring naughty behavior or using a stern voice and saying "no." Object permanence is expected at 9 months; therefore, the nurse would not refer to a specialist for intervention, such as Birth to Three, or for neurodevelopmental assessment.

18-month-old client brought to primary care for well child visit and to discuss temper tantrums. Tantrums occur several times per week, at daycare, home, and with grandparent who babysits a day or 2 per week. Otherwise, client eats well, is diapered during the day and night, and urinates and stools regularly. One daytime nap, sleeps well through the night. No significant past medical history noted, prior well child visits at ages 12 months and 15 months were normal. Immunizations current through 15-month visit.

The nurse evaluates the client outcomes. Drag from Word Choices to complete the sentence(s). The nurse determines that interventions were effective as evidenced by: Consistent routine and Use of a sticker chart. Rationale: The nurse would determine that interventions were effective as evidenced by consistent routines and use of a sticker (reward) chart. Consistency of routines is helpful for toddlers to feel in control of their environment. Likewise, use of a reward chart focuses on reinforcing good behaviors as opposed to all attention focused on negative behaviors, such as tantrums. Reduced negativism is expected as the child ages, but not as a result of managing tantrums. Likewise, the child would still be expected to have tantrums; therefore, elimination of tantrums is not reasonable or expected. Use of 10-minute time outs is excessive for a 2-year-old; rather, general recommendations for time-out duration is 1 minute per year of age. Decreased appetite would not be evidence that interventions were effective.

18-month-old client brought to primary care for well child visit and to discuss temper tantrums. Tantrums occur several times per week, at daycare, home, and with grandparent who babysits a day or 2 per week. Otherwise, client eats well, is diapered during the day and night, and urinates and stools regularly. One daytime nap, sleeps well through the night. No significant past medical history noted, prior well child visits at ages 12 months and 15 months were normal. Immunizations current through 15-month visit.

The nurse prepares to educate the parent regarding temper tantrums. For each education item, click to indicate whether the assessment technique is indicated (appropriate or necessary) or contraindicated (could be harmful) for the client's care at this time. "If safe, ignore the tantrum behavior." - Indicated "Offer rewards when a toddler ends a tantrum." - Contraindicated "When possible, offer the child choices versus 'all or nothing'." - Indicated "Make sure all care providers adhere to a consistent daytime routine." - Indicated "Tantrums are usually due to a child being unable to control their emotions." - Indicated "Encourage each care provider to develop an effective response to tantrums." - Contraindicated "Reasoning and explanation is one strategy to deescalate a toddler having a tantrum." - Contraindicated Rationale: The nurse would teach that ignoring the tantrum, when safe, is recommended as doing so does not provide attention or reinforce the behavior. When possible, the nurse would encourage offering the child choices rather than "all or nothing", as doing so gives the child a sense of control over the situation. Consistent and predictable routines are recommended to prevent tantrums; disruption of a routine is distressing and may trigger a tantrum. The nurse would teach that tantrums are often due to a child being unable to control their emotions, which results in anger initially and then distress as the anger subsides. The nurse would encourage offering rewards as positive reinforcement (good behavior) as opposed to rewarding the child when the tantrum subsides, which could reinforce tantrum behavior. The nurse would encourage consistent tantrum management responses among all care providers as opposed to variable responses among caregivers. Inconsistency is considered