Pediatrics

Which solid food can be given to a 6-month-old infant?

Crackers or Zwieback Rationale: A 6-month-old infant is able to digest crackers or Zwieback. A 6-month-old infant cannot digest raw pieces of fruit or firmly cooked vegetables. Well-cooked table foods can be effectively digested by a 12-month-old child, but not a 6-month-old infant.

An infant who is exhibiting signs of increased intracranial pressure (ICP) is admitted to the pediatric intensive care unit. What is the nurse's priority of care for this child?

Elevating the infant's head higher than the hips Rationale: Elevation of the head helps decrease intracranial pressure by promoting venous return by way of gravity. Many ill infants are weighed daily because it provides an accurate measure of hydration status; this intervention is not specific for increased ICP. Frequent checks of reflexes frequently may be disturbing to the infant and impair the ability to rest. Frequent stimulation may further irritate an already traumatized central nervous system.

A 13-year-old-child with type 1 diabetes is receiving 15 units of Novolin R insulin and 20 units of Novolin N insulin at 7 am each day. At what time should the nurse anticipate a hypoglycemic reaction from the Novolin N to occur?

In the afternoon Rationale: Novolin N is an intermediate-acting insulin that peaks approximately 6 to 8 hours after administration. It was administered at 7 am, so between 1 and 3 pm is when the nurse should anticipate that a hypoglycemic reaction will occur. During the evening or night is when a reaction from a long-acting insulin is expected. Long-acting insulin has a small peak 10 to 16 hours after administration. Noon is when a reaction from a short-acting insulin is expected. Short-acting insulin peaks in 2 to 4 hours after administration. Within 30 minutes of administration is when a reaction from a rapid-acting insulin is expected. Rapid-acting insulin peaks 30 to 60 minutes after administration.

A client is scheduled for a lumbar puncture. What nursing care should be implemented after the procedure?

Maintaining the client in the supine position for several hours. Rationale: Staying flat may help to prevent spinal fluid leakage and postprocedure headache; this is recommended, even though some people develop a headache despite this precaution. Encouraging the client to ambulate every hour for at least 6 hours may predispose to spinal fluid leakage; the client should be kept flat for 6 to 12 hours. The Trendelenburg position may increase intracranial pressure and is not appropriate. Placing the client in the high-Fowler position immediately after the procedure may predispose to spinal fluid leakage; the client should be kept flat for 6 to 12 hours.

A nurse reviews the preoperative instructions for a 3½-year-old child who is to undergo follow-up cleft palate surgery. Which instruction should the nurse question?

Tap water enema until clear this pm. Rationale: This prescription is unnecessary; the lower gastrointestinal tract is not involved with this procedure. Intravenous fluid is needed because the child is on nothing-by-mouth (NPO) status. The child is kept NPO to minimize the risk of aspiration associated with anesthesia administration. Obtaining blood for typing and crossmatching is an important routine preoperative instruction in the event that a transfusion might be needed.

The health care provider has prescribed enoxaparin (Lovenox) 1 mg/kg for a client who had a total knee replacement. The client weighs 187 pounds. This medication is available in a concentration of 30 mg/0.3 mL. What dose would the nurse administer in milliliters?

0.85

An intravenous infusion of 30 mg of an antibiotic in 50 mL of D5W every 6 hours is prescribed for an adolescent. It is to run over 30 minutes. At what hourly rate should the nurse set the infusion device? Record your answer as a whole number. ___ mL/hr

100

The primary health care provider instructs the nurse to administer a high dose of acyclovir (Zovirax) 60 mg/kg/day to a neonate with a body weight of 4.4 lbs. What dose does the nurse administer to the neonate each day? Record your answer in milligrams using a whole number. _______ mg

120

The nurse administers a second dose of inactivated polio vaccine (IPV) to a 4-month-old child. When does the child receive the third dose of IPV?

14 to 18 months of age Rationale: The inactivated polio vaccine (IPV) vaccine is given to children in four doses at 2 months, 4 months, 14 to 18 months, and 4 to 6 years of age, respectively. The child has received a second dose at 4 months of age, so he or she should receive the third dose at 14 to 18 months of age. Giving the vaccine at the age of 8 to 9 months may result in adverse reactions. After receiving the third dose, the child should receive the fourth dose at 4 to 6 years of age. Receiving a dose at 12 to 14 years of age would not be of benefit to the child.

Phenytoin (Dilantin) suspension 200 mg is prescribed for a client with epilepsy. The suspension contains 125 mg/5 mL. How much solution should the nurse administer? Record your answer using a whole number. _____ mL

8

A 6-month-old infant is to be on nothing-by-mouth (NPO) status for 4 hours before surgery for cleft palate repair. What is the most important concern for the infant before surgery?

Altered fluid intake before surgery Rationale: A 6-month-old, whose body weight is approximately 75% water, is very susceptible to fluid changes and ensuing dehydration. Although children with cleft palate breathe through the mouth, it does not impair their breathing; the surgery is performed before 2 years of age, before speech patterns become fixed, not because the cleft lip impairs breathing patterns. Although the parents may be anxious, the infant is too young to be aware of the impending hospitalization. Regressed behavior should not be a problem for a short-term hospitalization.

A client is admitted with post traumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. What score on the Glasgow Coma Scale (GCS) should the nurse document? Record your answer using a whole number.

Answer: 3 Rationale: The score on the GCS ranges from 3 to 15. The client's lack of response earns the minimum of one point in each of the categories: eye opening response, best verbal response, and best motor response.

A nurse is assessing the urine of a client with a urinary tract infection. For which characteristic should the nurse assess each specimen of urine?

Clarity Rationale: Cloudy urine usually indicates purulent drainage (pyuria) associated with infection. Viscosity is a characteristic that is not measurable. Urinary glucose levels are not affected by urinary tract infections. Specific gravity yields information related to fluid balance.

The neurologic assessment of a client who had a craniotomy includes the Glasgow Coma Scale. What does the nurse evaluate to assess the client's score on the Glasgow Coma Scale? Select all that apply.

Degree of purposeful movement by the client, Appropriateness of the client's verbal responses, Stimulus necessary to cause the client's eyes to open Rationale: The scale measures best motor response. The scale measures best verbal response. The scale measures eye opening response. Although the ability of the client's pupils to react to light is part of a neurologic assessment, it is not part of the Glasgow Coma Scale. Although the symmetry of muscle strength of the client's extremities is important to assess, it is not part of the Glasgow Coma Scale.

What is important nursing care for clients with leukemia on chemotherapeutic protocols?

Having them avoid contact with infected persons Rationale: Chemotherapy and acute lymphoblastic leukemia (ALL) cause immunosuppression (low white blood cells), thus increasing the risk for infection. The client should maintain physical activity that can be tolerated. Although vital signs must be checked to assess for changes in pulse or blood pressure, unless there is clinical evidence of bleeding, it is not necessary to obtain vital signs every two hours. Children need stimulation that is appropriate for their developmental level except when acutely ill.

While interacting with a 4-year-old child, the nurse observes that the child exhibits which behavior congruent with Piaget's cognitive development theory?

The child is unable to see things from others' perspectives. Rationale: A 4-year-old child has his or her own perspective and expects that others also think the same way. This behavior is seen in the preoperational stage of Piaget's development theory. A 1- to 2-year-old child who is in the sensorimotor stage, according to Piaget's theory, will begin to use language. An adolescent who is in the formal operations stage of Piaget's developmental theory will use abstract symbols and draw conclusions. The ability to draw conclusions from abstract symbols is not a finding in a 4-year-old. The ability to classify and sort problems is developed between the ages of 7 and 11 years. A child who is in the concrete operations stage of Piaget's development theory will exhibit the ability to classify and sort facts to solve problems.

While discussing immunizations with the nurse, the father of a 7-month-old boy states, "You know, my son doesn't sit up by himself yet. Shouldn't he be able to do this by now?" How should the nurse respond?

"Many babies don't sit up until they're 8 months old. Let's watch what he does when I sit him up." Rationale: Most infants by 6 months of age can remain in the sitting position when placed there; however, they do not sit up by themselves until 8 months. This response involves the parent in the assessment of the infant's capabilities. Stating that the child may just need encouragement questions the father's ability to assist the child and demeans the infant. Indicating that most babies are sitting up by this age is erroneous; many healthy infants do not sit steadily without support until 8 months of age. Telling the father not to worry cuts off communication and offers no directions to the father, who obviously is worried.

The nurse is caring for a child who has attention deficit hyperactivity disorder (ADHD). Which changes in the child's classroom will be beneficial? Select all that apply.

Providing breaks frequently at regular intervals, Writing instructions on the blackboard after verbalization, Scheduling academic subjects for times when the child is under the effect of medication Rationale: A child with attention deficit hyperactivity disorder (ADHD) will not be able to concentrate properly and experiences difficulty sitting in one place for a prolonged time. Therefore, frequent breaks are helpful to improve the child's concentration. Visual representations also help attract attention and improve concentration. Therefore, it is appropriate to write instructions after saying them. The child will have increased concentration under the effect of medication, which is generally in the morning. Therefore, academic subjects should be scheduled for the morning. A child with ADHD will have dysgraphia, or poor handwriting. Therefore, it is appropriate to concentrate on improving the child's computer skills, instead of improving handwriting. It is appropriate to allot more time to take tests and help the child complete tasks rather than giving homework and assignments.

An infant is to receive an intravenous antibiotic as a piggyback. The prescription is 10 mg/kg body weight/24 hr, to be administered in equal doses every 12 hours. The infant weighs 22 lb. How many milligrams of the antibiotic should the infant receive per dose? Record your answer using a whole number. ___ mg

50

Oral phenobarbital 30 mg every 6 hours is prescribed for a toddler who has had a seizure. A bottle of phenobarbital liquid labeled "20 mg/4 mL" is available. How much solution (mL) should the nurse administer? Record your answer using a whole number. ___ mL

6

Nitrofurantoin (Macrobid) 0.1 gm is prescribed for a client with a urinary tract infection. Each tablet contains 50 mg. How many tablets should the nurse administer? Record your answer using a whole number. _____ tablets

2

The nurse is giving nutritional counseling to the parents of an 8-month-old infant. Which statement does the nurse include in the counseling?

"Avoid peanuts and eggs in your baby's diet." Rationale: Foods such as peanuts, eggs, fish, and seafood can result in food allergy in infants. Therefore, these foods should not be given until 12 months of age. An 8-month-old infant can digest puréed vegetables; therefore, they can be given to the infant. Low-fat cow's milk can result in brain impairment in infants due to inadequate fat supplementation. Pasteurized whole cow's milk is low in iron, zinc, and vitamin C and may result in iron deficiency anemia in the infant.

A toddler with hemophilia A is receiving factor VIII. The mother asks the nurse, "If my son hurts himself, I'll give him 2 children's Advil. Is that right?" How should the nurse respond?

"Give him Tylenol. Advil may cause bleeding." Rationale: The parent is asking a specific question that should be answered by the nurse. Ibuprofen (Advil) is contraindicated because it may cause more bleeding. Ibuprofen interferes with platelet function and may cause more bleeding; therefore an analgesic such as acetaminophen (Tylenol) should be administered, because it does not interfere with coagulation. Analgesics are permitted, provided they do not have anticoagulant effects.

The parents of an infant tell a nurse in the pediatric clinic that they give their infant some whiskey when the baby is colicky. How should the nurse respond?

"Have other parents in your family given whiskey to their babies?" Rationale: Assessing family or cultural habits can provide insight into the behavior and determine the approach to health teaching. Asking whether the whiskey calms the baby is a direct question focused on just one aspect of the problem that may not foster further exploration of the situation. Asking the health care provider to prescribe medication is premature; this suggests an intervention before adequate information is collected. Telling the parent that giving the baby whiskey is not a good idea is a judgmental response that will cut off communication

A nurse in the pediatric clinic receives a call from the mother of an infant who has been prescribed digoxin (Lanoxin). The mother reports that she forgot whether she gave the morning dose of digoxin. How should the nurse respond?

"Skip this dose and give it at the next prescribed time." Rationale: An additional dose may cause over dosage, leading to toxicity; it is better to skip the dose. Giving the dose without waiting may cause an overdose, which could result in toxicity. Even waiting 2 hours may cause an overdose, leading to toxicity. Taking the pulse is not a reliable method for determining a missed dose; 90 to 110 beats/min is within the expected range for this age.

A health care provider prescribes 250 mg of an antibiotic intravenous piggyback (IVPB). A vial containing 1 gram of the powdered form of the medication must be reconstituted with 2.8 mL of diluent to form a volume of 3 mL. How many mL of the solution should the nurse administer? Record your answer using one decimal place including leading zero if applicable. __mL

0.8

A 4-year-old child who weighs 44 lb is prescribed prednisone. The recommended dosage for children is 2 mg/kg/day given in four divided doses. What should the child receive in each dose? Express your answer as a whole number. ______ mg

10

The nurse uses the Glasgow Coma Scale to assess a client with a head injury. The Glasgow Coma Scale score that indicates the client is in a coma is a score of:

Answer: 6 Rationale: The Glasgow Coma Scale is used to assess the extent of neurological damage; it consists of three assessments: eye opening, response to auditory stimuli, and motor response. Consciousness exists on a continuum from full consciousness to coma. A score can be from 3 to 15; the lower the score the more indicative of coma. To achieve the ratings of 9, 12, or 15 the client must be exhibiting some meaningful responses.

What nursing assessment best indicates the magnitude of fluid loss in an infant with gastroenteritis and diarrhea?

Comparing the infant's pre-illness and current weights Rationale: Loss of weight is the most accurate means of determining the magnitude of fluid loss because it is an objective assessment. One liter of fluid is equal to about 2.2 lb. Testing the infant's tissue turgor is a more subjective assessment than is weighing the infant. Although determining the degree of increase in the infant's hematocrit value will indicate the degree of dehydration, it is not an effective method of assessing fluid loss. Checking the moistness of the infant's mucous membranes is a more subjective assessment than is weighing the infant

A nurse instructs a client with a history of frequent urinary tract infections to drink cranberry juice to:

Decrease the urinary pH Rationale: Cranberry juice is excreted as hippuric acid, which helps acidify the urine (decrease the pH) and inhibit bacterial growth. Although bacterial growth may be inhibited, bacteria are not destroyed. Glomerular filtration is unaffected by cranberry juice. Cranberry juice acidifies the urine and may increase the burning sensation associated with urination when an infection is present.

An unconscious 16-year-old adolescent with type 1 diabetes is brought to the emergency department. The blood glucose level is 742 mg/dL. What finding does the nurse expect during the initial assessment?

Hyperpnea Rationale: Rapid breathing is an attempt by the respiratory system to eliminate excess carbon dioxide; it is a characteristic compensatory mechanism for correcting metabolic acidosis. An increase in temperature will occur if an infection is present; it is not a response to hyperglycemia. Tachycardia, not bradycardia, results from the hypovolemia of dehydration. Hypotension, not hypertension, may result from the decreased vascular volume associated with hyperglycemia.

A nurse inserts a nasogastric tube before an infant is to receive a tube feeding. What action should the nurse take when the infant begins to cough and gag?

Removing the tube, then reinserting it Rationale: The infant's response indicates that the tube may be in the trachea rather than the stomach. The tube should be removed, reinserted, and verified for its placement before the feeding is started. Auscultating for breath sounds does not provide information about the placement of the tube. The tube should be removed immediately; it is unsafe to assess the infant for additional signs of respiratory distress. It is unsafe to administer the feeding until placement in the stomach has been confirmed.

A nurse is caring for a client who is experiencing urinary incontinence. The client has an involuntary loss of small amounts (25 to 35 mL) of urine from an overdistended bladder. This should be documented in the medical record as:

Overflow incontinence Rationale: Overflow incontinence describes what is happening with this client; overflow incontinence occurs with retention of urine with overflow of urine. Urge incontinence describes a strong need to void that leads to involuntary urination. Stress incontinence occurs when a small amount of urine is expelled because of an increase in intraabdominal pressure that occurs with coughing, lifting, or sneezing. Reflex incontinence is an involuntary loss of urine at fairly predictable intervals when certain urinary bladder intervals are reached.

The nurse assists the health care provider to perform a lumbar puncture. When pressure is placed on the jugular vein during a lumbar puncture, the spinal fluid pressure is expected to increase. Which sign should the nurse expect the health care provider to document?

Queckenstedt Rationale: If there is no obstruction, pressure on the jugular vein causes increased intracranial pressure (Queckenstedt sign). This, in turn, causes an increase in spinal fluid pressure. Homan sign is calf pain possibly elicited by dorsiflexion of the foot if thrombophlebitis is present. Romberg sign is failure to maintain balance when the eyes are closed; it indicates cerebellar pathology. Chvostek sign is twitching elicited by tapping the angle of the jaw; it occurs if hypocalcemia is present.

A nurse is caring for a client with a fracture of the head of the femur. The health care provider places the client in Buck's extension. What explanation does the nurse give the client for why the traction is being used?

Reduces muscle spasms Rationale: Buck's extension is used to reduce the fracture, align the bone, and temporarily reduce muscle spasm. Edema occurs because of tissue trauma and will not be prevented by Buck's extension. A fractured head of the femur is repaired via internal fixation; a cast is unnecessary. Damage already has occurred at the time of trauma and is not prevented by Buck's extension.

A 5-month-old child undergoes heart surgery to repair the defects associated with tetralogy of Fallot. Prevention of what behavior is a priority for the nurse after the surgery?

Staining at stool Rationale: Forceful evacuation involves taking a deep breath, holding it, and straining (Valsalva maneuver). This increases intrathoracic pressure, which puts excessive strain on the heart sutures. Crying is not a problem after cardiac surgery; it may, in fact, help prevent respiratory complications. Coughing and deep breathing are essential for the prevention of postoperative respiratory complications. Activity is gradually increased.

A 5-month-old infant is admitted with a diagnosis of respiratory syncytial virus (RSV) infection. The infant's condition suddenly deteriorates and a dose of epinephrine is prescribed to relieve bronchospasm. For what side effect of the medication should the nurse assess the infant?

Tachycardia Rationale: Epinephrine stimulates β- and α-receptors; its actions include increasing heart rate and blood pressure and inducing bronchodilation. Increased blood pressure, not hypotension, is a potential side effect. Epinephrine relieves respiratory problems; it does not cause respiratory arrest. Epinephrine stimulates, not depresses, the central nervous system.

A nurse is planning to assess the vomitus of an infant with pyloric stenosis. Why does the nurse anticipate that the vomitus will be white rather than bile-stained?

There is an obstruction above the opening of the common bile duct. Rationale: The common bile duct enters the duodenum. The pyloric sphincter is located between the end of the stomach and the beginning of the duodenum; therefore when it is hypertrophied the tight sphincter prevents any mixing of vomited formula with bile. Pyloric stenosis involves hypertrophy and hyperplasia of the muscle of the pyloric sphincter; the bile duct is intact. The bile duct enters the duodenum at a site different from the pyloric sphincter and is uninvolved in pyloric stenosis. The area affected in pyloric stenosis is the pyloric sphincter (which is between the stomach and duodenum), not the cardiac sphincter (which is between the stomach and esophagus).

A client is cautioned to avoid vitamin D toxicity while increasing protein intake. Which nutrient selected by the client indicates to the nurse that the dietary teaching is understood?

Tofu Tofu Rationale: Tofu products increase protein without increasing vitamin D because, unlike milk products, tofu does not contain vitamin D. Eggnog contains milk and should be avoided. Cottage cheese, a milk product, contains vitamin D, which should be avoided. Powdered whole milk contains vitamin D and should be avoided.

An IV catheter is to be inserted into a 3-year-old toddler's peripheral vein. As local topical anesthetic is applied, the toddler starts to cry and asks whether the insertion is going to hurt. How should the nurse respond?

"Yes, it may hurt, but not for very long." Rationale: Although the local anesthetic will help minimize the discomfort, the needle insertion may still hurt. Telling the child that the insertion will hurt but not for very long is an honest, simple answer that is appropriate for a 3-year-old child. Telling the child that big kids don't cry is a judgmental response that is inappropriate for a 3-year-old child; children sometimes need to cry to express their feelings. Although the child should hold still, there is no guarantee that doing this will cause the insertion to hurt less. Saying, "Maybe it will hurt" or "It may hurt" constitutes false reassurance. Saying that the insertion will hurt just a little because the nurse is skilled is also false reassurance; there is no guarantee of success, despite the nurse's self-proclaimed expertise.

Which common initial clinical effects should the nurse expect a client with multiple sclerosis to exhibit? Select all that apply.

Nystagmus, Scanning speech, Intention tremors Rationale: Involuntary, rhythmic movements of the eyes (nystagmus) and other visual disturbances, such as diplopia and blurred vision, are common initial symptoms of optic nerve lesions. The most common initial signs of multiple sclerosis are scanning speech, intention tremors, and nystagmus; this group of signs is known as Charcot's triad. These adaptations are associated with disseminated demyelination of nerve fibers of the brain and spinal cord. Although this is a neuromuscular disorder, headaches are not a common symptom. Pressure ulcers may occur late, not early, in the progression of the illness because of immobility, and these pressure ulcers may become infected.

The nurse is caring for a client with a long leg cast. Which clinical findings indicate compromised circulation? Select all that apply.

Swelling of the toes, Prolonged capillary refill Rationale: Constriction of circulation decreases venous return and increases pressure within the vessels. Fluid then moves into the interstitial spaces, causing edema. Impaired circulation is evidenced by prolonged capillary refill after the toes are compressed. A foul odor may indicate the presence of an infection. Drainage on the cast may indicate the presence of an infection. An increased temperature may indicate the presence of an infection.