PEDS: Nursing Care of Children #2

A nurse is caring for a child who has a possible intussusception. The parents of the child ask the nurse how the diagnosis is made. Which of the following responses should the nurse make? "An abdominal ultrasound will confirm the pocket in the intestine." "Genotyping will be done to identify this condition." "A biopsy will be done on a small amount of tissue from the colon." "An upper GI series should identify the area involved."

"An abdominal ultrasound will confirm the pocket in the intestine." Intussusception is the invasion of one part of the intestine into the other, creating a pocket. The presence of an intussusception is confirmed by an abdominal x-ray, ultrasound, or CT scan.

A nurse is providing teaching to an adolescent who has scoliosis and a new prescription for a Boston brace. Which of the following responses by the adolescent indicates an understanding of the teaching? "I can take my brace off to sleep every night at bedtime." "I can take my brace off for about an hour daily to shower." "I should loosen the straps on my brace if it is rubbing my skin." "I should place the pads of brace against my skin with a t-shirt over them."

"I can take my brace off for about an hour daily to shower." The nurse should instruct the child to wear the brace for 23 hr each day and to only remove it for showering or participating in physical therapy.

A clinic nurse is providing teaching to the parent of a 1-month-old infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching? "I will give the lansoprazole 30 min after my baby's feedings." "I will lay my baby on her side after feedings." "I will give my baby a bottle just before bedtime." "I will add rice cereal to my baby's feedings."

"I will add rice cereal to my baby's feedings." The mother should add 1 tsp to 1 tbsp of rice cereal per ounce of formula or expressed breast milk to thicken the feedings because this will decrease the number of vomiting episodes.

A nurse is teaching the parent of a preschool-age child about the treatment for pinworms. Which of the following statements by the parent indicates an understanding of the teaching? "I will give my child a dose of albendazole today and again in 2 weeks." "I will collect specimens immediately after my child has a bowel movement." "I will give my child a tub bath twice each day." "I will place my child's bed linens in a sealed plastic bag for 7 days."

"I will give my child a dose of albendazole today and again in 2 weeks." The nurse should instruct the parent to repeat the dose of albendazole in 2 weeks to completely eradicate the parasite and prevent reinfection.

A nurse is providing discharge teaching to the parent of a school-age child who has leukemia and is receiving chemotherapy. Which of the following statements by the parent indicates an understanding of the teaching? "I will take my child's rectal temperature daily." "I will make sure my child gets his MMR vaccine this week." "I will inspect my child's mouth every day for sores." "I will allow my child to ride his bicycle tomorrow."

"I will inspect my child's mouth every day for sores." A child who has leukemia is at an increased risk for mucositis; therefore, the parent should inspect the child's mouth daily for lesions or ulcerations.

A nurse is providing teaching to the parents of a school-age child who has type 1 diabetes mellitus about management of hypoglycemia. Which of the following responses by the parents indicates an understanding of the teaching? "I will make sure my child drinks 240 mL (8 oz) of milk as soon as possible." "I will give my child 2 units of regular insulin." "I will insist that my child lies down to rest for 30 minutes." "I will check my child's urine for glucose twice daily."

"I will make sure my child drinks 240 mL (8 oz) of milk as soon as possible." Giving the child 10 to 15 g of simple carbohydrates, such as 240 mL (8 oz) of milk, will elevate the blood glucose level and alleviate the hypoglycemia.

A nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM). Which of the following responses by the adolescent indicates an understanding of the teaching? "I will breathe in through the mouthpiece, hold my breath for 5 seconds, and then exhale." "If I get a reading in the green zone, I will tell my parents immediately so they can call the doctor." "I will slowly exhale through the mouthpiece over a 10 second interval." "I will record the highest reading of three attempts."

"I will record the highest reading of three attempts." Once the client establishes a personal best, she should routinely check the PEFM by performing three attempts and recording the highest reading of the three.

A nurse is providing teaching to the parent of a 2-year-old toddler about nutrition. Which of the following statements by the parent indicates an understanding of the teaching? "My child should consume 1,000 calories per day." "My child should have 4 ounces of protein per day." "I should give my child 32 ounces (4 cups) of milk per day." "I should feed my child 4 ounces (1/2 cup) of vegetables per day."

"My child should consume 1,000 calories per day." Toddlers who are 2 years old should consume 1,000 calories daily.

A nurse is providing teaching about immunizations to the parents of a severely immunocompromised child who has human immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching? "Your child's immunizations today will be half-doses." "The pneumococcal and influenza vaccines are recommended for your child." "Immunizations will be delayed until your child tests HIV negative." "Your child will need to start the immunization schedule over once his laboratory values are within reference range."

"The pneumococcal and influenza vaccines are recommended for your child." Immunization against common childhood illnesses, including the influenza and pneumococcal disease, is recommended for all children exposed to and infected with HIV.

A nurse is preparing to obtain an antistreptolysin O (ASO) titer from a child who has acute glomerulonephritis. The child's parent asks the nurse to explain the purpose of the test. Which of the following responses should the nurse make? "The test determines the level of antibiotics in your child's blood." "The test tells us if your child ever had the measles." "The test verifies the amount of albumin in your child's blood." "The test shows us if your child had a recent strep infection."

"The test shows us if your child had a recent strep infection." An ASO titer indicates that the child has had a recent strep infection. In determining a definitive diagnosis for acute glomerulonephritis, this must be documented as it is usually the result of this type of infection.

A nurse is reviewing the laboratory results of a child who has experienced diarrhea for the past 24 hr. Which of the following values for urine specific gravity should the nurse expect? 1.010 1.035 1.020 1.005

1.035 1.035 is a concentrated specific gravity, which is an expected value for a child who is dehydrated; therefore, this is an expected urine specific gravity for a child who has experienced diarrhea for 24 hr.

A nurse is assessing a 6-month-old infant following a cardiac catheterization. Which of the following findings should the nurse report to the provider? Temperature of 37.5° C (99.5° F) Apical pulse rate 140/min BP 86/40 mm Hg Respiratory rate of 32/min

BP 86/40 mm Hg A BP of 86/40 mm Hg is indicative of hypotension and bleeding in a 6-month-old infant and should be immediately reported to the provider.

A nurse is teaching about clinical manifestations of tracheomalacia to a parent of an infant who had tracheoesophageal fistula repair as a newborn. Which of the following findings should the nurse include in the teaching? Absence of bowel sounds Neck contortions Barking cough Projectile vomiting

Barking cough Infants who have tracheomalacia have a weakened trachea, which leads to collapse. Clinical manifestations of tracheomalacia include barking cough, stridor, wheezing cyanosis, and apnea

A nurse is caring for a 12-month-old infant following surgical repair of a cleft palate. The nurse should plan to feed the infant using which of the following instruments? Spoon Straw Firm nipple Cup

Cup The infant should be fed clear liquids using a cup for 7 to 10 days following a cleft palate repair to prevent trauma and injury to the suture line.

A nurse is teaching a school-age child and his parents how to self-administer insulin. Which of the following actions should the nurse take first? Allow a parent to administer an injection to the nurse. Have the child teach the injection technique to the parents. Have a parent administer the insulin injection to the child. Demonstrate the injection technique on an orange.

Demonstrate the injection technique on an orange. The nurse should apply the safety and risk reduction priority setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. Demonstrating the injection technique on an orange poses no risk to the client and is therefore the first action the nurse should take. The nurse should use Maslow's hierarchy of needs, the ABC priority setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client.

A nurse in an emergency department is caring for a 4-year-old child who has burns to the neck and face following a house fire. Which of the following actions should the nurse take first? Cover the child's wounds with a clean, dry cloth. Establish IV access for the child with a large-bore catheter. Provide reassurance to the child's parents. Determine the child's breathing pattern.

Determine the child's breathing pattern. The nurse should apply the ABC priority setting framework. This framework emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore the nurse's priority concern. When applying the ABC priority setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Determining the child's breathing pattern is the first action the nurse should take. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them.

A nurse in an emergency department is caring for a toddler who is in acute respiratory distress. Which of the following findings should alert the nurse to the possibility of epiglottitis? Lethargy Spontaneous coughing Drooling Hoarseness

Drooling Epiglottitis is a disorder caused by an inflammation of the epiglottis. It results in rapid swelling of the epiglottis, which can obstruct breathing. Drooling is common finding due to the toddler's inability to swallow saliva.

A nurse is caring for a child who is in skeletal traction. Which of the following actions is the nurse's priority? Perform passive range of motion for unaffected joints. Massage the child's pressure areas. Increase the child's fluid intake. Encourage the child to use an incentive spirometer.

Encourage the child to use an incentive spirometer. The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore the nurse's priority concern. When applying the ABC priority setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Encouraging the child to use an incentive spirometer will assist the child in adequate oxygenation and is the priority nursing action. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them

A nurse is assessing pain in a 3-year-old child following a tonsillectomy. Which of the following rating scales should the nurse use to determine the child's pain level? Word-Graphic Rating Scale Color Tool Poker Chip Tool FACES Rating Scale

FACES Rating Scale The nurse should use the FACES rating scale to assess this child's pain level. This scale is appropriate for a 3 year old and provides a series of facial expressions representing amounts of pain.

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings is the nurse's priority? Nausea Hoarse voice Frequent swallowing Sore throat

Frequent swallowing The nurse should apply the urgent versus non-urgent priority-setting framework. Using this framework, the nurse should consider urgent needs the priority need because they pose more of a threat to the client. Frequent swallowing can be an indication of bleeding, therefore is the nursing priority finding to address. The nurse may also need to use Maslow's hierarchy of needs, the ABC priority setting framework, or nursing knowledge to identify which finding is the most urgent.

A nurse is reviewing the laboratory report of a toddler who is receiving chemotherapy for leukemia. Which of the following laboratory values should the nurse report to the provider? Platelets 150,000/mm3 Hgb 6 g/dL WBC 6,000/mm3 Potassium 4.5 mEq/L

Hgb 6 g/dL This hemoglobin level is below the expected reference range and is indicative of anemia; therefore, the nurse should report this finding to the provider.

A nurse is teaching a newly hired nurse about the care of an infant who is postoperative following myelomeningocele repair. The nurse should teach the newly hired nurse to monitor the infant for which of the following complications? Hydrocephalus Congenital hypotonia Otitis media Osteomyelitis

Hydrocephalus In the surgical repair of the myelomeningocele, the pathway for the cerebral spinal fluid is altered; therefore, the infant is at risk for hydrocephalus and the nurse should monitor the infant for this condition. Myelomeningocele: With this form of spina bifida, a little bit of the baby's spinal cord and nerves protrude through an opening in the spine into a flat disc or sac that's visible on the back.

A nurse is providing dietary teaching to the parent of a child who has cystic fibrosis. Which of the following dietary recommendations should the nurse make? Increase the child's protein intake. Decrease the child's calorie intake. Increase the child's fiber intake. Decrease the child's salt intake.

Increase the child's protein intake. The nurse should recommend an increase in protein intake for the child who has cystic fibrosis. These children require up to 150% of the recommended daily allowances to meet their nutritional needs.

A home health nurse is developing a plan of care for the parents of a toddler who has hemophilia. Which of the following instructions should the nurse include in the plan? Administer low-dose aspirin for pain. Inspect the toddler's toys for sharp edges. Perform passive range-of-motion to the affected joint during a bleeding episode. Avoid contact with people who have respiratory infections.

Inspect the toddler's toys for sharp edges. The nurse should instruct the parents to inspect the toddler's toys for sharp edges or parts because this decreases the risk of injury and bleeding to the toddler.

A nurse is caring for an 8-year-old child who has acute glomerulonephritis. Which of the following findings should the nurse expect? Hypotension Stomatitis Bloody diarrhea Periorbital edema

Periorbital edema Periorbital edema is an expected finding in a child who has glomerulonephritis.

A nurse is providing discharge teaching to the parents of a child who has nephrotic syndrome. Which of the following instructions should the nurse include in the teaching? Restrict the child's potassium intake. Administer acetaminophen to the child twice daily. Weigh the child once each week. Keep the child away from people who have an infection.

Keep the child away from people who have an infection. Children who have nephrotic syndrome are at increased risk for infection and should avoid contact with people who have infections.

A nurse is assessing a toddler who has measles (rubeola). Which of the following findings should the nurse expect? Koplik spots Parotitis Strawberry tongue Paroxysmal cough

Koplik spots Koplik spots are small, irregular oral lesions with a bluish-white center and are characteristic of measles (rubeola). Koplik spots appear about 2 days before the maculopapular rash appears and are accompanied by manifestations of fever, malaise, conjunctivitis, and other cold manifestations.

A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan? Apply cold compresses to the child's extremities. Administer meperidine every 4 hr until the crisis has resolved. Maintain the child on bed rest. Decrease the child's fluid intake for 8 hr.

Maintain the child on bed rest. The nurse should maintain bed rest for the child who is experiencing a vaso-occlusive crisis to minimize energy expenditure and avoid additional oxygen needs.

A nurse is providing teaching to the parents of an infant who has acute otitis media about how to administer antibiotic eardrops. Which of the following instructions should the nurse include? Chill the medication prior to administration. Massage the anterior area of the infant's ear following administration. Hyperextend the infant's neck during administration. Pull the auricle up and back during medication administration.

Massage the anterior area of the infant's ear following administration. The nurse should instruct the parents to massage the anterior area of the ear following administration of eardrops to facilitate instillation of the medication.

A nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy. Which of the following interventions should the nurse include in the plan? Maintain the child on bed rest. Monitor the child for increased temperature. Administer oxygen to the child. Monitor the child for bleeding.

Monitor the child for increased temperature. Leukopenia places the child at risk for infection; therefore, the nurse should monitor the child for a fever.

A nurse is assessing a child who has a ventricular septal defect. Which of the following findings should the nurse expect? Diastolic murmur Murmur at the left sternal border Cyanosis that increases with crying Widened pulse pressure

Murmur at the left sternal border A ventricular septal defect, a hole in the septal wall between the ventricles, is an acyanotic heart defect. A systolic murmur can be best heard at the lower left sternal border. Sound is transmitted in the direction of blood flow, so any backflow of blood from the left to the right ventricle through the septal defect is best heard in this area.

A nurse is providing teaching to an adolescent who has a fiberglass arm cast. Which of the following instructions should the nurse include in the teaching? Place a plastic bag over the cast when showering. Insert a dull knitting needle into the cast to rub itchy skin. Exercise fingers every 8 hr for the first 24 hr. Draw on the cast using magic markers.

Place a plastic bag over the cast when showering. The nurse should instruct the adolescent to keep the cast dry by placing a plastic bag over it while showering. Although water will not damage the fiberglass cast, water can enter the openings of the cast and result in maceration of the skin.

A nurse is reviewing the laboratory report of a 2-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the following findings should the nurse report to the provider? Hct 40% Potassium 2.5 mEq/L Serum creatinine 0.4 mg/dL BUN 6 mg/dL

Potassium 2.5 mEq/L A potassium level of 2.5 mEq/L indicates hypokalemia, which can cause arrhythmias or even cardiac arrest; therefore, the nurse should report this finding to the provider.

A nurse is admitting a child who has Wilms' tumor. Which of the following actions should the nurse take? Initiate contact precautions for the child. Explain to the parents that chemotherapy will start 3 months following surgery. Put a "no abdominal palpation" sign over the child's bed. Prepare the child for a spinal tap.

Put a "no abdominal palpation" sign over the child's bed. The nurse should place a sign over the child's bed reading "no abdominal palpation" because palpation is not necessary to confirm diagnosis and could aid in metastasis.

A nurse is providing nutritional teaching to an adolescent client who has celiac disease. Which of the following breakfast foods should the nurse recommend? Plain flour pastry Wheat cereal Scrambled eggs Rye toast

Scrambled eggs The client who has celiac disease should be on a low-gluten diet and should avoid foods containing barley, oat, rye, and wheat; therefore, scrambled eggs are an appropriate breakfast item for the nurse to recommend to the client.

A nurse is caring for a 6-week-old infant following a pyloromyotomy. Which of the following forms of feeding should the nurse anticipate for the infant 6 hr after the procedure? Bottle formula with added protein Small, frequent bottle feedings of electrolyte solution Continuous nasoduodenal tube feedings Bolus feedings via gastrostomy tube

Small, frequent bottle feedings of electrolyte solution Feedings begin 4 to 6 hr after the surgical procedure. The nurse should anticipate feeding the infant small, frequent increments of an electrolyte solution or sterile water. pyloromyotomy: surgery to treat pyloric stenosis

A nurse is caring for an infant following surgical repair of a cleft lip and palate. Which of the following actions should the nurse take? Keep the infant's mouth open by using a tongue blade for 4 hr following surgery. Suction the infant gently with a bulb syringe PRN. Place the infant in prone position. Clean the infant's incision with chlorhexidine.

Suction the infant gently with a bulb syringe PRN. The nurse should gently suction the infant's mouth with a bulb syringe to maintain a patent airway.

A nurse in an emergency department is assessing a school-age child who is experiencing an acute asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider? Excessively prolonged expiration Increased diaphoresis Increased production of frothy sputum Sudden decrease in wheezing

Sudden decrease in wheezing The nurse should apply the urgent versus nonurgent priority setting framework. Using this framework, the nurse should consider urgent needs the priority need because they pose a larger risk to the client. A sudden decrease in wheezing can be an indication that the child is experiencing decreased air movement and should be reported to the provider. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority setting framework, or nursing knowledge to identify which finding is the most urgent. A sudden decrease in wheezing (silent chest) indicates ventilator failure and an imminent respiratory arrest.

A nurse is assessing a 6-month-old infant who was recently admitted with acute vomiting and diarrhea. Which of the following findings indicates the infant has moderate dehydration? Bulging anterior fontanel Bradycardia Tachypnea Polyuria

Tachypnea An infant who has moderate dehydration will have a slight tachypnea.

A nurse is assessing a 2-month-old infant who has a ventricular septal defect. Which of the following findings should the nurse report to the provider? Weight gain of 1.8 kg (4 lb) Heart rate 125/min Soft, flat fontanel Systemic murmur

Weight gain of 1.8 kg (4 lb) A 4 lb weight gain indicates increased fluid and worsening of the child's heart failure; therefore, the nurse should report this finding to the provider.