Chapter 44 PrepU: Nursing Care of a Family when a Child has a Hematologic Disorder

A child with congenital hypoplastic anemia who has been receiving transfusions of packed red blood cells over the long term has developed hemosiderosis. The child is prescribed deferoxamine. After teaching the parents how to administer the drug, the nurse determines that the parents need additional teaching when they make which statement?

"We will plan to give the drug on the same day each week." Deferoxamine binds with iron and aids its excretion from the body in urine; it is given 5 or 6 days a week over an 8-hour period. This is one of the few times that an infusion is given subcutaneously. Parents can do this at home after careful instruction, often while their child is asleep at night.

A nurse is conducting a physical examination of a 5-year-old with suspected iron-deficiency anemia. How would the nurse evaluate for changes in neurologic functioning?

"Will you show me how you walk across the room?" Neurologic effects of iron deficiency may be demonstrated when the child's ability to sit, stand, and walk are impaired. Inspecting the mouth, looking for bruises, and checking the hands and feet provide information about signs of petechiae, purpura, or pallor.

The nurse is caring for a 10-year-old boy with hemophilia. He asks the nurse for suggestions about appropriate physical activities. Which activity would the nurse most likely recommend?

Children with hemophilia should stay active. Good physical activities would be swimming, baseball, basketball, and bicycling (with a helmet). He would still need to be careful about falls and sliding into base. Intense contact sports like football, wrestling, and soccer should be avoided.

A group of students are reviewing the effects of sickle cell anemia on the various parts of the body. The students demonstrate a need for additional study when they identify what as an effect?

High urine specific gravity Low urine specific gravity (hyposthenuria) occurs with sickle cell anemia. Chest syndrome is an acute manifestation of sickle cell anemia. Pulmonary hypertension is a chronic manifestation of sickle cell anemia. Cholelithiasis is a chronic manifestation of sickle cell anemia.

The mother of a 5-year-old girl brings the child to the clinic for an evaluation. The mother tells the nurse, "She seems to be so tired and irritable lately. And she looks so pale." Further assessment reveals pale conjunctiva and oral mucous membranes. The nurse suspects iron-deficiency anemia. Which additional finding would help provide additional evidence for this suspicion?

Spooning or concave shape of the nails suggests iron-deficiency anemia. Other findings would include decreased oxygen saturation levels, tachycardia, and possible splenomegaly.

In caring for a child with sickle cell disease, the highest priority goal is:

The child's fluid intake will improve. The highest priority goals for this child are maintaining comfort and relieving pain. The child is prone to dehydration because of the kidneys' inability to concentrate urine, so increasing fluid intake is the next highest priority. Other goals include improving physical mobility, maintaining skin integrity, reducing the caregiver's anxiety, and increasing the caregiver's knowledge about the causes of crisis episodes — but these goals are not the highest priority.

A pediatric client is being screened for a macrocytic anemia? Which types of diagnosis would be considered? Select all that apply.

anemia of folic acid deficiency and pernicious anemia Macrocytic anemias include anemia of folic acid deficiency and pernicious anemia. Iron-deficiency anemia is a hypochromic anemia. Acute blood loss anemia and hypersplenism are examples of normochromic, normocytic anemias.

The nurse will select which meal as the best choice for a child with iron-deficiency anemia?

cheeseburger, broccoli, and fresh strawberries Children with iron-deficiency anemia require diets rich in iron and vitamin C (vitamin C enhances iron absorption). Meats are excellent sources of iron. Broccoli is a good source of iron, and strawberries are a good source of vitamin C. To help the body absorb the most iron from the meal, tea and foods rich in calcium (such as milk and cheese) should be avoided.

After teaching the parents of a child diagnosed with pernicious anemia about the disorder and treatment, the nurse determines that the teaching was successful when the parents state:

"He'll need to have those vitamin shots for the rest of his life." Monthly injections of vitamin B12 are required for life. Although diet is important, diet alone will not cure the anemia. Iron used to treat iron-deficiency anemia can lead to constipation. Bone marrow transplant is used to treat aplastic anemia.

A nurse is providing teaching to the parents of a child diagnosed with sickle cell anemia. The discussion is focused on precipitating factors for sickle cell crisis. Which statement by the parents requires the nurse to reinforce the teaching?

"Our family is taking a fun hiking trip up in the mountains next week." High altitudes are a contributing factor for sickle cell crisis and should be avoided, as should flights in planes that are not pressurized. Extreme temperatures (hot or cold) are also triggers for a crisis so keeping warm during the winter is important. Dehydration and exposure to infection or other illness are precipitating factors for sickle cell crisis. Adequate hydration and keeping up with immunizations are imperative for health and wellness in a child diagnosed with sickle cell anemia.

The nurse is preparing a child for discharge following a sickle cell crisis. Which statement by the mother indicates a need for further teaching?

"She has been down, but playing in soccer camp will cheer her up." Following a sickle cell crisis, the child should avoid extremely strenuous activities that may cause oxygen depletion. Fluids are encouraged, pain management will be needed, and the child's legs may be elevated to relieve discomfort, so these are all statements that indicate an understanding of caring for the child who has had a sickle cell crisis.

A nurse is conducting a class to a group of parents on sickle cell anemia. Which statement by a parent indicates teaching has been effective?

"The sickle shape of red blood cells decreases oxygen to tissues." The sickle shape of the red blood cells impedes the flow of blood through the vessels, thus causing hypoxia to the tissues. Sickle cell anemia is a hereditary disease but it is autosomal recessive, meaning it requires two genes in order for the disease to be transmitted. Sickle cell anemia is common in people of African, Mediterranean, and Indian descent. Hydration is important to controlling sickle cell anemia. Dehydration is a trigger for sickle cell crisis.

The nurse is educating parents of a child with acute kidney injury about expected outcomes for erythropoietin treatment. Which statement by the parents indicates that further education is needed?

"This will cause increased urine production." Acute kidney injury can cause decreased production of erythropoietin, which results in decreased production of red blood cells. Erythropoietin is a hormone released by the kidneys that works by stimulating bone marrow to produce red blood cells, which can improve activity tolerance. Erythropoietin will not improve the kidney injury or increase urine production.

The nurse is caring for a 13-year-old girl with von Willebrand disease. After teaching the adolescent and her parents about this disorder and care, which response by the parents indicates a need for additional teaching?

"We should administer desmopressin as often as needed." The parents need to know that desmopressin spray Stimate is used for controlling bleeding; the other brands are used for homeostasis and enuresis. Additionally, Stimate should only be used for 3 days in a row as lessening of the response (tachyphylaxis) occurs with frequent use. Stimate should be used before dental work. Menorrhagia and nosebleeds may occur.

A 1-year-old child is diagnosed with pernicious anemia due to lack of intrinsic factor and is prescribed vitamin B12 injections. After teaching the child's parents about this treatment, the nurse determines that the teaching was successful based on which statement?

"We will give the injection once a month for the rest of our child's life." If the anemia is identified as being caused by a diet deficient in vitamin B12, temporary injections of vitamin B12 will reverse the symptoms. If the anemia is caused by a lack of the intrinsic factor, lifelong monthly intramuscular injections of vitamin B12 may be necessary.

A 5-year-old girl is diagnosed with iron-deficiency anemia and is to receive iron supplements. The child has difficulty swallowing tablets, so a liquid formulation is prescribed. After teaching the parents about administering the iron supplement, which statement by the parents indicates the need for additional teaching?

"We will place the liquid in the front of her gums, just below her teeth." When giving liquid iron supplements, the liquid should be placed behind the teeth because it can stain the teeth. Iron can lead to constipation, so increased fluid and fiber intake is appropriate. The dosage needs to be measured carefully to prevent overdosing the child, leading to iron toxicity.

The caregiver of a child with sickle cell disease asks the nurse how much fluid her child should have each day after the child goes home. In response to the caregiver's question, the nurse would explain that for the child with sickle cell disease, it is best that the child have:

1,500 to 2,000 ml of fluid per day. Prevention of crises is the goal between episodes. Adequate hydration is vital; fluid intake of 1,500 to 2,000 ml daily is desirable for a child weighing 20 kg and should be increased to 3,000 ml during the crisis.

A child is hospitalized with a diagnosis of sickle cell crisis. The nurse has completed an assessment with the above findings. Which intervention is the nurse's priority in providing care?

Administer intravenous fluids as prescribed. A nurse's priority in providing care for a client in sickle cell crisis is promoting fluid hydration. Fluid dilutes the blood, decreasing viscosity and allowing the sickled cells to flow more freely. The assessment provides no indication to keep the client NPO. Administering a blood transfusion or pain medication is important to the plan of care, but neither is the priority.

The nurse is caring for a 10-year-old girl with iron toxicity. What would the nurse expect the physician to order?

Deferasirox is indicated for iron toxicity. It binds with iron, which is removed via the kidneys. Dimercaprol is indicated for blood lead levels greater than 45 mcg/dl. It removes lead from soft tissues and bone, allowing for its excretion via the renal system. Edetate calcium disodium is indicated for blood lead levels greater than 45 mcg/dl. The medication removes lead from soft tissues and bone, allowing for its excretion via the renal system. Succimer is indicated for blood lead levels greater than 45 mcg/dl; it removes lead from soft tissues and bone, allowing for its excretion via the renal system.

A nurse caring for an 8-year-old with a bleeding disorder documents the following nursing diagnosis: ineffective tissue perfusion related to intravascular thrombosis and hemorrhage. This diagnosis is most appropriate for a client with:

Disseminated intravascular coagulation (DIC) is an acquired coagulopathy that, paradoxically, is characterized by both thrombosis and hemorrhage. The goal is for the child to maintain adequate tissue perfusion of all body systems affected by DIC and regain adequate laboratory values for hemostasis. Hemophilia and von Willebrand disorders are genetic and symptoms are caused by a deficiency in a factor needed for clotting. Iron-deficiency anemia occurs when there is not enough iron for adequate hemoglobin capacity in the red blood cells.

The nurse is caring for a child who begins vomiting after receiving cyclophosphamide. Which nursing action is priority?

Ensure intravenous fluids are infusing. Children receiving chemotherapy are likely to experience extreme nausea, vomiting, and diarrhea despite antiemetics, which places the child at risk for dehydration. Although it is appropriate to provide therapeutic play and educate the family on side effects of medications, the priority for this child is intravenous fluid.

A nurse is teaching the parents of a child with sickle cell disease about factors that predispose the child to a sickle cell crisis. The nurse determines that the teaching was successful when the parents identify what as a factor?

Factors that may precipitate a sickle cell crisis include: fever, infection, dehydration, hot or humid environment, cold air or water temperature, high altitude, or excessive physical activity. Respiratory distress and pallor are general signs and symptoms of a sickle cell crisis.

A 15-year-old client diagnosed with von Willebrand disease has reached menarche. Based on this fact, what information is most important for the nurse to convey to the client?

Females diagnosed with von Willebrand disease are at risk for menorrhagia. Bruising in the perineal area is not a risk unless there is some sort of trauma at the site. Von Willebrand disease does not cause intermittent periods or shorten the duration of menses.

The parents of a 6-year-old child with idiopathic thrombocytopenic purpura (ITP) ask the nurse conducting an assessment of the child what causes the disease. What is the nurse's best response?

Idiopathic thrombocytopenic purpura (ITP) is primarily an autoimmune disease, which is an acquired, self-limiting disorder of hemostasis characterized by destruction and decreased numbers of circulating platelets. The child will exhibit symptoms of excessive petechiae, purpura, and bruising. Hemophilia A and hemophilia B are distinguished by the particular procoagulant factor that is decreased, absent, or dysfunctional. Iron-deficiency anemia occurs when the body's iron stores are depleted. Hereditary spherocytosis (HS) is characterized by loss of surface area on the red blood cell membrane.

The nurse is caring for a child admitted to the hospital for an open fracture of the femur following a motor vehicle accident. The nurse notes the following lab values: white blood cells 10,000/mm3, hemoglobin 7.9 g/dl (79 g/L), hematocrit 28%, platelets 151,000/mm3. Which nursing action is priority?

In a situation where the child exhibits signs of anemia related to acute hemorrhage, the nurse should anticipate administering a transfusion of packed red blood cells to improve oxygenation and circulation. Administration of antibiotics, pain assessment, and family education can be performed after the beginning the blood transfusion.

A 4-month-old infant is found to be anemic. Which is the most likely cause of anemia in this child?

Inadequate intake of dietary iron in the mother during late gestation A newborn usually has enough iron in reserve to last for the first 6 months of life. After that, the infant needs iron incorporated into the diet. Because iron stores are laid down near the end of gestation, women with iron deficiency during pregnancy tend to give birth to iron-deficient babies because the babies do not receive iron stores. At birth, hemoglobin is largely of the infant type (hemoglobin F), which is composed of two alpha and two gamma polypeptide chains. During the first 6 months of life, this infant type is gradually replaced by adult hemoglobin (hemoglobin A), which is composed of two alpha and two beta chains. For this reason, diseases such as sickle-cell anemia or the thalassemias, which are disorders of the beta chains, do not become apparent clinically until this hemoglobin change has occurred (at approximately 6 months of age).

A child is prescribed monthly injections of vitamin B12. When developing the teaching plan for the family, the nurse would focus on which type of anemia?

Monthly injections of vitamin B12 are used to treat pernicious anemia. Aplastic anemia is characterized by a decrease in all blood cells necessitating a bone marrow transplant. Folic acid deficiency anemia is treated with dietary measures and possible folic acid supplementation. Sickle cell anemia is treated supportively with a focus on preventing sickling crisis, infection, and other complications.

The nurse is assessing a child and notices pinpoint hemorrhages appearing on several different areas of the body. The hemorrhages do not blanch on pressure. The nurse documents this finding as:

Petechiae are pinpoint hemorrhages that occur anywhere on the body and do not blanch with pressure. Purpura are larger areas of hemorrhage in which blood collects under the tissues and appear purple in color. Ecchymosis refers to areas of bruising. Poikilocytosis refers to the variation in the size and shape of the red blood cells commonly found in children with thalassemia.

The nurse is providing postoperative care to a school-age child after a splenectomy and notes the following: temperature 102.1ºF (39ºC), heart rate 120 bpm, respiratory rate 28 breaths/minute, blood pressure 78/36 mm Hg, and oxygen saturation 90%. Which nursing action is priority?

Place the child in a supine position. For a child showing signs of acute blood loss, a priority is to lay the child flat to provide adequate circulation to the brain. Administering acetaminophen and reassessing the temperature can be performed later. Erythropoietin may be given to increase RBC production, but this is not a priority in the immediate period of acute blood loss.

A child with hemophilia A has had repeated episodes of hemarthrosis. Which assessment finding is most important to consider?

Repeated bleeding into a joint causes cartilage erosion and joint space narrowing, decreased range of motion, and proximal muscle weakening; disabling arthropathy may follow.

The nurse is reviewing the chart of a child scheduled for a stem cell transplant. The child will be receiving a syngeneic transplant. The nurse understands that which of the following would be the donor?

Syngeneic transplantation involves a genetically identical donor and recipient (i.e., identical twins). Allogeneic transplantation involves the transfer of stem cells from an immune-compatible (histocompatible) donor, usually a sibling, although a national registry allows compatible volunteer donors to be located. Autologous transplantation involves the use of the child's own stem cells.

A child with iron-deficiency anemia is prescribed ferrous fumarate, 3 mg/kg/day in two divided doses. What does this prescription indicate to the nurse?

The child has mild to moderate iron deficiency. The recommended dosage for iron supplementation for a child with mild to moderate iron deficiency is 3 mg/kg/day of ferrous fumarate. A prophylactic dose is 1 to 2 mg/kg/day of up to a maximum of 15 mg elemental iron per day. Severe iron deficiency requires 4 to 6 mg/kg/day of elemental iron in three divided doses. Transfusion of packed red blood cells is reserved for the most severe cases. Prior to the transfusion of packed red blood cells, the nurse would follow specific blood bank guidelines.

The nurse is caring for a child with idiopathic thrombocytopenic purpura (ITP). Which assessment finding requires immediate notification of the health care provider? Select all that apply.

The child with idiopathic thrombocytopenic purpura (ITP) is expected to have petechiae and purpura (bruising), which would not require notification of the health care provider. Headache, vomiting, and lethargy indicate possible intracranial hemorrhage and should be reported to the health care provider.

A toddler who is beginning to walk has fallen and hit his head on the corner of a low table. The caregiver has been unable to stop the bleeding and brings the child to the pediatric clinic. The nurse is gathering data during the admission process and notes several bruises and swollen joints. A diagnosis of hemophilia is confirmed. This child most likely has a deficiency of which blood factor?

The most common types of hemophilia are factor VIII deficiency and factor IX deficiency, which are inherited as sex-linked recessive traits, with transmission to male offspring by carrier females.

When assessing a child for a possible hematologic disorder, which would the nurse need to keep in mind as most important?

The nurse needs to keep in mind that hematologic alterations can affect multiple body sites, so assessment needs to address all body systems. A child's nutritional status may be helpful in assessing certain hematologic disorders such as iron deficiency anemia, but this information is not the most important to remember. Sequelae commonly occur with hematologic alterations, especially chronic conditions such as hemophilia or sickle cell disease. The child's demographic data are important, because some hematologic diagnoses are more commonly associated with a certain age group, sex, race, or geographic location.

The nurse is reviewing the results of a clotting study for a healthy 6-year-old. What would the nurse document as a normal prothrombin finding?

The nurse would identify a prothrombin time of 11.0 to 13.0 seconds as normal for a healthy child. A result of 21.0 to 35.0 seconds would be the expected range for partial thromboplastin time and activated partial thromboplastin time. Findings of 6.0 to 9.0 seconds and 16.0 to 18.0 seconds are outside the normal range.

Which site is most frequently used to perform a bone marrow aspiration?

The preferred site for bone marrow aspiration in children is the iliac crest. The other sites are not used for a bone marrow aspiration.

When evaluating the hemogram of an 8-month-old infant, the nurse would identify which type of hemoglobin as being the predominant type?

Three types of normal hemoglobin are present at any given time in the blood: A, F, and A2. By 6 months of age, hemoglobin A is the predominant type. Hemoglobin S is associated with sickle cell disease.

The child is prescribed liquid ferrous sulfate. The nurse should encourage the child to take which action immediately after each dose to best eliminate possible side effects?

To prevent staining of the teeth, the child should brush the teeth after administration of iron preparations such as ferrous sulfate. There is no need to remain upright, drink milk or to refrain from eating or drinking for one hour.

A 14-year-old girl who is a vegetarian has recently developed anemia. Blood smear results show large, fragile, immature erythrocytes. She claims to take an iron supplement regularly and is surprised to learn that she is anemic, as she is otherwise healthy. As the nurse considers all of the data in the case, which anemia will the nurse discuss when collaborating with the primary healthcare provider?

Vitamin B12 is necessary for the maturation of RBCs. Pernicious anemia results from deficiency or inability to use the vitamin, resulting in RBCs that appear abnormally large and are immature megaloblasts (nucleated immature red cells). Thus, pernicious anemia is one of the megaloblastic anemias. In children, the cause is more often lack of ingestion of vitamin B12 rather than poor absorption. Adolescents may be deficient in vitamin B12 if they have a long-term, poorly formulated vegetarian diet, as the vitamin is found primarily in foods of animal origin. Since the client is taking iron, iron deficiency anemia is ruled out. The blood cells in a client with sickle cell anemia are crescent-shaped and do not display the characteristics noted. There are no symptoms of blood loss or acute bleeding, as the client is otherwise healthy.

A nurse is providing care for a child with disseminated intravascular coagulation (DIC). What would alert the nurse to possible neurologic compromise?

Widely fluctuating blood pressure A key aspect of the nurse's role is to assess the child for signs and symptoms of impaired tissue perfusion in the various body systems that may be affected by DIC. Unstable or abnormal blood pressure (such as wide BP fluctuations) or unequal pupil size may suggest neurologic compromise. Hematuria would suggest renal compromise. Petechiae would be indicative of bleeding into the skin.

The nurse is developing a plan of care for a child with thalassemia. What nursing interventions would the nurse include? Select all that apply.

administer packed rbc transfusions as ordered and administer deferoxamine therapy RBC transfusions and deferoxamine for chelation are used to treat thalassemia. Heparin therapy is used for treating DIC. Opioid analgesics would be used to treat severe pain associated with sickle cell crisis. Platelet transfusions and intravenous immunoglobulin would be used to treat idiopathic thrombocytopenic purpura (ITP).

The nurse is working with a child who is in sickle cell crisis. Treatment and nursing care for this child include which actions? Select all that apply.

administering o2, administering analgesics, and maintaining fluid intake A vaso-occlusive crisis occurs when sickle-shaped cells are clumped together in a joint or organ. This causes severe pain and hypoxia to the tissues. The management for a vaso-occlusive crisis is to provide adequate pain relief, oxygen to correct the hypoxemia, and increased IV fluids to thin out viscosity and allow the cells to flow in the vascular system. Platelet administration is not indicated as part of the treatment. Children and adults experiencing a sickle cell crisis experience a high degree of pain, so exercise and activity is postponed until the crisis is over. Activity is encouraged when the child is not in crisis as it promotes growth and a positive self-image.

A nursing instructor is describing childhood hematologic disorders to students. Which would the instructor include as being commonly affected by hematologic disorders? Select all that apply.

erythrocytes, leukocytes, thrombocytes The formed elements, the erythrocytes, leukocytes, and thrombocytes are the portions of the blood most commonly affected by hematologic disorders in children. Plasma and whole blood are not major sites of hematologic disease.

The nurse develops a meal plan for a child with iron-deficiency anemia. Which meal would the nurse teach the parent has the highest amount of iron?

red meat, eggs, oatmeal, and dried fruit Iron-deficiency anemia occurs when the blood does not have enough iron to produce hemoglobin. The anemia can be corrected via iron supplementation, nutrition, and even blood transfusion if the anemia is severe. Foods that have the highest sources of iron include red meat, tuna, eggs, tofu, enriched grains, dried beans and peas, dried fruits, green leafy vegetables and iron-fortified breakfast cereals. The nurse should teach the meal containing red meat, eggs, oatmeal, and dried fruit has the highest amount of iron. Chicken has less iron than red meat, and corn has only a small amount. All the fruits listed have iron, but when dried, the iron levels increase. Pork has a limited amount of iron, and white rice contains almost no iron. Brown rice and whole grains contain higher iron amounts.

While assessing an adolescent, the nurse notes pallor and a beefy red tongue. Upon questioning, the adolescent reports eating a vegetarian diet to help with weight loss. Which health care provider prescription will the nurse anticipate?

vitamin b12 injections Children with pernicious anemia have a vitamin B12 deficiency and have symptoms such as pallor, irritability, beefy red tongue, and diarrhea. Children with iron-deficiency anemia require ferrous sulfate. Folic acid is needed for children with macrocytic anemia. Hydroxyurea could be prescribed for a child with sickle cell anemia.

The nurse is caring for a toddler taking ferrous sulfate for severe iron-deficiency anemia. Which report by the parent is most concerning?

"I mix ferrous sulfate with milk in a bottle." Ferrous sulfate may not be absorbed if taken with milk or tea, and if the parent mixes the medicine with milk in a bottle, there is also concern that if the child does not drink the entire amount of medication. Ferrous sulfate may be taken after meals to prevent gastrointestinal irritation. Dark stools are a common side effect of ferrous sulfate. Parents should be encouraged to brush the child's teeth thoroughly to prevent teeth staining.

A child is to receive oral iron therapy in liquid form three times per day. After teaching the parents about administering the iron, which statement indicates a need for additional teaching?

"Our child can drink the medicine from a medicine cup." Liquid iron can stain the teeth; therefore, the parents should give the liquid iron through a straw or syringe, placing it toward the back of the child's mouth. Iron turns stools dark. To maximize absorption, it is best to give the iron with water or juice between meals.

The nurse is collecting data from the caregivers of a child brought to the clinic setting. The parents tell the nurse that the child's skin seems to be an unusual color. The nurse notes that the child's skin appears bronze-colored and jaundiced. This observation alerts the nurse to the likelihood that this child has which disorder?

In the child with thalassemia the skin may appear bronze-colored or jaundiced. The child with hemophilia may have bruised areas on the skin. The skin color in children with sickle cell disease may be pale in color, and with Kawasaki disease the child may have a rash on the trunk and extremities.

A 3-year-old child is hospitalized with a diagnosis of sickle cell anemia and is experiencing a pain crisis. Using the FACES scale, the nurse assesses the child's pain to be a 10 on a scale of 1 to 10. The child is receiving intravenous fluids and oxygen at 2 L/min via nasal cannula. The parent is at the bedside holding the child's hand and has a concerned look. What is the nurse's priority in caring for the child?

In this case, the nurse's priority is to address the child's pain. The child is already receiving IV fluids and oxygen. That, in combination with analgesia, will assist in resolving the crisis. Asking the parent if he or she has questions, asking the health care provider to meet with the parent, and providing distraction for the child are all appropriate interventions, but the priority is to address the child's pain.

A child diagnosed with hemophilia presents with warm, swollen, painful joints. Which action will the nurse take first?

Prepare to administer factor replacement medication Many clients with hemophilia have repeated episodes of hemarthrosis or bleeding into the joints, and develop functional impairment of the joints, despite careful treatment. To assist in limiting impairment, the nurse would prepare to administer factor replacement medications, such as plasma, recombinant clotting factor VIII, or a clotting promotor medication. The nurse would document the finding, notify the health care provider, and assess the client for additional symptoms after limiting the amount of blood loss.

The nurse is caring for a child who had a stem cell transplant and is being monitored for engraftment. Which nursing action is priority?

With stem cell transplants, children are at greatest risk for infection and sepsis. The nurse should ensure neutropenic precautions are used to reduce the change of infection. Monitoring laboratory values, reminding the parent to contact the school, and encouraging therapeutic play are important, but preventing infection in the immunocompromised child is a priority.

The nurse is assessing a child who is experiencing an acute splenic sequestration secondary to sickle cell disease. What treatment would be a priority?

emergent transfusion Acute splenic sequestration can rapidly progress to cardiovascular collapse and death. Prepare the child for emergent transfusion with packed red blood cells. Pain relief would be a priority for a vaso-occlusive crisis. Antibiotic administration would be a priority for a febrile child with sickle cell disease. Oxygen administration would be a priority for a child with acute chest syndrome (a vaso-occlusive crisis).

The nurse is providing care for a 13-year-old child diagnosed with iron-deficiency anemia. The client's current hemoglobin level is 11 g/dL (110 g/L). Which intervention will the nurse anticipate including in the client's care?

giving ferrous sulfate with orange juice between meals Treatment for iron-deficiency anemia is the administration of ferrous sulfate for a 13-year-old client with a hemoglobin at 11 g/dL (110 g/L). It should be administered with orange juice, because vitamin C helps absorb iron. It should not be taken with milk. It can cause teeth staining in children and should be given with a straw. Intravenous immunoglobulin would be administered for idiopathic thrombocytopenic purpura. The client's hemoglobin level is not severe enough to warrant blood transfusions at this time. There is also no indication the child is symptomatic. Anemia is generally diagnosed for a hemoglobin less than 12 g/dL (120 g/L) in children 12 to 14 years of age. The normal level for children 12 to 18 years of age is 14 g/dL (140 g/L). While increasing fresh fruits and vegetables is good for the client's overall health, this client needs foods specifically high in iron. These include broccoli, bananas, tomatoes, spinach, liver, nuts, dates, legumes, beef, eggs, and pork.