Focus on Child Health Exam
A nurse provides instructions to the parents of an infant with bronchopulmonary dysplasia about the safe use of oxygen at home. Which statement by a parent indicates a need for further instruction? A. "We need to keep the oxygen tank upright." B. "We should have a fire extinguisher close at hand." C. "We can put petroleum jelly on her lips to relieve the dryness." D. "We need to keep the oxygen tank at least 5 feet (1.5 metres) from electrical devices."
"We can put petroleum jelly on her lips to relieve the dryness." Rationale: If oxygen is being used at home, the parents are instructed to avoid using alcohol-based substances or oil, which are flammable and increase the risk for fire, around the infant's mouth. Products that should be avoided include petroleum jelly, vitamin A and D ointment, and baby oil. The remaining statements reflect correct use of oxygen at home.
The health care provider prescribes the following interventions for a child with suspected meningitis. Prioritize these interventions by numbering them in the order in which they should be performed, with 1 as the first prescription to be carried out and 4 as the last.
1. Respiratory isolation 2. Lumbar puncture 3. Administer antibiotics 4. Continued neurologic assessments every 2 hours Rationale: It is important that nurses protect themselves and others from possible infection, so the child should immediately be placed in isolation if meningitis is suspected. The next priority is setting up for the lumbar puncture so that specimens for culture may be obtained. Once this is done, antibiotics are administered. Antibiotics given before lumbar puncture has been performed and cultures have been obtained could kill the causative bacteria and lead to a misdiagnosis. A neurological assessment is conducted every 2 hours and should have been part of the admission criteria. It is the lowest priority of the four options based on the timeframe identified in the question.
The health care provider prescribes oral amoxicillin 60 mg 3 times daily for a child who weighs 12.5 lb. The safe pediatric dosage is 20 to 40 mg/kg/day in 3 equal doses. The medication label reads, "Amoxicillin 125 mg/5 mL." How many milliliters will the nurse administer per dose?
2.4 Rationale: First, change the child's weight in pounds to kilograms: Divide the child's weight in pounds (12.5) by 2.2 (1 kg = 2.2 lb). This yields 5.7 kg. Next check safe dosing parameters by multiplying the child's weight in kilograms by the minimum and maximum daily doses (20 to 40 mg/kg/day in 3 equal doses) of the medication. Therefore 20 mg/kg/day × 5.7 kg = 114 mg/day and 40 mg/kg/day × 5.7 kg = 228 mg/day. Therefore the recommended safe dose is between 114 and 228 mg/day. Next, multiply the prescribed dosage (60 mg 3 times daily) by the frequency to determine the daily dose. The prescription for oral amoxicillin 60 mg 3 times daily means that three doses will be given per day; 60 mg × 3 doses = 180 mg. Because the daily dose of amoxicillin (180 mg) falls within the recommended range (114 to 228 mg/day), it is considered a safe dose. Finally, use the formula for determining the number of milliliters per dose. Ratio and proportion: 125 mg : 5 mL :: 60 mg : X mL. 125 X = 300 = 2.4 mL. The nurse would administer 2.4 mL per dose.
The nurse is discharging a child with primary nocturnal enuresis. Which statements by the parents indicate that they understand the techniques used to manage this disorder? Select all that apply. A. "An alarm system might help prevent the bedwetting." B. "We need to limit his fluid intake throughout the day." C. "We need to be sure that he urinates just before bedtime." D. "We've already developed a reward system for when he stays dry for a certain number of consecutive nights." E. "We'll teach him to perform Kegel or pelvic muscle exercises and encourage him to do them every hour of the day."
A. "An alarm system might help prevent the bedwetting." C. "We need to be sure that he urinates just before bedtime." D. "We've already developed a reward system for when he stays dry for a certain number of consecutive nights." Rationale: Treatment of primary nocturnal enuresis includes limiting fluids after supper (not throughout the day) and encouraging the child to urinate before bedtime. A reward system of some type may be helpful, and the child and parents can decide on a special reward when the child has achieved a certain number of consecutive dry nights. Behavioral conditioning with the use of alarms may be helpful. One such alarm system includes a device worn on the child's pajamas that contains a moisture-sensitive alarm. As the child starts to void, the alarm goes off, awakening the child. Kegel or pelvic muscle exercises may be helpful for daytime enuresis but are not useful in preventing nocturnal enuresis.
A nurse is conducting an assessment of a 12-year-old with Osgood-Schlatter disease. Which question does the nurse ask the child to elicit data regarding the cause of the disease? A. "Do you participate in sports?" B. "Did you fall off your bicycle?" C. "Have you ever fallen and hit your head?" D. "Does anyone else in your family have this disease?"
A. "Do you participate in sports?" Rationale: Osgood-Schlatter disease is believed to result from repetitive stress in sports, combined with overuse of immature muscles and tendons over an extended period, and an imbalance in the strength of the quadriceps muscle during adolescent growth. The classic picture is bilateral knee pain that is exacerbated by running, jumping, or climbing stairs in a very active boy or girl who is involved in sports. The child will point to the tibial tubercle as the site of pain. The disease occurs in boys and girls between the ages of 8 and 16 years, although it is more common in boys. Usually both knees are involved. The assessment questions noted in the remaining options are unrelated to the cause of this disease.
A nurse is providing instructions on the use of a metered-dose inhaler (MDI) to an adolescent with asthma. Which statements by the adolescent indicates an understanding of the instructions? Select all that apply. A. "I need to shake the inhaler well before I use it." B. "I really need to use the spacer when I inhale the corticosteroid." C. "After I breathe the medication in, I should hold my breath for 1 or 2 seconds." D. "I have to put my lips tightly around the mouthpiece, press down on the inhaler, and breathe in slowly." E. "The doctor has prescribed two inhalations, so I need to breathe in the second inhalation immediately after the first."
A. "I need to shake the inhaler well before I use it." B. "I really need to use the spacer when I inhale the corticosteroid." D. "I have to put my lips tightly around the mouthpiece, press down on the inhaler, and breathe in slowly." Rationale: If the health care provider has prescribed two inhalations, the nurse teaches the adolescent to wait at least 2 minutes after the first inhalation before taking the second. The adolescent is also taught to shake the inhaler before repeating the dose. The client should hold his or her breath for as long as possible, at least 5 to10 seconds, to allow the medicine to penetrate deep into the lungs. A spacer must be utilized with the MDI when corticosteroids are being inhaled to prevent yeast infection of the mouth
A nurse provides instruction to an adolescent client with exercise-induced asthma. Which statement by the adolescent indicates a need for further instruction? A. "I should use the bronchodilator after I finish working out." B. "The signs/symptoms usually begin after 5 to 10 minutes of exercise." C. "I should use progressive muscle-relaxation techniques to keep from hyperventilating." D. "When I exercise in cold weather, I should cover my nose and mouth with a scarf to warm up the air I'm breathing."
A. "I should use the bronchodilator after I finish working out." Rationale: Exercise-induced asthma may be triggered by the rapid breathing of large volumes of cool, dry air, such as that taken in with mouth breathing during exercise. The symptoms of exercise-induced asthma usually begin after 5 to 10 minutes of exercise and often last 30 to 60 minutes. Measures to prevent exercise-induced asthma include warming the air by breathing through the nose or covering the mouth and nose with a scarf when exercising in cold weather, using an inhaled bronchodilator before exercise, and practicing techniques to decrease hyperventilation, such as progressive muscle relaxation and diaphragmatic breathing.
A nurse provides home care instructions to the mother of an infant with gastroesophageal reflux disease (GERD). Which statement by the mother indicates a need for further instruction? A. "I shouldn't give the baby a pacifier." B. "I should thicken feedings with rice cereal." C. "I should put the baby on her right side with her head raised." D. "I need to give the baby small, frequent feedings and use a predigested formula."
A. "I shouldn't give the baby a pacifier." Rationale: Small, frequent feedings of a predigested formula will reduce the amount of formula in the stomach, ease distension, and minimize reflux. These smaller, more frequent feedings with frequent burping are often tried as the first line of treatment. Thickened feedings tend to decrease the chances of reflux, vomiting, and aspiration. Placing the affected infant in a 30-degree head-elevated prone or right-side-lying position helps prevent reflux. The use of a pacifier allows the infant to practice swallowing. Pacifier use also decreases the incidence of crying and reflux episodes and may increase clearance of reflux stomach contents.
A nurse is preparing to administer digoxin (Lanoxin) to an infant. The nurse notes that the infant's heart rate is 110 beats/min. The appropriate response on the part of the nurse is to take which action? A. Administer the prescribed dose B. Contact the primary health care provider C. Obtain a blood sample to check the digoxin level D. Withhold the dose and reassess the heart rate in 1 hour
A. Administer the prescribed dose Rationale: Before administering digoxin, the nurse counts the infant's heart rate for 1 full minute. The nurse would withhold the dose and contact the health care provider if the heart rate were slower than 100 beats/min in an infant. Therefore the appropriate action on the part of the nurse would be to administer the prescribed dose. Contacting the health care provider , obtaining a blood sample to check the digoxin level, and withholding the dose and reassessing the heart rate in 1 hour are incorrect on the basis of the information in the question.
A nurse is reviewing the results of an infant's serum digoxin test. The digoxin level is 0.6 ng/mL (0.77 nmol/L). In light of this finding, which action should the nurse take? A. Administering the prescribed dose because the level is within the therapeutic range B. Calling the primary healthcare provider with the results and asking for further prescriptions C. Giving the prescribed dose and notifying the primary healthcare provider of the low digoxin level D. Holding the dose and immediately notifying the primary healthcare provider of the toxic digoxin level
A. Administering the prescribed dose because the level is within the therapeutic range Rationale: Digoxin is a cardiac glycoside that increases cardiac output and improves cardiac contractility. The effectiveness of digoxin depends on achieving and maintaining a therapeutic serum drug level. The difference between a therapeutic and a toxic level is narrow, the optimal therapeutic range as 0.5 to 0.8 ng/mL. (0.64 to 1.02 nmol/L). A digoxin level of 0.6 ng/dL (0.77 nmol/L) is therapeutic. A level greater than 0.8 ng/mL (1.02 nmol/L) exceeds the therapeutic range. Therefore the nurse should administer the prescribed dose. The remaining options are incorrect actions.
An HIV-positive woman delivers an infant. The pediatrician prescribes testing for the newborn, and the nurse prepares for which action? A. Ask the laboratory to perform virologic testing B. Obtain blood from the umbilical cord to send to the laboratory C. Perform a heel-stick to obtain a specimen for a Western blot assay D. Perform a fingerstick to obtain a specimen for an enzyme-linked immunosorbent assay (ELISA)
A. Ask the laboratory to perform virologic testing Rationale: Traditional HIV antibody measurement by ELISA or Western-blot assay is not accurate in infants younger than 18 months because of the persistence of maternal antibodies. Because of the potential for maternal contamination during delivery, umbilical cord blood should not be used for testing. HIV-exposed infants should undergo virologic testing within 48 hours of birth and follow-up testing, depending on the initial results.
The nurse is caring for a child admitted with absence seizures. What manifestations of this condition does the nurse expect to assess on this child? Select all that apply. A. Blank expression B. Brief episodes of altered consciousness C. Lasts only 5 to 10 seconds but may occur one after another, several times a day D. Quick loss of postural tone, impairment of consciousness, confusion, lethargy, and sleep E. No muscle activity noted except for eyelid fluttering and twitching, or head bobbing F. Brief, random contractions of a muscle group that may occur on both sides of the body and may occur singly or in clusters
A. Blank expression B. Brief episodes of altered consciousness C. Lasts only 5 to 10 seconds but may occur one after another, several times a day E. No muscle activity noted except for eyelid fluttering and twitching, or head bobbing Rationale: Absence seizures, formerly called petit mal seizures, are characterized by brief episodes of altered consciousness. There is no muscle activity except for eyelid fluttering, twitching, or head bobbing, and the child has a blank expression. Absence seizures last only 5 to 10 seconds but may occur one after another, several times a day. Atonic seizures are marked by an abrupt loss of postural tone, impairment of consciousness, confusion, lethargy, and sleep. Myoclonic seizures are brief, random contractions of a muscle group that may occur on both sides of the body and may occur singly or in clusters.
The nurse is assigned a child who has been admitted to the hospital with suspected cystic fibrosis (CF). Which tests does the nurse anticipate will be prescribed to diagnosis CF? Select all that apply. A. Chest x-ray B. Barium swallow C. Intestinal biopsy D. Sweat chloride assay E. Stool examination for ova and parasites
A. Chest x-ray D. Sweat chloride assay Rationale: The diagnosis of CF is established with the use of several tests findings: a quantitative sweat chloride test result of more than 60 mEq/L (60 mmol/L),, a chest x-ray showing patchy atelectasis, and a stool analysis revealing fat. The barium swallow is used to diagnose gastrointestional disorders such as pyloric stenosis but not CF. Intestinal biopsy is not used to diagnose CF. Stool examination for ova and parasites is used to diagnose parasitic infestation; CF is not caused by a parasite.
The nurse should contact the health care provider with concerns about a prescription for valproic acid for an adolescent who has a history of which disorder? A. Hepatitis B. Diabetes mellitus C. Migraine headaches D. Tonic-clonic seizures
A. Hepatitis Rationale: Valproic acid, an anticonvulsant used to treat seizures, is principally used as an adjunct to other anticonvulsant agents. It is also used as prophylaxis against migraine headaches. Valproic acid is contraindicated in hepatic disease and used with caution in persons with a history of hepatic disease or bleeding abnormalities. It is not contraindicated in clients with diabetes mellitus.
The mother of a child with hemophilia calls the clinic nurse and reports that her child has hit his knee on the corner of a coffee table and that the joint appears swollen. The nurse should tell the mother immediately to take which action? A. Immobilize the affected joint B. Take the child to the emergency department C. Elevate the affected joint and apply a heating pad D. Bring the child to his primary healthcare provider
A. Immobilize the affected joint Rationale: If a muscle or joint injury occurs in the child with hemophilia, the affected part is immobilized, elevated, and treated with ice and compression. Initial immobilization will help prevent further injury until the bleeding resolves. There is no information in the question indicating that bringing the child to the emergency department is necessary. Heat will increase circulation to the site and increase bleeding. The physician should be notified if a blunt injury, especially that involving a joint, occurs, but it is not necessary to immediately bring the child to the primary healthcare provider.
A child being seen in the clinic is found to have rubeola (measles), and the father asks the nurse how to care for the child. The nurse should provide which instruction to the father? A. Keep the child in a room with dim lights B. Give the child warm baths to help prevent itching C. Allow the child to play outdoors, because sunlight will help heal the rash D. Take the child's temperature every 4 hours and administer 1 baby aspirin for fever
A. Keep the child in a room with dim lights Rationale: One nursing consideration in rubeola is eye care. The affected child usually has photophobia, so the nurse should suggest that the parent keep the child out of brightly lit areas. Children with viral infections are not to be given aspirin because of the risk of Reye syndrome. Warm baths and sunlight will aggravate itching. Additionally, the child needs rest.
A pediatric community health nurse is conducting a screening program to identify children at risk for a hematologic disorder. The nurse determines that the child at most risk for beta-thalassemia is which child? A. Of Mediterranean descent B. Whose dietary intake of iron is poor C. Who has a known factor VIII deficiency D. Whose parent is known to have abnormal hemoglobin S (HbS)
A. Of Mediterranean descent Rationale: The thalassemias are a group of inherited disorders characterized by an abnormality in hemoglobin synthesis that results from a reduction in or absence of one of the chains found in normal hemoglobin. They are primarily found among people of Mediterranean descent. Beta-thalassemia, also known as thalassemia major or Cooley's anemia, is the most common and severe form of thalassemia. Poor dietary intake of iron is associated with iron-deficiency anemia. Factor VIII deficiency is associated with hemophilia. An abnormal HbS trait is associated with sickle cell disease.
In which position should the nurse place the child who has just undergone tonsillectomy to facilitate drainage? A. Prone B. Supine C. High Fowler D. Semi-Fowler
A. Prone Rationale: After tonsillectomy, the child should be placed in a prone or side-lying position to facilitate drainage. The supine, high Fowler and semi-Fowler positions will not facilitate drainage and may, in fact, increase the risk for aspiration.
The nurse is caring for a 3-year-old with leukemia. The child is not eating and is losing weight as a result of nausea and mucositis stemming from the chemotherapy. Which interventions are appropriate? Select all that apply. A. Providing small, frequent high-protein foods B. Administering oral viscous lidocaine before meals C. Having the parents bring in the child's favorite foods D. Providing cool liquids and soft foods at room temperature E. Applying a solution of Benadryl and Maalox as prescribed to the mouth
A. Providing small, frequent high-protein foods D. Providing cool liquids and soft foods at room temperature E. Applying a solution of Benadryl (diphenhydramine) and Maalox as prescribed to the mouth Rationale: High-protein, high-calorie foods should be given to the child. Protein promotes tissue healing, and calories are needed for growth. Small, frequent meals are easier for a child to handle. Viscous lidocaine is not recommended for young children, because it may depress the gag reflex and increase the risk of aspiration. Local anesthetics without alcohol, such as a solution of diphenhydramine (Benadryl) and Maalox, may be recommended. Favorite foods should not be given to a child who is nauseated, because the child will associate these foods with being sick. Cool liquids are soothing and reduce the risk of burning fragile mucosa. Soft foods are gentler on inflamed mucosa.
A nurse reviews a child's record and notes documentation that the child is obtunded. On the basis of this documentation, which finding would the nurse expect to note while conducting a neurological assessment? A. The child sleeps unless aroused. B. The child requires considerable stimulation to be aroused. C. The child awakens easily but exhibits limited responsiveness. D. Once aroused, the child has limited interaction with the environment. E. The child is awake, alert, oriented, and interacts with the environment.
A. The child sleeps unless aroused D. once aroused, has limited interaction with the environment. Rationale: A child is considered obtunded when he or she sleeps unless aroused and, once aroused, has limited interaction with the environment. A lethargic child awakens easily but demonstrates limited responsiveness. A child in a stupor requires considerable stimulation to be aroused. A child who is awake, alert, oriented and interacts with the environment is fully conscious.
An immunocompromised child who never had chickenpox is exposed to a child with varicella. The nurse should provide which information to the mother of the immunocompromised child? A. The child will receive varicella zoster immune globulin B. There is no need to be concerned about the exposure to varicella C. The child will be hospitalized and placed in respiratory isolation D. The child should be monitored closely for early signs of chickenpox
A. The child will receive varicella zoster immune globulin Rationale: Immunocompromised children are unable to fight varicella adequately. If a child who has not had chickenpox is exposed to someone with varicella, the child should receive the varicella zoster immune globulin within 96 hours of exposure. Stating that there is no need to be concerned about exposure to varicella, placing the child on respiratory isolation, and monitoring for signs chickenpox are all incorrect.
A nurse is developing a plan of care for a child at risk for seizures. Which interventions should be carried out if a seizure occurs? Select all that apply. A. Turning the child on her side B. Monitoring the child's movements C. Restraining the child's arms and legs D. Loosening the clothing around the child's neck E. Gently inserting a padded tongue blade between the child's upper and lower teeth
A. Turning the child on her side B. Monitoring the child's movements D. Loosening the clothing around the child's neck Rationale: When a seizure begins, it is important to note the child's movements and keep track how long the seizure lasts. This information will help the health care provider treat the seizure. Positioning the child on the side will help prevent aspiration because saliva will drain from the child's mouth. Clothing around the child's neck is loosened to help maintain a patent airway. The nurse would not restrain the child's arms or legs, because this could cause injury. The nurse would not insert any object into the child's mouth. Forcing an object into the child's mouth may cause injury to the child's mouth, gums, or teeth.
A nurse is providing discharge dietary instructions to the mother of a child who has undergone tonsillectomy. Which items should the nurse tell the mother that it is safe to give the child? Select all that apply. A. Water B. Dark toast C. Cherry gelatin D. Scrambled eggs E. Mashed potatoes
A. Water D. Scrambled eggs E. Mashed potatoes Rationale: Adequate fluid and food intake promotes healing and maintains hydration. Clear, cool liquids are encouraged. Water will maintain hydration. Red liquids and foods, such as cherry gelatin, are avoided because they will give the appearance of blood if the child vomits. Rough foods such as toast could irritate the throat. Soft foods such as mashed potatoes and scrambled eggs will not irritate the throat.
A nurse is caring for several children who have been fitted with a variety of traction devices. Which child should be monitored most closely for signs and symptoms of osteomyelitis?
B Rationale: The most serious complication associated with skeletal traction is osteomyelitis, an infection involving the bone. Organisms gain access to the bone systemically or through the opening created by the metal pins or wires used for traction. Osteomyelitis may occur with any open fracture. Clinical manifestations include localized pain, swelling, warmth, tenderness, and unusual odor. An increased temperature may accompany the symptoms. Balanced suspension traction may be used with or without skin and skeletal traction. When it is used with skeletal traction, however, the client is at risk for osteomyelitis. Buck's extension and Russell traction are types of skin traction. Crutchfield tongs are inserted in the skull and as a result are less likely to give rise to osteomyelitis.
A nurse is providing home care instructions to the mother of a child who has undergone cleft lip repair. Which statements by the mother indicate an understanding of these instructions? Select all that apply. A. "I should put her on her stomach to sleep." B. "I shouldn't brush her teeth for 1 to 2 weeks." C. "I should rinse her mouth with water after feeding her." D. "I should watch for signs/symptoms of infection like drainage or fever." E. "I should never use a bulb syringe to clear secretions from her mouth."
B. "I shouldn't brush her teeth for 1 to 2 weeks." C. "I should rinse her mouth with water after feeding her." D. "I should watch signs of infection like drainage or fever." Rationale: "I shouldn't brush her teeth for 1 to 2 weeks," "I should rinse her mouth with water after feeding her," and "I should watch for signs of infection like drainage or fever" are all accurate statements. Gentle aspiration of oral secretions may be needed to prevent respiratory complications, and bulb syringes are often sent home with the family for removal of these secretions. After cleft lip repair the child should be kept supine, on the side opposite the repair, or in an infant seat. The prone position could result in contact of the suture line with the bed linens, leading to disruption of the suture line.
A nurse has provided dietary instructions to the mother of a child with Crohn's disease. Which statements by the mother indicate an understanding of the instructions? Select all that apply. A. "It's important to include meat in his diet." B. "I won't give him/her high-fiber vegetables like corn." C. "Snacks such as nuts will help provide the extra protein he/she needs." D. "I should give him/her ice cream every day to be sure that he gets his calcium." E. I'll make sure that he/she takes a multivitamin and iron supplement every day."
B. "I won't give him high-fiber vegetables like corn." C. "Snacks such as nuts will help provide the extra protein he needs." E. "I'll make sure that he takes a multivitamin and iron supplement every day." Rationale: A well-balanced, high-protein, high-calorie diet is recommended in Crohn's disease; a multivitamin and iron supplement should also be taken. Meat is high in protein and necessary for optimal growth and development. High-fiber foods such as corn, nuts, and seeds can produce obstructions in children with intestinal strictures and should be avoided. Ice cream is a milk product and should be avoided. Test-Taking Strategy: Focus on the subject, a child with Crohn's disease. Recalling that Crohn's disease is an inflammatory bowel disease will direct you to the correct options. Review the dietary measures for Crohn's disease.
The use of a Pavlik harness has been prescribed for an infant with developmental dysplasia of the hip, and the nurse provides instructions to the mother about the use of the harness. Which statement by the mother indicates the need for further instruction? A. "The diaper is put on under the harness." B. "The harness is placed against the skin to provide support." C. "I need to support her hips and buttocks when the harness is off." D. "The harness straps should be secure enough to keep her hips flexed but not tight."
B. "The harness is placed against the skin to provide support." Rationale: When the infant is in a Pavlik harness, the skin under the harness must be protected. The parents are instructed to place a shirt and socks on the infant under the harness to reduce rubbing. The diaper should go on under the harness as well. The harness straps should be secure enough to keep the child's hips flexed but not tight. The harness should be worn 23 hours a day and should be removed only in accordance with the health care provider's recommendation. The infant's hips and buttocks should be carefully supported whenever the infant is out of the harness.
The nurse is planning care for a child admitted to the emergency Department (ED) who sustained a severe burn injury at home. While reviewing the paramedic's documentation, what actions does the nurse note were conducted at the scene? Select all that apply. A. Child initially rolled in blanket including covering face and head B. After flames are extinguished, burn area covered with clean cloth C. Child placed in vertical position to stop burning process and smother flames D. Burned clothing and jewelry removed to prevent further burning of skin and disruption of skin integrity E. Child is kept warm to prevent hypothermia and immediately transported to nearest emergency facility
B. After flames are extinguished, burn area covered with clean cloth D. Burned clothing and jewelry removed to prevent further burning of skin and disruption of skin integrity Rationale: Burned clothing and jewelry are removed to prevent further burning of the skin and disruption of skin integrity. After flames are extinguished, the burn area is covered with a clean cloth. The child is also kept warm to prevent hypothermia and then rapidly transported to the nearest emergency facility. The child if initially rolled in a blanket but the face and head are not covered because of the danger of inhaling smoke and fumes. The child should be placed in a horizontal not vertical position because the the vertical position could cause the victim's hair to ignite or have the victim inhale flames, heat, or smoke.
A nurse is monitoring a 3-year-old with diarrhea for signs of dehydration. The child now weighs 42 lb (19 kg), a decrease from his weight of 44 lb (20 kg) 24 hours ago. In addition to dry mucous membranes and lack of tears, what assessment finding would the nurse find? A. Decreased heart rate B. Bilateral 1+ pedal pulses C. Increased blood pressure D. Urine output of 80 mL in the last 3 hours
B. Bilateral 1+ pedal pulses Rationale: The minimum urine output for a child is 1 mL/kg/hour. The child weighs 42 lb, or 19 kg, so 80 mL in the last 4 hours is within the minimum range. A child with dehydration will have a rapid, weak, thready pulse. Blood pressure may be decreased in moderate and severe dehydration, but it is a late sign of hypovolemia. A child with dehydration will exhibit 1+ pedal pulses: difficult to palpate, weak, and thready.
A cardiac catheterization is performed on an infant. After the procedure, the nurse should tell the mother which about the infant? A. Needs to remain in the crib for 6 hours B. Can be held in a prone position on the mother's lap C. Needs to have the affected leg restrained for 8 hours D. Will have to remain in a 20-degree head-elevated position for several hours
B. Can be held in a prone position on the mother's lap Rationale: After cardiac catheterization, the affected leg is kept straight for 4 to 6 hours. Keeping the infant in the crib does not ensure that the affected leg will remain in a straight position. The infant may be held prone on a parent's lap. Older children remain in bed, with the head of the bed raised just 20 degrees.
A nurse is monitoring a child who sustained a head injury. Which assessment finding is an early sign of increased intracranial pressure (ICP)? A. Bradycardia B. Change in behavior C. Widened pulse pressure D. Change in respiratory rate and pattern
B. Change in behavior Rationale: A change in the child's normal behavior is an important early sign of increased ICP. The Cushing response — which consists of an increased systolic blood pressure with widening pulse pressure, bradycardia, and a change in respiratory rate and pattern, usually apparent just before or at the time of brainstem herniation —is a late sign of increased ICP.
A nurse is monitoring a school-age child who is being treated for dehydration. The nurse notes that the child's urine output has been 1 mL/kg/hr over the past 3 hours and that the specific gravity of the urine is 1.020. Which is the appropriate nursing action? A. Contact the pediatrician B. Document the findings C. Encourage the child to drink more fluids D. Increase the rate of flow of the intravenous (IV) solution
B. Document the findings Rationale: Urine output of less than 2 to 3 mL/kg/hr in infants and toddlers, 1 to 2 mL/kg/hr in preschoolers and young school-age children, and 0.5 to 1 mL/kg/hr in school-age children or adolescents indicates dehydration. A specific gravity of the urine above 1.020 may indicate dehydration. The nurse would document the findings, because they are normal.
A nurse is caring for an infant with Hirschsprung's disease. Which manifestation of the disease should the nurse expect to note? A. Non-bilious projectile vomiting B. Foul-smelling, ribbon-like stools C. A sausage-shaped abdominal mass D. Bloody, mucousy "currant jelly" stools
B. Foul-smelling, ribbon-like stools Rationale: The child with Hirschsprung's disease will have constipation that has been present since the neonatal period and the frequent passage of foul-smelling, ribbon-like or pellet stools. Non-bilious projectile vomiting is a manifestation of pyloric stenosis. Bloody, mucousy "currant jelly" stools and a sausage-shaped abdominal mass are manifestations of intussusception.
The nurse is assessing a child suspected of having meningitis. The nurse knows that what specific diagnostic tests could indicate a diagnosis of meningitis? Select all that apply. A. Romberg Test B. Nuchal rigidity C. Positive Kernig's sign D. Positive Chvostek's sign E. Positive Trousseau's sign F. Positive Brudzinski's sign
B. Nuchal rigidity C. Positive Kernig's sign F. Positive Brudzinski's sign Rationale: Signs of meningeal irritation compatible with meningitis include nuchal rigidity, a positive Brudzinski sign, and a positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is flexed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the leg is fully flexed at the knee and hip. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. The Romberg test determines the client's cerebellar function. Here the client stands with feet together and arms at the sides and closes the eyes while holding the position; normally the client can maintain posture and balance. Chvostek's sign is the twitching of the facial muscles in response to tapping over the area of the facial nerve and is caused by latent tetany. Trousseau's sign is carpopedal spasm caused by inflating the blood-pressure cuff to a level above systolic pressure for 3 minutes. Trousseau sign is more specific than Chvostek sign for latent tetany, which can be caused by hypocalcemia, hypomagnesemia and metabolic alkalosis.
Hydrostatic reduction is performed in a hospitalized child with a diagnosis of intussusception. Which outcome indicates that the procedure was successful? A. Passage of barium in the stool B. Passage of stool without blood C. Visible peristalsis across the abdomen D. Presence of a sausage-shaped abdominal mass
B. Passage of stool without blood Rationale: Intussusception is an invagination of a section of the intestines into the distal bowel that results in bowel obstruction. In children, this condition most often occurs as a section of the terminal ileum telescopes into the ascending colon through the ileocecal valve. The goal of treatment is to restore the bowel to its normal position and function as quickly as possible. In children who do not show symptoms of shock or sepsis, attempts at hydrostatic reduction are made with the use of a barium or air enema until a free flow of barium into the terminal ileum is evident. The passage of stool without blood is a successful outcome. The nurse watches for the passage of barium after this procedure, but it does not indicate a successful procedure. Visible peristalsis across the abdomen is a manifestation of Hirschprung's disease. Presence of a sausage-shaped abdominal mass is a sign of intussusception.
A nurse reviews the prescriptions for a child with Kawasaki disease and notes that the health care provider has prescribed intravenous immune globulin (IVIG). The nurse should tell the child's mother that this medication has been prescribed for which purpose? A. Reduce the child's fever B. Prevent coronary artery damage C. Alleviate pain from joint inflammation D. Prevent the transmission of the infection to others
B. Prevent coronary artery damage Rationale: Therapeutic management of Kawasaki disease is directed at preventing or reducing the coronary artery damage that may occur. High-dose IVIG has been shown to reduce the prevalence of coronary artery abnormalities when given within 10 days of fever onset. IVIG is not specifically administered to reduce a fever or to alleviate pain. Kawasaki disease is not communicable
A nurse is providing information to the parents of a child with suspected Hirschsprung's disease. The nurse informs the parents that diagnosis is definitively confirmed by the findings of which? A. Blood tests B. Rectal biopsy C. Barium enema D. Rectal examination
B. Rectal biopsy Rationale: The definitive diagnosis of Hirschsprung's disease is made by means of rectal biopsy. During biopsy, a small core or punch sample that contains all layers of the bowel mucosa is removed. Absence of ganglionic cells in the sample confirms the diagnosis of Hirschsprung's disease. Blood tests are not used to diagnose the disease. A barium enema and a rectal examination will detect significant characteristics of the disease but will not confirm the diagnosis.
A child with a history of sickle cell disease is seen in the emergency department, where acute sequestration crisis is diagnosed. The nurse should immediately prepare to take which action? A. Administer pain medication B. Start an intravenous (IV) line C. Obtain informed consent for a splenectomy D. Place a cold pack on the abdomen over the area of the spleen
B. Start an intravenous (IV) line Rationale: Acute sequestration crisis is a complication of sickle cell disease. It is characterized by pooling of blood in the spleen, resulting in splenic enlargement. Acute sequestration crisis is a life-threatening condition if hypovolemic shock occurs. Emergency treatment involves restoring circulating blood volume with a crystalloid and colloid (blood) infusion. Therefore an IV line is needed immediately. Pain is not a priority concern with this type of crisis. Splenectomy may be necessary in cases in which the condition recurs frequently. Placing a cold pack on the abdomen over the area of the spleen will not stop the pooling of blood and might cause more discomfort for the child, so this is not an appropriate measure.
The nurse is providing home care instructions to the parents of a child with immune thrombocytopenic purpura (ITP) whose platelet count is 195 × 103/μL (195 × 109/L). Which statements by the parents indicate that they understand the instructions? Select all that apply. A. "We'll use ibuprophen if he has a fever." B. "It's all right to let him ride his bike." C. "We need to avoid giving him aspirin." D. "He should use an extra-soft toothbrush." E. "We need to watch for signs/symptoms of bleeding."
C. "We need to avoid giving him aspirin." D. "He should use an extra-soft toothbrush." E. "We need to watch for signs of bleeding." Rationale: Immune thrombocytopenic purpura is a hematologic disorder resulting in the reduction and destruction of platelets. A decreased platelet count places the child at risk for bleeding. The normal platelet count is 150-400 × 103/μL (150-400 × 109/L). If the platelet count falls below 20 × 103/μL (20 × 109/L)., high-risk activities such as contact sports, bicycle riding, roller skating, and diving are avoided. The child should also use an extra-soft toothbrush to prevent mucosal trauma. Parents are instructed to monitor the child for signs of bleeding. Medications that may affect platelet function, such as aspirin and nonsteroidal antiinflammatory drugs (NSAIDs, e.g., iboprophen are avoided. Acetaminophen is an acceptable alternative to aspirin and NSAIDs.
Which high-calcium food does the nurse direct the parents of a child with lactose intolerance to include in the child's diet? A. Yogurt B. Raisins C. Broccoli D. Ice cream
C. Broccoli Rationale: Yogurt, ice cream, and broccoli are high in calcium, but the child with lactose intolerance should avoid all high-lactose foods, such as milk, yogurt, and ice cream. Foods that are high in calcium and will be tolerated by a child with lactose intolerance include egg yolk, dried beans, cauliflower, and molasses. Raisins are high in magnesium and phosphorus.
A nurse receives a telephone call from the admissions office and is told that a child with acute bacterial meningitis will be admitted to the pediatric unit. The nurse prepares for the child's arrival and plans to implement which type of precautions? A. Enteric B. Contact C. Droplet D. Neutropenic
C. Droplet Rationale: The child is also placed in a private room, with droplet-transmission precautions, for at least 24 hours after antibiotics are given. Enteric, contact, and neutropenic precautions are not implemented to prevent the spread of meningitis. Enteric precautions are instituted when the mode of transmission involves the gastrointestinal tract. Contact precautions are instituted when contact with infectious items or materials is likely. Neutropenic precautions are instituted when a child has a low neutrophil count.
A child with severe respiratory distress is seen in the emergency department and treated for an acute asthmatic episode. Which assessment finding indicates that the child's condition is improving? A. Stridor B. Shortness of breath C. Increased wheezing D. Dyspnea on exertion
C. Increased wheezing Rationale: A child in severe respiratory distress may not demonstrate wheezing during an acute asthma attack because of decreased air movement. Decreased wheezing in a child who is not improving clinically may signal an inability to move air. This is referred to as a "silent chest" and is an ominous sign during an asthma episode. With treatment, increased wheezing may actually signal that the child's condition is improving. Shortness of breath, dyspnea on exertion, and stridor are manifestations of an asthmatic episode that indicate airway obstruction.
A nurse is providing home care instructions to the parents of a child with bacterial conjunctivitis. The nurse should provide which information to the parents? A. That the child may attend school if antibiotics have been started B. To save any unused eye medication in case a sibling gets the eye infection C. That the child's towels and washcloths should not be used by other members of the household D. To wipe any crusted material from the eye with a cotton ball soaked in warm water, starting at the outer aspect of the eye and moving toward the inner aspect
C. That the child's towels and washcloths should not be used by other members of the household Rationale: Bacterial conjunctivitis is highly contagious, and infection control measures should be taught. These include practicing good handwashing and not sharing towels and washcloths with others. The child should be kept home from school until 24 hours after antibiotics have been started. Bottles of eye medication should never be shared with others. Crusted material may be wiped from the eye with a cotton ball soaked in warm water, starting at the inner aspect of the eye and moving toward the outer aspect.
A girl with systemic lupus erythematosus (SLE) wants to go to the beach with her friends on the day after their junior prom. The girl asks the nurse for guidance regarding sun exposure. The nurse should provide which information to the girl? A. She cannot be exposed to any sunlight at all B. She must bring a beach umbrella and remain under it all day C. Waterproof sunscreen with a minimum sun protection factor (SPF) of 15 is a necessity D. It is all right to go to the beach as long as she wears sunglasses, a sun hat, and clothes that cover her entire body
C. Waterproof sunscreen with a minimum sun protection factor (SPF) of 15 is a necessity Rationale: SLE, a chronic multi-system autoimmune disease characterized by inflammation of the connective tissue, varies in severity and is marked by remissions and exacerbations. Although the origin of SLE is not known, genetic, environmental, hormonal, and immune response factors are likely responsible. These factors include exposure to sun and other UV light, stress, fatigue, viruses, bacteria, certain medications, and some food additives. Avoiding triggers that set off exacerbation is essential, so wearing appropriate sunscreen is a necessity. The sunscreen should contain an SPF higher than 15 and should be waterproof. The remaining options present incorrect information.
A nurse is assigned to care for an infant with congenital diaphragmatic hernia (CDH). Which clinical finding supports this diagnosis? A. Presence of an anal membrane B. Failure to pass meconium stool C. Viscera located outside the abdominal cavity D. Auscultation of cardiac sounds on the right side of the chest
D. Auscultation of cardiac sounds on the right side of the chest Rationale: CDH is an opening in the diaphragm through which abdominal contents herniate into the thoracic cavity during prenatal development. Clinical findings depend on the severity of the defect but may include the presence of abdominal organs in the chest (revealed by fetal ultrasonography), diminished breath sounds or an absence of such sounds on the affected side, auscultation of bowel sounds over the chest, auscultation of cardiac sounds on the right side of the chest, respiratory distress, and a scaphoid abdomen. The presence of an anal membrane and failure to pass meconium stool are findings noted in imperforate anus. The presence of viscera outside the abdominal cavity is noted in gastroschisis.
What discharge instructions are important to provide the parents after their child undergoes cardiac catheterization? Select all that apply. A. A fever is normal after the procedure. B. Some bleeding from the catheter insertion site is expected. C. The child may play in a tub bath 1 day after the procedure. D. Contact sports should be avoided for 1 week after the procedure. E. Acetaminophen or ibuprofen may be given to ease pain or discomfort.
D. Contact sports should be avoided for 1 week after the procedure. E. Acetaminophen or ibuprofen may be given to ease pain or discomfort Rationale: The parents are instructed that the health care provider must be notified if a fever higher than 38° C (101° F) develops, if bleeding or drainage (pus) from the catheter insertion site is noted, or if the child exhibits pallor, coolness, or numbness of the affected extremity. Acetaminophen or ibuprofen is recommended for mild pain as needed. Bathing should be limited to a shower, sponge bath, or brief tub bath (no soaking) for the first 1 to 3 days. The parents are also instructed to keep the child from engaging in strenuous exercise (e.g., climbing trees, swimming, contact sports) for 1 week after the procedure.
The mother of a child who underwent myringotomy with the insertion of tympanostomy tubes 1 day ago calls the surgeon's office and reports to the nurse that the child has a small amount of reddish drainage coming from the ears. The nurse should provide which information to the mother? A. Irrigate the ears gently with warm water B. Bring the child to the surgeon's office to be checked C. Carefully push the tubes a little farther into the ear canal D. Continue to monitor the drainage, because this is a normal finding
D. Continue to monitor the drainage, because this is a normal finding Rationale: After myringotomy with insertion of tympanostomy tubes, the child is monitored for ear drainage. A small amount of reddish drainage is normal for the first few days after surgery, but the mother should report any heavier bleeding or bleeding that occurs after 3 days. Having the surgeon check the child is unnecessary. Irrigating the ears with warm water and pushing the tubes further into the ear canal are inappropriate and could cause harm to the child.
A nurse is providing home care instructions to the mother of a child with juvenile idiopathic arthritis. Which action should the nurse tell the parents to take during a painful exacerbation? A. Splinting the painful joints and avoiding any joint movement B. Encouraging the child to perform simple isometric exercises C. Alternating splinting of the painful joints with joint exercises every hour D. Encouraging the child to perform the prescribed joint exercises to maintain muscle and joint integrity
D. Encouraging the child to perform simple isometric exercises Rationale: During an exacerbation of the disease, the child's natural reaction is to rest the painful joint, but such inactivity could lead to muscle wasting and flexion deformity. Therefore it is important for the child to perform simple isometric exercises. These exercises are appropriate during exacerbations of the disease because they do not involve joint movement. Exercises that involve joint movement are avoided during an exacerbation of the disease.
A nurse is reviewing the chart of a child with a brain tumor. Which symptom(s) would the nurse expect to note in the history and physical? A. Nausea that occurs at bedtime B. Fatigue that occurs after activity C. Dizziness that occurs late in the day D. Headache and morning vomiting related to the child's getting out of bed
D. Headache and morning vomiting related to the child's getting out of bed Rationale: Manifestations of brain tumors vary with tumor location and the age and development of the child, but the hallmark symptoms of a brain tumor in a child are headache and morning vomiting related to the child's getting out of bed. The sudden increase in intracranial pressure that occurs with the change of position causes the vomiting. Nausea at bedtime, dizziness that occurs late in the day, and fatigue after activity are not symptoms specifically associated with brain tumors.
What manifestation of hypertrophic pyloric stenosis should the nurse reviewing the record of an infant with this disorder expect to see documented? A. Fever B. Profuse diarrhea C. Alternating constipation and diarrhea and fecal impaction D. Olive-shaped mass palpated in the right upper abdominal quadrant
D. Olive-shaped mass palpated in the right upper abdominal quadrant Rationale: Progressive non-bilious projectile vomiting in a previously healthy infant is the major manifestation of pyloric stenosis. The vomitus may become blood-tinged if esophageal irritation occurs. A movable, palpable, firm, olive-shaped mass is felt in the right upper quadrant. This mass is most easily palpated when the stomach is empty and the infant is relaxed. Deep gastric peristaltic waves from the left upper quadrant to the right upper quadrant may be visible immediately before vomiting commences. If the condition progresses, the infant may become dehydrated and experience metabolic alkalosis. Fever, profuse diarrhea, and alternating constipation and diarrhea and fecal impaction are not manifestations of this disorder.
Oral nystatin suspension is prescribed for an infant with thrush (oral candidiasis). Which instruction should the nurse provide to the mother? A. Avoid breastfeeding the infant B. Apply the suspension before feeding the infant C. Apply the suspension with a cotton-tipped applicator D. Rub the suspension onto the mucous membranes with a gloved finger
D. Rub the suspension onto the mucous membranes with a gloved finger Rationale: Thrush is a superficial fungal infection of the oral mucous membranes. It occurs as a result of overgrowth of Candida albicans. Cotton-tipped applicators tend to absorb the medication; a more effective method of administration is to rub the suspension onto the mucous membranes, using a gloved finger. To increase the amount of time the medication is in contact with the mucous membranes, nystatin should be applied after feedings. Breastfeeding does not need to be avoided. If the infant is breastfed, the mother's breasts should also be treated with nystatin.
A child has a plaster of Paris cast applied to his arm after fracturing the arm in a fall. The nurse should tell the mother which about the cast? A. Is water resistant B. Is very lightweight C. Will quickly dry if it gets wet D. Takes 24 hours or more to dry
D. Takes 24 hours or more to dry Rationale: Plaster of Paris is a heavy material that molds easily to the extremity and is less expensive than synthetic cast materials. It takes 24 hours or longer to dry. Plaster of Paris is not water resistant; when wet, a cast made of plaster will begin to disintegrate.
A child is admitted to the hospital with suspected infective endocarditis. Place in order of priority how the nurse will carry out the health care provider's prescriptions for the child, with 1 being the first prescription to be carried out and 4 the last. Administering intravenous (IV) antibiotics Scheduling an echocardiogram Starting an IV line Obtaining blood for cultures
The correct order is: Obtaining blood for cultures Starting an IV line Administering intravenous (IV) antibiotics Scheduling an echocardiogram Rationale: The diagnosis of infective endocarditis is established primarily on the basis of blood cultures that yield the causative organism. The nurse would prepare to obtain blood cultures first so that the diagnosis could be confirmed. An IV line would then be initiated and the antibiotics started. The echocardiogram should be scheduled once the antibiotics have been started. The visualization of a vegetation (an abnormal growth of infected tissue) on echocardiographic studies helps establish the diagnosis.
