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, x-Ray, or CT, will confirm the pocket in the intestine.

A nurse is assessing a 6 month old infant following cardiac catheterization. Which of the following findings should the nurse report to the provider?

BP 86/40 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 findings should the nurse include in the teaching?

Barking cough, stridor, wheezing, cyanosis, 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 instrument?

Cup - 7-10 days to prevent trauma and injury to suture line. 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?

Demonstrate the injection technique on an orange.

A nurse in the ER is caring for a 4 year old child who has burns to the neck and face following a house fire. Which of the following should the nurse take first?

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 the ER 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?

Drooling (inability to swallow saliva) 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 in an emergency department is assessing a school-age child who is experiencing an azure asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider?

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 2 month old infant who has a ventricular septal defect. Which finding should be reported to the provider?

Weight gain of 1.8 kg (4 lb)

A nurse is assessing a child with VSD. Which findings should the nurse expect?

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 caring for an 8 year old who has acute glomerulonephritis. Which of the following findings should the nurse expect?

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

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. 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 lab report of 2 year old child who has diarrhea and has been vomiting for 24 hours. Which findings should be reported to the provider?

Potassium 2.5

A nurse is admitting a child who has Wilm's tumor. Which of the following actions should the nurse take?

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?

Scrambled eggs - no gluten (NO BROWS) 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 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?

Slight tachypnea

A nurse is caring for a 6 week old infant following pyloromyotomy. Which of the following forms of feeding should the nurse anticipate for the infant 6 hours after the procedure ?

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.

A nurse is caring for an infant following a surgical repair of a cleft lip and palate. Which action should the nurse take?

Suction the infant gently with a bulb syringe PRN.

A nurse is providing teaching to an adolescent who has scoliosis and a new prescription for a Boston brace. Which response by the adolescent indicates an understanding of the teaching?

"I can take my brace off for about an hour daily to shower"

A clinic nurse is providing teaching to the parent of a 1 month old infant who has GER. Which statement made by the parent indicates an understanding of the teaching?

"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" 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 inspect my child's mouth everyday 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 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 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 1000 calories per day" & 2 oz of protein, no more than 3 cups of milk, 1 cup of vegetables per day

A nurse is providing teaching about immunizations to the parents of a severely immunocompromised child who has HIV. Which of the following statements should the nurse include in the teaching?

"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 ASO titer from a child who has acute glomerulonephritis. The parent asks the nurse to explain what the purpose of the test is. Which response should the nurse make?

"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 lab 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?

1.035 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 providing teaching to the parents of an infant who has acute otitis media about how to administer antibiotic ear drops. Which of the following instructions should the nurse include?

Massage the anterior area of the infants 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 caring for a child in skeletal traction. Which of the following actions is the nurses priority?

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 yr old child following a tonsillectomy. Which rating scales should the nurse use to determine pain level?

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 nurses priority?

Frequent swallowing

A nurse is reviewing the lab report of a toddler who is receiving chemotherapy for leukemia. Which of the following lab values should the nurse report to the provider?

Hgb 6

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 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.

A nurse is providing teaching to the parents of a school-age child who has type 1 DM about management of hypoglycemia. Which of the following responses by the parents indicate an understanding of the teaching?

I will make sure my child drinks 240 ml (8 oz) or milk ASAP (15 g simple carb)

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 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 instructions should the nurse include in the plan?

Inspect 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 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?

Keep 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 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?

Maintain the child on bed rest.

A nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy. Which intervention should the nurse include in the plan?

Monitor child for increased temperature