Pediatric PASSPOINT
A child is admitted to the emergency department with an acute asthma attack. Which early assessment finding does the nurse expect? inspiratory stridor expiratory wheezing cyanosis decreased respiratory rate
Correct response: expiratory wheezing Explanation: Expiratory wheezing is common during an acute asthma attack and results from narrowing of the airway caused by edema. Acute asthma causes an increased respiratory rate. Inspiratory stridor more commonly accompanies croup. Cyanosis would be a sign of severe hypoxia and would be a late sign.
A nurse is teaching the parent of a 5-month-old infant diagnosed with bronchiolitis. Which statement by the mother indicates that teaching has been effective? "My baby has been sick. A machine will help him breathe." "My baby needs to be cured this time so it won't happen again." "I know that this disease is serious and can lead to asthma." "I hope my baby will come home from the hospital."
Correct response: "I know that this disease is serious and can lead to asthma." Explanation: By saying that bronchiolitis places the child at risk for developing asthma, the parent demonstrates understanding of the infant's condition. If diagnosed and treated promptly, most infants recover from the illness and return home. Infants typically don't have recurrences of bronchiolitis. Infants diagnosed with bronchiolitis rarely require mechanical ventilation.
An infant who weighs 7.5 kg is to receive ampicillin 25 mg/kg intravenously every 6 hours. How many milligrams would the nurse administer per dose? Record your answer using one decimal place.
Correct response: 187.5 Explanation: The nurse would calculate the correct dose using the following equation:25 mg/kg × 7.5 kg = 187.5 mg
The nurse is instructing a 4-year-old child about an upcoming procedure. What approach should the nurse employ during teaching? Speak gently and use a high-pitched voice. Use simple terms. Offer a toy to keep the child happy. Include colorful details.
Correct response: Use simple terms. Explanation: When explaining a procedure to a 4-year-old child, the nurse must use simple terms that the child can understand. Speaking gently may ease the child, but this is not most important. Distracting the child with a toy is more appropriate during the procedure than before it. Because preschoolers have a limited attention span, the nurse should provide only the necessary, basic facts — not colorful details — to prevent anxiety.
The nurse is calculating the digoxin dose for a pediatric client who weighs 11.36 kg (25 lb). The dose for the client is 30 mcg/kg. How many mcg will the client receive per dose? Record your answer using one decimal place.
Correct response: 340.8 Explanation: The order is for 30 mcg/kg/dose. Multiplying 11.36 kg by 30 mcg/kg yields a dose of 340.8 mcg (when rounded to one decimal place).
A preschooler with a fractured femur of the left leg in traction tells the nurse that his leg hurts. It is too early for pain medication. The nurse should: remove the weight from the left leg. assess the feet for signs of neurovascular impairment. place a pillow under the child's buttocks to provide support. reposition the pulleys so the traction is looser.
Correct response: assess the feet for signs of neurovascular impairment. Explanation: The nurse should assess the client frequently for signs of neurovascular impairment of the feet, such as pallor, coldness, numbness, or tingling. Pillows are not placed under the buttocks because the pillows would alter the alignment of the traction. Weights provide traction and should not be removed. Pulleys help to maintain optimal alignment of the traction and therefore should be left alone.
For a client with a circumferential chest burn, what is the most important factor for the nurse to assess? breathing pattern body temperature heart rate wound characteristics
Correct response: breathing pattern Explanation: Breathing pattern is the most important factor to assess because eschar impedes chest expansion in a client with a circumferential chest burn, causing breathing difficulty. Wound characteristics, body temperature, and heart rate are also factors that should be assessed, but they aren't as important as breathing pattern.
A nurse performs cardiopulmonary resuscitation (CPR) for 2 minutes on an infant without calling for assistance. In reassessing the infant after 2 minutes of CPR, the nurse finds the infant still isn't breathing and has no pulse. The nurse should then: resume CPR beginning with chest compressions. reposition the infant. resume CPR beginning with breaths. call for assistance.
Correct response: call for assistance. Explanation: After 2 minutes of CPR, the nurse should call for assistance and then resume efforts. CPR shouldn't be stopped after it has been started unless the nurse is too exhausted to continue. A cycle usually ends with breaths, so the next beginning cycle after pulse check and summoning help would begin with chest compressions.
When preparing to deliver back slaps to an infant who is choking on a foreign body, the nurse should place the infant in which position? head to one side and even with the trunk lower than the head head parallel to the nurse and supported at the buttocks head up and raised above the trunk head down and lower than the trunk
Correct response: head down and lower than the trunk Explanation: To deliver back slaps, the nurse should place the infant face down, straddled over the nurse's arm, with the head lower than the trunk and the head supported. This position, together with the back slaps, facilitates dislodgment and removal of a foreign object and minimizes aspiration if vomiting occurs.Placing the infant with the head up and raised above the trunk would not aid in dislodging and removing the foreign object. In addition, this position places the infant at risk for aspiration should vomiting occur.Placing the head to one side may minimize the risk of aspiration. However, it would not help with removal of an object that is dislodged by the back slaps.Placing the infant with the head parallel to the nurse and supported at the buttocks is more appropriate for burping the infant.
The nurse is caring for an infant in the emergency room who has symptoms of irritability and a high fever. When assessing for increased intracranial pressure using the anterior fontanel, identify the area where the nurse would palpate.
Explanation: The anterior fontanel is formed by the junction of the sagittal, frontal, and coronal sutures. It is shaped like a diamond and normally measures 4 to 5 cm at its widest point. A widened, bulging fontanel is a sign of increased intracranial pressure.
The parents of a 12-year-old girl ask why their daughter, who is not sexually active, should receive the human papillomavirus (HPV) vaccine. What should the nurse should tell the parents? "Parents are never sure when their child might become sexually active." "If your daughter is sexually assaulted, she may be exposed to HPV." "The vaccine is most effective against cervical cancer if given before becoming sexually active." "HPV is most common is teens and women in their late 20s."
Correct response: "The vaccine is most effective against cervical cancer if given before becoming sexually active." Explanation: Vaccines are preventative in nature and ideally given before exposure. Focusing on the benefits of cancer prevention is most appropriate, as opposed to discussing with parents the potential that their child may become sexually active without their knowledge. It is true HPV is most common in adolescents and women in their late twenties, but parents still may not perceive that their child is at risk. Discussing the possibility of exposure through assault raises fears and does not focus on prevention.
After insertion of bilateral tympanostomy tubes in a toddler, which instruction should the nurse include in the child's discharge plan for the parents? Insert ear plugs into the canals when the child bathes. Administer antibiotics daily while the tubes are in place. Gently clean the ear canal with cotton swabs. Disregard any drainage from the ear after 1 week.
Correct response: Insert ear plugs into the canals when the child bathes. Explanation: Placing ear plugs in the ears will prevent contaminated bathwater from entering the middle ear through the tympanostomy tube and causing an infection. Inserting cotton swabs into the ear canal is not recommended. Antibiotics may be given for a short period after insert and are appropriate only when an ear infection is present. Tympanostomy tubes may remain in place for several years. It is not necessary to administer antibiotics continuously to a child with a tympanostomy tube. Drainage from the ear may be a sign of middle ear infection and should be reported to the health care provider (HCP).
The public health nurse is teaching the parents of a 5-year-old client diagnosed with sickle cell disease. What education will the nurse include? Select all that apply. Avoid giving the client pain medication. Keep the client's immunizations up to date. Wait 24 hours to call the healthcare provider if the client has a fever. Monitor for abnormal skin color. Schedule regular appointments with a hematologist.
Correct response: Keep the client's immunizations up to date. Schedule regular appointments with a hematologist. Monitor for abnormal skin color. Explanation: Sickle cell disease occurs when red blood cells (RBCs) morph into sickle cell shape and plug up the blood vessels causing extreme pain. To prevent sickle crisis, the client should have scheduled immunizations, regular appointments with a hematologist, and be monitored for abnormal skin color. The client will have pain due to the sickling of the cells and will need pain medication as needed. When a fever presents, the parents should call the healthcare provider immediately to prevent a sickle cell crisis.
The nurse is caring for a toddler who is visually impaired. What is the most important action for the nurse to take to ensure the safety of the child? Maintain a tidy environment around the child. Avoid startling the child by limiting excess noise. Request that the parent stay with the child. Use visual aids to facilitate communication.
Correct response: Maintain a tidy environment around the child. Explanation: Children with visual impairment explore the environment by feel. A tidy and organized environment can support this and promote the child's safety. It is a priority to make sure all items that could potentially injure the child are removed from the environment. This includes meal trays and supplies for procedures. It is not reasonable to expect the parent to be available at all times or to expect the parent to take on the nurse's responsibility. Visual aids won't be effective for a child with visual impairment. While limiting noise volume is helpful to avoid startling the child, this does not promote safety as effectively as establishing and maintaining an environment free of dangerous objects and obstacles.
The nurse is offering nutritional instruction to the parents of a preschooler who has undergone a tonsillectomy and adenoidectomy. What food choice by the parents would indicate successful teaching? hot dog and potato chips cream of chicken soup and orange sherbet pork and noodle casserole meat loaf and uncooked carrots
Correct response: cream of chicken soup and orange sherbet Explanation: For the first few days after a tonsillectomy and adenoidectomy, liquids and soft foods are best tolerated by the child while the throat is sore. Children typically do not chew their food thoroughly, and solid foods are to be avoided because they are difficult to swallow. Although meat loaf would be considered a soft food, uncooked carrots would not be. Pork is frequently difficult to chew. Foods that have sharp edges, such as potato chips, are contraindicated because they are hard to chew and may cause more throat discomfort.
When obtaining a nursing history from parents who are suspected of abusing their child, which characteristic about the parents should the nurse particularly assess? difficulty with controlling aggression attentiveness to the child's needs self-blame for the injury to the child ability to relate the child's developmental achievements
Correct response: difficulty with controlling aggression Explanation: Parents of an abused child have difficulty controlling their aggressive behaviors. They may blame the child or others for the injury, may not ask questions about treatment, and may not know developmental information.
After staying several hours with her 9-year-old daughter who is admitted to the hospital with an asthma attack, the mother leaves to attend to her other children. The child exhibits continued signs and symptoms of respiratory distress. Which finding should lead the nurse to believe the child is experiencing anxiety? frequent requests for someone to stay in the room verbalization of a feeling of tightness in her chest not able to get comfortable inability to remember her exact address
Correct response: frequent requests for someone to stay in the room Explanation: A 9-year-old child should be able to tolerate being alone. Frequently asking for someone to be in the room indicates a degree of psychological distress that, at this age, suggests anxiety.The inability to get comfortable is more characteristic of a child in pain. Inability to answer questions correctly may reflect a state of anoxia or a lack of knowledge.Tightness in the chest occurs as a result of bronchial spasms.
The nurse is caring for a child in the early stages of burn recovery. Which nursing diagnosis does the nurse prioritize? disturbed body image impaired skin integrity impaired physical mobility constipation
Correct response: impaired skin integrity Explanation: Impaired skin integrity is a serious problem for the burned child. The open skin causes fluid to leak and can contribute to fluid and electrolyte issues. Also, because the skin is open there is a portal for infectious organisms. The diagnoses of impaired physical mobility, disturbed body image, and constipation are relevant in the care of the child with burns, but they are concerns for later in the recovery process.
Which use of restraints in a school-age child should the nurse question? to aid in carrying out procedures to substitute for observation to ensure the child's comfort or safety to facilitate examination
Correct response: to substitute for observation Explanation: Restraints should never be used as a punishment or as a substitute for observation because if a child is at risk for self-harm when left alone, the child requires one-on-one observation. Ensuring the child's comfort or safety (restraining to keep an I.V., drainage tube, or orthopedic device in place), facilitating examination, and carrying out procedures are all valid reasons for restraint. Restraining devices aren't without risk and must be checked and documented every 1 to 2 hours.
