Saunders child health Cardiovascular/Eye/Ear/Immune

A health care provider prescribes "eye patching" for a child with strabismus of the right eye. The nurse reinforces instructions to the mother to use which procedure for eye patching?

Place the patch on the left eye.

The nurse is assigned to care for an infant with a diagnosis of tricuspid atresia. The nurse plans care, knowing which is true regarding this diagnosis?

There is no communication from the right atrium to the right ventricle.

The nurse receives a call from the mother whose child has a foreign body in the eye. The object is clearly visible and not embedded. When the mother asks for the most effective way to get it out, the nurse should give which response?

Touch the object gently with a cotton swab, and lift it out.

The nurse is attempting to ensure the parent is able to safely administer at home the prescribed ear drops to the 2-year-old client. The parent demonstrates understanding of the teaching by listing the steps of the process in which priority order? Arrange the actions in the order that they should be performed. All options must be used.

1. Warm the bottle of ear drops by rolling it in the palms of the hands to help decrease discomfort. 2. Have the child lie on his or her back with the affected ear facing up. 3. Straighten the ear canal by pulling the pinna of the affected ear down and back. 4. Slowly instill the number of drops prescribed by the health care provider into the ear. 5.Massage the area anterior to the ear to facilitate entry of the drops. 6. Keep the child in the same position for 2 to 3 minutes.

A 4-year-old child is diagnosed with otitis media, and the mother asks the nurse about the causes of this illness. The nurse responds, knowing that which is an unassociated risk factor related to otitis media?

A history of urinary tract infections

The nurse is monitoring the daily weight of an infant with heart failure (HF). Which finding alerts the nurse to suspect fluid accumulation and thus the need to notify the registered nurse?

A weight gain of 1 lb in 1 day

The nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse should observe for which early sign of HF?

Tachycardia

The nurse is reinforcing home care instructions to the mother of a child with bacterial conjunctivitis. Which instruction should the nurse give the mother?

That the child's towels and washcloths should not be used by other members of the household

The day care nurse is observing a 2-year-old child and suspects that the child may have strabismus. Which observation may be indicative of this condition?

The child consistently tilts his or her head to see.

The nurse reinforces discharge instructions to the mother of a child following a myringotomy with insertion of tympanostomy tubes. Which statement by the mother indicates a need for further teaching?

"I need to be sure my child uses soft tissues to blow his nose."

The nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question should the nurse ask the family to elicit information specific to the development of RF?

"Did the child have a sore throat or a fever within the past 2 months?"

The nurse is caring for a mother and her infant who was born 12 hours ago. Which statements made by the mother should prompt the nurse to have the baby evaluated for early heart failure? Select all that apply.

"I'm chilly but my baby's forehead is sweaty." "I can feel my baby's heart rate when he's sleeping, it seems much faster than it did yesterday." "My baby latches on to my nipple well and has a strong suck, but seems to get weak very quickly, then stops too soon."

The mother of a child who had a myringotomy with insertion of tympanostomy tubes calls the nurse and tells the nurse that the "tubes" fell out. The nurse should make which response to the mother?

"This is not an emergency. I will speak to the health care provider and call you right back."

Acetylsalicylic acid (aspirin) is prescribed for a child with rheumatic fever (RF). The nurse should question this prescription if the child had documented evidence of which condition?

A viral infection

The nurse is caring for a child with a suspected diagnosis of rheumatic fever (RF). The nurse reviews the laboratory results. Which laboratory study should assist in confirming the diagnosis of RF?

Antistreptolysin O titer

A 5-year-old child has been transferred to the pediatric unit after a cardiac catheterization. Which intervention has the highest priority in the care of this child immediately following the procedure?

Assess for any bleeding on the dressing.

The nurse is assigned to care for a child admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The nurse prepares the child for which diagnostic test that will confirm the diagnosis?

Blood cultures

The nurse is reinforcing discharge instructions to the mother of a child who had a myringotomy with insertion of tympanostomy tubes. The nurse instructs the mother that if the tubes fall out, she should take which action?

Contact the health care provider.

A child is admitted to the pediatric unit with a diagnosis of coarctation of the aorta (COA). The health care provider prescribes that the child's blood pressure be taken every 4 hours in the legs and arms. The nurse should expect which blood pressure readings in the child's legs and arms?

Decreased in the legs and increased in the arms

The nurse is caring for an infant with congenital heart disease. Which signs, if noted in the infant, should alert the nurse to the early development of heart failure (HF)?

Diaphoresis during feeding

The nurse is assigned to care for a child after a myringotomy with the insertion of tympanostomy tubes. The nurse notes a small amount of reddish drainage from the child's ear after the surgery. On the basis of this finding, which action should the nurse take?

Document the findings.

A 10-month-old child presents to the clinic with irritability, rubbing and pulling at the right ear, and a temperature of 102.4° F. The health care provider diagnoses the child with acute otitis media (OM) of the right ear, prescribes broad-spectrum antibiotics, and provides instructions to the parent, who verbalizes an understanding of the treatment plan. The parent later asks the nurse how to prevent future episodes of OM. Which instructions should the nurse reinforce in parent teaching? Select all that apply.

Ensure the child is not exposed to smoke. Have the child remain in a sitting position while awake. Consider avoiding individuals with upper respiratory infections.

Which home care instructions should the nurse plan to reinforce to the mother of a child with acquired immunodeficiency syndrome (AIDS)? Select all that apply.

Frequent hand washing is important. The child should avoid exposure to other illnesses. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach).

A mother of a child who underwent a myringotomy with insertion of tympanostomy tubes calls the nurse and reports that the child is complaining of discomfort. Which should the nurse instruct the mother to do?

Give the child acetaminophen (Tylenol) for the discomfort as per discharge instructions.

The nurse is assisting in developing a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse suggests that the child should be monitored for which signs?

Heart failure (HF)

The nurse is reviewing a health care provider's prescription for a child who was just admitted to the hospital with a diagnosis of Kawasaki disease. Which prescription should the nurse anticipate being part of the treatment plan?

Immune globulin

The nurse is caring for a child with a diagnosis of Kawasaki disease. The mother of the child asks the nurse about the disorder. Which statement most accurately describes Kawasaki disease?

It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown cause.

The nurse is reviewing the immunization schedule for a child with human immunodeficiency virus (HIV) infection with the mother. Which should be a component of the instructions that the nurse reinforces to the mother?

No live virus vaccines should be administered to the child.

The nurse is reinforcing discharge teaching to the parents of an infant diagnosed with tetralogy of Fallot. Which statements made by the parents indicate a need for further teaching? Select all that apply.

Our child will eventually grow out of this condition. It is not necessary to avoid individuals with the common cold.

A 5-year-old child is admitted to the hospital for heart surgery to repair tetralogy of Fallot. The nurse notes that the child has clubbed fingers, and the nurse knows that this symptom is likely a result of which condition?

Peripheral hypoxia

The nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. Which action should the nurse take?

Place the infant in a knee-chest position.

The mother of a child arrives at the clinic because the child has been experiencing scratchy, red, and swollen eyes. The nurse notes a discharge from the eyes and a culture is sent to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. Based on this diagnosis, which should require further investigation?

Possible sexual abuse

Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The mother of the child asks the nurse why the child needs the medication. The nurse correctly responds that which is the purpose of this medication?

Provides adequate oxygen saturation and maintains cardiac output

A 1-year-old child is seen in the health care provider's office with complaints of an elevated temperature that began the previous evening. When gathering subjective data from the mother, the nurse notices that which sign/symptom would most likely indicate the child has acute otitis media?

The mother states the child had purulent discharge from the ear last night.

A nursing student is assigned to care for an infant with a diagnosis of heart failure (HF). The student develops a plan of care for the child that is focused on monitoring for fluid overload. The student plans to best assess the urine output of the infant by taking which action?

Weighing the diapers

An infant with heart failure (HF) is receiving diuretic therapy, and the nurse is closely monitoring the intake and output. Which is the best method for the nurse to use to monitor the urine output?

Weighing the diapers

The health care provider prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV) to determine the presence of HIV antigen in the infant. The nurse anticipates that which laboratory study will be prescribed for the infant?

p24 antigen assay

The nurse has reinforced home care instructions to the mother of a child who is being discharged after cardiac surgery. Which statement by the mother indicates the need for further teaching?

"I can apply lotion or powder to the incision if it is itchy."

The nurse assists to prepare a teaching plan regarding the administration of eardrops for the parents of a 2-year-old child. Which should be included in the plan?

Pull the earlobe down and back before instilling the eardrops.

The nurse in the pediatric clinic is planning care for a 2-month-old client who has been brought to the clinic for a well-child exam and 2-month immunizations. The infant is afebrile and does not exhibit signs of a respiratory infection. The mother tells the nurse that the child developed a rash and difficulty breathing after the mother applied Neosporin ointment to a scrape on the baby's leg. The nurse knows which vaccines are safe to administer to the child? Select all that apply.

Rotavirus Hepatitis B Pneumococcal Diphtheria, tetanus, pertussis Haemophilus influenza type b

The nurse reinforces instructions to parents regarding the methods that will decrease the risk of recurrent otitis media in infants. Which should the nurse include in the instructions?

"Feed the infant in an upright position."

The nurse is collecting data on a child with a diagnosis of rheumatic fever. Which question should the nurse initially ask the mother of the child?

"Has the child complained of a sore throat within the past few months?"

The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for the administration of digoxin (Lanoxin). Which statement by a parent indicates the need for further teaching?

"If my child vomits after medication administration, I will repeat the dose."

The nurse assists with admitting a child with a diagnosis of acute-stage Kawasaki disease. When obtaining the child's medical history, which manifestation is likely to be noted?

Conjunctival hyperemia

A health care provider has told the mother of a newborn diagnosed with strabismus that surgery will be necessary to realign the weakened eye muscles. The mother asks the nurse when the surgery might be performed. Which time frame for the surgery should the nurse explain to the mother?

Before the child is 3 years old

The nurse is reviewing the health care provider's prescriptions for a child with rheumatic fever who is suspected of having a viral infection. The nurse notes that acetylsalicylic acid (aspirin) is prescribed for the child. Which nursing action is appropriate?

Consult with the registered nurse to verify the prescription.

A 9-year-old child is diagnosed with chlamydial conjunctivitis. The nurse consults with the health care provider regarding necessary follow-up because this infection can be associated with which finding?

Possible sexual abuse

Antibiotics are prescribed for a child following a myringotomy with insertion of tympanostomy tubes, and the nurse provides instructions to the parents regarding the administration of the antibiotics. Which statement made by a parent would indicate that the instructions were understood?

"We will administer the antibiotics until they are gone."

The nurse has provided instructions to the mother of a child who has been diagnosed with bacterial conjunctivitis. Which statement by the mother would indicate the need for further teaching?

"It is okay to share towels and washcloths."

A mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant to the clinic for a routine checkup. A health care provider has documented that the infant is asymptomatic for HIV infection. After the checkup, the mother tells the nurse that she is so pleased that the infant will not get HIV. Which response by the nurse is appropriate?

"Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic at some point before the age of 3 years."

The nurse reviews the record of a child who was just seen by a health care provider (HCP). The HCP has documented a diagnosis of suspected aortic stenosis. Which specific sign/symptom of aortic stenosis should the nurse anticipate?

Exercise intolerance

The nurse is preparing to administer digoxin (Lanoxin) to an infant with heart failure (HF). Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 88 beats per minute. Based on this finding, which is the appropriate nursing action?

Withhold the medication.

A health care provider has prescribed oxygen as needed for a 10-month-old infant with heart failure (HF). In which situation should the nurse administer the oxygen to the child?

When drawing blood for electrolyte levels

The client presents to the pediatrician's office with a temperature of 103° F for the past 3 days. The nurse also observes conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes. Using situation, background, assessment, and recommendation (SBAR communication), which statements and/or questions should the nurse use in communication with the health care provider regarding this client's condition? Select all that apply.

"I am concerned this client has Kawasaki's disease. Can you please come assess this client?" "This client is a 4-year-old male who presented to the clinic with a temperature of 103° F for the past 3 days." "I think this client is at risk for aneurysm and thrombi development and should be taken to the hospital immediately." "I observed this client to have conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes."