Toddlers/Preschoolers-Pediatric Nursing

A nurse must administer a medication by means of injection to a 2-year-old whose parent is not present. What is the most therapeutic approach for the nurse to use?

Warning the child about the injection just before administering it, saying that it is OK to cry, and then comforting the child Rationale: Toddlers have not yet developed a concept of time. The child should be warned just before the injection is given, then shown acceptance when he or she cries and is comforted. Children are sensitive to a dishonest approach; this results in their losing trust in the caregiver. Toddlers' attention span is too short and their cognitive ability too limited for them to watch a demonstration and listen to an explanation. Toddlers are too young to participate in therapeutic play; this approach is more appropriate for the preschooler.

A 4-year-old child with nephrotic syndrome has repeated relapses. As the child gets older, what is the most important attribute for the child to develop

A positive body image Rationale: Children with nephrotic syndrome are treated with immunosuppressive agents, including steroids. During exacerbations they may have a characteristic pale, overweight appearance as a result of edema. Steroid side effects include growth retardation, cataracts, obesity, and hirsutism. Children may become very sensitive about these changes as they grow older. Although the ability to test the urine may be indicated, body image poses a greater concern. Engaging in usual childhood activities between attacks should promote the development of fine muscle coordination. Sterility is not associated with nephrotic syndrome.

A nurse is teaching a group of assistants in a daycare center about toddlers' developmental milestones. What behavior should indicate to the assistants that one of the milestones has been achieved?

Accepting external limits Rationale: One task of toddlers is to accept limit setting and discipline, which are necessary for them to develop self-control while learning the boundaries of their abilities. An infant must learn to trust before moving on to other developmental goals. Superego control begins in the preschooler. Roles within society are learned by the school-aged child.

A nurse on the pediatric unit receives a change-of-shift report. In which order should the nurse assess the children? Begin with the child whose status is most critical and end with the child whose status is most stable.

1. 8-month-old with vomiting and diarrhea lasting 1 day, 2. 5-year-old with diarrhea lasting 2 days, 3.11-year-old with abdominal cramps lasting 4 hours, 4. 6-year-old with low-grade fever lasting 3 days, 5. 3-year-old with celiac disease who is to be discharged within 2 hours Rationale: An infant, whose body consists of a larger percentage of water than that of an older child or adult, can become dehydrated and experience severe electrolyte imbalances within several hours of becoming ill. This is a life-threatening situation that requires immediate intervention. A 5-year-old can become dehydrated after a prolonged session of diarrhea; therefore reassessment of the degree of dehydration should be performed as soon as possible. Although appendicitis may be the cause of the 11-year-old child's abdominal cramps, there is no apparent emergency because the child has been tolerating the abdominal cramps for several hours. Although the 6-year-old child should be assessed further to determine the cause of the fever, it has been tolerated for 3 days. The 3-year-old with celiac disease who is to be discharged within 2 hours is stable and ready for discharge.

A toddler with lead poisoning is started on chelation therapy. Succimer (Chemet) is ordered. What information should the nurse give the parents concerning the administration of this medication?

The contents of the capsules may be sprinkled on food. Rationale: Succimer is given orally in capsules; for the child who cannot swallow a whole capsule, it may be opened and sprinkled on food. Succimer is administered for 19 days. Succimer is an oral medication; EDTA, another chelating agent, is given intramuscularly, and this treatment is painful. Fluids should be increased, not limited, to facilitate elimination of waste products.

If a toddler cannot be given or is not responding to oral chelating agents, parenteral medication must be used. What is the priority nursing intervention to effectively prepare a child to cope with this painful treatment?

Therapeutic play with a needleless syringe and a doll before therapy is initiated and after the child receives each injection Rationale: The child should be given an outlet for tension, and therapeutic play involving the equipment needed for the injections is the most appropriate activity. Rotating the injection sites and adding procaine to the chelating agent may ease discomfort, but providing an outlet for feelings takes priority. Fear is not directed at unfamiliar adults but at the painful treatments. Explaining the rationale for the injections is part of the preparation, but it is not the most important; the child must be encouraged to express feelings.

A 2-year-old toddler is admitted to the pediatric unit with tachycardia, tachypnea, and shortness of breath. While completing a nursing assessment the nurse auscultates the toddler's lungs. What term should the nurse use in the medical record to document the following sound heard during auscultation of the lungs?

Wheezes Rationale: A wheeze is an adventitious breath sound. It is a continuous high-pitched, squeaky, musical sound best heard on exhalation. Wheezes are commonly heard over all lung fields and can be auscultated or heard with the naked ear. A wheeze is caused by narrowing of the lumen of the respiratory passages. It is associated with asthma, bronchitis, croup syndromes, lung infections, pulmonary edema, emphysema, and other chronic obstructive lung conditions. Stridor is an adventitious breath sound. It is a high-pitched, shrill, harsh sound that generally occurs on inspiration but may occur on expiration. Depending on its severity, it may be heard on auscultation of the lung or with the naked ear. Stridor occurs with laryngeal obstruction (upper airway obstruction) and is associated with croup syndromes. Rhonchi (gurgles) are adventitious breath sounds. They are continuous low-pitched, coarse sounds, often described as having a snoring or moaning quality. Rhonchi indicate partial bronchial obstruction caused by mucus or other fluids in the airway, bronchial hyperreactivity, or the presence of a tumor. Crackles (rales) are adventitious breath sounds. They are fine, short, interrupted crackling sounds that are best heard on inspiration but may be heard on expiration. Crackles are heard on auscultation of the base of the lung as air passes over secretions retained within the alveoli.

The parents of a 20-month-old toddler tell a nurse that they are concerned that bedtime thumbsucking will cause their child's teeth to protrude. What is the best response by the nurse?

"You needn't be concerned unless the thumbsucking persists after the permanent teeth have come in." Rationale: The closure of lips and teeth around a finger or thumb results in suction that can move permanent teeth forward, causing malocclusions; until a child is 4 to 6 years of age there is no cause for concern. Thumbsucking in a toddler is not a sign of an emotional problem. Use of a pacifier can also cause malocclusions after the permanent teeth have appeared. There is no indication that the first teeth are loosened by thumbsucking.

The nurse is assessing a toddler with a diagnosis of pinworms. What complication of pinworm infestation, although rare, should the nurse be aware of?

Appendicitis Rationale: Pinworms, which attach themselves to the bowel wall in the cecum and appendix, can damage the mucosa, causing appendicitis. Pinworms do not migrate to the liver. Although pinworms (and their ova) are ingested by mouth, they do not attach themselves there; inflammation of the mouth is not a complication of pinworm infestation. Pinworms do not migrate to the respiratory system.

An unconscious toddler requires intermittent nasogastric feedings. When should the nurse check placement of the tube?

Before each feeding Rationale: It is the nurse's responsibility to assess tube placement before each feeding; withdrawing gastric contents before each feeding ensures that the tip of the tube is in the stomach. The other times are not frequent enough; the tube could be displaced between feedings.

A toddler on the pediatric unit is required to have temporary dietary restrictions after colorectal surgery. What is the best way for the nurse to promote adherence to the restrictions?

By handling dietary changes in a matter-of-fact way Rationale: Toddlers are ritualistic and do not tolerate change well; any change in diet should be done matter-of-factly. Because of their characteristic struggle for autonomy, toddlers should not be forced to eat. Limited restrictions on nonessential foods are not always possible. Although the parents should consult with the dietitian, this will not affect the toddler's response to the dietary restrictions. The toddler is still dependent on the parents and therefore will respond better to them than to a stranger.

During a well-child visit the parents tell a nurse, "Our 3-year-old doesn't listen to us when we speak—he ignores us!" An auditory screening reveals that the child has a mild hearing loss. What should the nurse explain to the parents about this degree of hearing loss?

Speech therapy in addition to hearing aids may be required. Rationale: A mild degree of hearing loss causes the child to miss approximately 25% to 40% of conversations; it may result in speech deficits and interfere with the child's educational progress if it is not corrected. Hearing aids usually help improve function. There is no evidence that this child's hearing loss is progressive. The significance of the hearing loss requires further analysis and intervention.

The mother of a 2-year-old child expresses concern to the nurse in the pediatric clinic that her child still takes a bottle of milk to bed at night. How should the nurse explain to the mother that this practice should be stopped?

The child is at increased risk for dental caries. Rationale: Allowing a child to keep a bottle of milk or juice overnight results in prolonged exposure of the teeth to sugars, making them susceptible to bacterial invasion and eventual decay. Having a nighttime bottle does not contribute to anemia as long as adequate nutrients are ingested during the daytime. A 2-year-old may still have some need for sucking. A nighttime bottle may predispose a child to middle, not inner, ear infections.

A nurse is performing health screenings of toddlers in a culturally diverse neighborhood. Which child should the nurse consider at risk for β-thalassemia (Cooley anemia)?

Two-year-old child of Greek descent with a large abdomen Rationale: β-Thalassemia is common in children who are black or of Mediterranean descent (Italian, Greek, Syrian); an enlarged abdomen may be the result of hepatomegaly or splenomegaly. Pale skin is expected in children of Irish descent; children with β-thalassemia may have bronze skin as a result of hemosiderosis if the excess iron is not chelated. Defective hemoglobin leads to damaged red blood cells and a decreased hematocrit. Asian descent is not a risk factor for β-thalassemia.