UWorld MSK & Neuro - Child Health

The nurse is preparing the infant for discharge several days after ventriculoperitoneal shunt placement. Drag the parent statement that indicates correct understanding of the lifestyle and home care teaching to the box on the right. d. Swimming and other noncontact sports (eg, track) are appropriate and beneficial to the child's development and growth.

"The shunt may require revision surgeries as the child grows." "Certain sports should be avoided when my child is older." '"Early childhood development programs may help my child catch up to peers." = Early childhood development programs can be used to monitor the infant's development and provide early detection of areas in which the infant needs additional supportive services. "Persistent irritability, poor feeding, and vomiting can be signs that the tubing has become obstructed."

Concerning findings during infancy include:

- Prominent scalp veins, wide-spaced suture lines, and a bulging anterior fontanel may indicate increasing intracranial pressure (ICP). These findings become more visible when the infant cries and can be caused by hydrocephalus or meningitis. By age 3 months, the posterior fontanel closes; however, the anterior fontanel does not close until age 12 to 18 months and is soft and flat without bulging. - A continuous downward gaze with protrusion of the frontal area of the head (ie, setting sun sign) is an ophthalmic finding indicating that periaqueductal structures are compressed from increased ICP, impairing upward gaze. - Increased head circumference may indicate increasing ICP. By age 2 months, the infant should smile and look at a parent's face when hearing the parent's voice. voice. Lack of this developmental finding may indicate impaired neurologic function.

The nurse is assessing a 4-year-old boy in a pediatric clinic. Which behaviors by the client would concern the nurse for possible Duchenne muscular dystrophy? Select all that apply. Duchenne muscular dystrophy is an X-linked recessive (carried by females and affecting males) disorder that causes the progressive replacement of dystrophin, a protein needed for muscle stabilization, with connective tissue. The proximal lower extremities and pelvis are affected first. Joint pain that is worse in the morning is a symptom of juvenile idiopathic arthritis. Children with this type of arthritis also experience symptoms of joint swelling and stiffness, high fever, and skin rash. Rigid extension of the arms and legs is seen in the tonic phase of a tonic-clonic seizure. During this time, muscles become stiff, the jaw becomes clenched, and pupils can be fixed and dilated.

1) Frequently trips and falls in the home 3) Places hands on thighs to push up and stand 4) Walks on tiptoes with disproportionately large calves n response to proximal muscle weakness, the calf muscles hypertrophy (pseudohypertrophy) initially and are later replaced by fat and connective tissue. Children with Duchenne muscular dystrophy raise themselves to a standing position using the classic Gower sign/maneuver (placing hands on the thighs to push up to stand) and walk on tiptoes (Options 3 and 5). Parents may also report frequent tripping and falling (Option 1).

A nurse is teaching the parent of an 8-month-old infant who had a febrile seizure about management of future fevers. Which instruction is appropriate to include in the teaching? Bathing an infant in tepid water and placing ice bags under the arms and around the neck are not recommended techniques as these induce shivering, increase metabolic activity, have no antiseizure effects, and cause discomfort for the child.

1. "Give acetaminophen or ibuprofen every 6 hours to control the fever." Simple febrile seizure management typically involves reassurance regarding the benign nature of most febrile seizures, and education about the risk of recurrence and seizure safety precautions (eg, side-lying positioning, removal from harmful environments). Parents should use antipyretics such as acetaminophen or ibuprofen (in children age >6 months) to control fever and make the child more comfortable (Option 1). However, there is no evidence that antipyretics reduce the risk of future febrile seizures. After the administration of antipyretics, additional cooling methods that may be beneficial for reducing fever include applying cool, damp compresses to the forehead; increasing air circulation in the room; and wearing loose or minimal clothing.

The nurse is teaching the parent of a 5-year-old client with newly diagnosed absence seizure disorder. Which of the following statements by the parent would indicate a correct understanding of the teaching? Absence seizures are brief generalized seizures (lasting <20 sec) that occur in children age 4-10. During these episodes, which are often mistaken for inattention, clients maintain postural tone but are unresponsive to vocal or tactile stimulation. Symptoms of impaired consciousness (eg, blank stare) occur suddenly and are followed by an abrupt return to full consciousness.

1. "My child may experience an episode after hyperventilating. Motor automatisms during the seizure are common and can include oral (eg, lip smacking, chewing) or eyelid (eg, blinking, fluttering) movements. Many clients have a personal history of febrile seizures and/or a family history of seizures. Absence seizures are characteristically provoked by hyperventilation (Option 1). Urinary incontinence is associated with tonic-clonic seizures, not absence seizures.

A child with autism spectrum disorder is being admitted to an acute care unit. Which is the most important nursing action? A private room is an appropriate placement; however, the noise and activity from the playroom may be distracting to the child with ASD. (Option 3) A semi-private room near the nurses' station is likely to have a stimulating environment due to the noise, lighting, and work pace in the area

1. Placing the child in a private room away from the nurses' station Children with autism spectrum disorder (ASD) often exhibit sensory processing problems; they may be hyper- or hypo-sensitive to sounds, lights, movement, touch, taste, and smells. A calming environment with minimal stimulation should be provided; a private room away from the nurses' station is the best location. The nurse can also facilitate a calming environment by: - Using a quiet or monotone voice when speaking to the child - Using eye contact and gestures carefully - Moving slowly - Limiting visual clutter - Maintaining minimal lighting - Providing the child with a single object to focus on

The nurse should prioritize monitoring for the development of _____ at this time, which may indicate ____ Treatment depends on the cause but typically includes placement of a ventriculoperitoneal shunt or endoscopic third ventriculostomy. Shaken baby syndrome is a type of abusive head trauma caused by shaking the infant. Clinical manifestations occur due to the brain shifting within the skull (ie, coup-countercoup injury) and include retinal hemorrhage and signs of intracranial bleeding.

1. Unilateral pupil dilation 2. Increased intracranial pressure Clinical manifestations of increased ICP in infancy include unilateral pupil dilation, a bulging fontanel, increasing head circumference, and sunset eyes. In infants, lower brainstem dysfunction can cause a high-pitched, shrill cry and difficulty with feeding coordination. Symptoms can rapidly progress into cardiopulmonary distress, seizures, and somnolence.

Signs of increased intracranial pressure

1. change in behavior, agitation, confusion. 2. decreasing level of consciousness. 3. pupil dilation or construction, pupillary sensory or motor function. 4. INCREASING BP WITH WIDENING OF PULSE PRESSURE. 5. decreasing pulse & respiratory rates. 6. projectile vomiting.

The nurse is assisting with well-child examinations in a pediatric clinic. Which finding requires further evaluation?

3. Lateral curvature to the spine of a 10-year-old girl Scoliosis, one of the most common spinal deformities, is characterized by lateral curvature of the spine and spinal rotation. Although scoliosis may result from congenital or pathologic conditions, it is most often idiopathic (ie, of unknown cause). It is commonly first noticed during periods of rapid growth (ie, early adolescence (10-13 or 10-15). Early detection (ie, screening for girls twice, at age 10 and 12, and boys once at age 13 or 14) and prompt treatment (eg, brace) may reduce the need for surgical intervention (Option 3). ) S3, reflecting rapid filling of the left ventricle, is considered normal in children and young adults (up to age 40). This sound is heard in diastole immediately after S2 as a dull, low-pitched sound. S3 is heard louder in the mitral or apical area, which distinguishes it from a split S2 that is heard best in the pulmonic area.

The nurse is talking about use of a Pavlik harness (soft splint) with the parents of a 2-month-old with developmental dysplasia of the hip. Which of the following information should the nurse include? - a condition where the "ball and socket" joint of the hip does not properly form in babies and young children - the hip joint attaches the thigh bone (Femur) to the pelvis Developmental dysplasia of the hip (DDH) is instability or dislocation of the hip joint that may be present at birth or develop during the first few years of life. A Pavlik harness, the most common nonsurgical treatment method for DDH, maintains the infant's hips in a slightly flexed and abducted position, allowing for proper hip development. Pavlik harnesses are typically worn for about 3-5 months or until the hip joint is stable. The straps are adjusted periodically by the health care provider to account for infant growth.

2. "Check skin folds frequently for redness or irritation." 3."Dress the child in a shirt and knee socks under the straps." 4."Place the diaper under the straps." - Regularly assess the skin under the straps for redness or breakdown (Option 2) - Dress the child in a shirt and knee socks under the harness to protect the skin (Option 3) - Apply the infant's diaper underneath the straps to keep the harness clean and dry (Option 4) Lotions and powders applied to the skin under the straps can cause irritation and excess moisture, which can lead to skin breakdown. The Pavlik harness is usually worn at all times, particularly during the first few weeks of treatment, including during diaper changes.

A 3-month-old child with developmental dysplasia of the hip (DDH) is being fitted for a Pavlik harness. Which statement made by the parent indicates a need for further instruction? The Pavlik harness is the most common tool used to treat early DDH. It maintains the infant's hips in a slightly flexed and abducted position (ie, legs bent and spread apart), allowing for proper hip development (Option 4).

2. "I will adjust the harness straps every 3-5 days." - The straps are assessed every 1-2 weeks by the health care provider (HCP) and adjusted as necessary to account for infant growth. However, parents should not alter the strap placements at home as incorrect positioning can lead to damage to the nerves or vascular supply of the hip (Option 2). - Assess skin 2-3 times daily for redness or breakdown under the straps (Option 3) - Dress the child in a shirt and knee socks under the harness to protect the skin - Apply diapers underneath the straps to keep the harness clean and dry - Leave the harness on at all times, unless otherwise indicated by the HCP (Option 1)

The nurse is evaluating a parent's understanding of home care management for a 2-week-old client after initial cast placement for treatment of congenital clubfoot. Which of the following statements by the parent indicate a correct understanding? Select all that apply.

2. "I will check my baby's toes several times a day to ensure that they are pink and warm." "4."My baby will need to have a new cast applied weekly for 5-8 weeks." 5."When I bathe or diaper my baby, I will be sure to keep the cast dry." Clients with clubfoot typically receive manipulation and stretching of the affected foot and serial casting soon after birth to correct the deformity. The nurse should instruct parents about cast care, which includes monitoring for adequate circulation (eg, toes pink and warm) and keeping the cast dry. Weekly recasting over 5-8 weeks (ie, Ponseti method) is necessary to gradually reposition the foot (Option 4). To maintain the correction after successful casting, the client commonly wears custom shoes secured to a bar brace.

The nurse is preparing for the admission of a 9-year-old client with new-onset tonic-clonic seizures. It is important for the nurse to ensure that what is in the room? Select all that apply. During seizure activity, nothing should be placed in the client's mouth. Placing objects in the mouth could result in injury to the client or health care provider. Maintaining an open airway is important A client should never be restrained during seizure activity. Restraints could cause muscle or tissue injury.

2. Oxygen delivery system 3. Padding on the bed siderails 5. Suction equipment Client safety is a priority when caring for a client with seizure activity. Protecting the airway and improving oxygenation includes turning the client on the side and providing oxygen and oral suctioning as needed. Padding the bed siderails provides the client protection and decreases the potential for injury from the metal in the event that the head or extremities hit the siderails during seizure activity.

The nurse is caring for a 3-month-old infant who has bacterial meningitis. Which of the following clinical findings support this diagnosis? Select all that apply. Bacterial meningitis is an inflammation of the meninges in the brain and spinal cord that is caused by specific types of bacteria, including group B streptococcal, meningococcal, or pneumococcal pathogens. Depressed/sunken fontanelles indicate severe dehydration. The Babinski reflex is a normal expected finding in infants which starts to disappear at age 1. It does not indicate meningitis.

2.High-pitched cry 3.Poor feeding 5.Vomiting Clinical manifestations of bacterial meningitis in clients age <2 include: - Fever or possible hypothermia - Irritability, frequent seizures - High-pitched cry (Option 2) - Poor feeding and vomiting (Options 3 and 5) - Nuchal rigidity - Bulging fontanelle possible but not always present One of the most common acute complications of bacterial meningitis in children is hydrocephalus. Long-term complications include hearing loss, learning disabilities, and brain damage. Due to the severity of potential complications, prompt identification and immediate treatment are vital for any client with suspected bacterial meningitis.

The nurse is caring for an infant with suspected meningitis and preparing to assist with a lumbar puncture. What is the appropriate nursing intervention? Unless the client has improper air exchange, oxygen administration is not needed. The HCP performing the lumbar puncture will feel the spine for correct needle placement and then sterilize and prepare the chosen area for needle insertion. Unless the client is unstable, there is no need to record vital signs every 15 minutes. The client should be awake and alert, and the procedure should be fairly short in duration.

3. Hold the child with the head and knees tucked in and the back rounded out The optimal position for access during a lumbar puncture is to have the client's head and knees tucked in and the back rounded out. This provides the most room for the health care provider (HCP) to perform the procedure and allows for a good hold to keep the client still. A lumbar puncture is a sensitive procedure, and it is important to keep the child from moving during needle insertion (Option 3).

The nurse is caring for an infant with osteogenesis imperfecta admitted with a new fracture. The client also has old fractures in multiple stages of healing but no bruising, abrasions, or redness of the skin. Which nursing intervention should be included in the plan of care? Osteogenesis imperfecta (OI) (brittle bone disease) is a rare genetic condition resulting in impaired synthesis of collagen by osteoblasts. Collagen allows bone to be somewhat flexible while still maintaining strength. Impaired collagen causes bones to be frail and easily fractured. Clinical manifestations can range from mild defects to lethal disease in utero. OI is usually transmitted by autosomal dominant inheritance. Lifting by the ankles or under the arms puts too much pressure on the delicate bones (eg, legs, ribcage). Nonaccidental traumas with fractures (eg, child abuse) are usually associated with soft-tissue injury (eg, bruising, abrasions, redness) from the force of an external source.

3. Obtain blood pressure manually to avoid cuff over-tightening The nurse's priority for a client with OI is careful handling to minimize additional fractures. Care of the infant with OI includes: - Checking blood pressure manually to avoid cuff over-tightening, which may occur with automatic blood pressure cuffs (Option 3) - Lifting the infant by slipping a hand under the broadest areas of the body (eg, back, buttocks) so the pressure is distributed - Repositioning the infant frequently using supportive devices and gel padding to avoid molding of the soft bones of the skull

The clinic nurse is screening children for developmental dysplasia of the hip (DDH). Which finding is consistent with DDH in a 3-week-old client? DDH decreases smooth movement of the femoral head Developmental dysplasia of the hip (DDH) is a set of hip abnormalities ranging from mild dysplasia of the hip joint to full dislocation of the femoral head. Because it is much easier to treat during infancy, DDH screening is a standard assessment for newborns and infants. With DDH, the health care provider (HCP) may note laxity of the hip joint on the affected side which is assessed for using the Barlow and Ortolani maneuvers. However, these maneuvers should only be performed by an experienced HCP to avoid further hip injury; the maneuvers are most reliable from birth to age 4 weeks.

3. Presence of extra gluteal folds on the right side (asymmetry) One of the most notable manifestations of DDH in infants is the presence of asymmetrical or extra gluteal or inguinal folds (Option 3). When the infant is age 6-10 weeks, the Ortolani sign disappears and limited hip abduction can occur as adduction contractures develop. Infants with DDH may experience bilateral hip dislocation, which results in broadening of the perineuM If DDH is not corrected in infancy, the child may walk with a limp or on their toes and develop severe lordosis and/or Trendelenburg sign.

A 4-year-old boy is diagnosed with Duchenne muscular dystrophy. Which nursing teaching is most appropriate to reinforce for this child's parents? Skeletal muscle relaxants such as baclofen (along with benzodiazepines) are used in cerebral palsy to control spasticity and seizures Clients are encouraged to participate in regular gentle recreation-based exercises and swimming to avoid disuse muscle atrophy and social isolation.

3. Remove throw rugs from the home There is no effective cure. Most children are wheelchair bound by adolescence and die by age 20-30 from respiratory failure. It is important to avoid floor clutter (eg, throw rugs) and prevent falls/injury (Option 3).

The parent of a newborn is concerned about the possibility of the child developing hip dysplasia. Which intervention should the nurse encourage to help reduce the risk in this newborn?

3. Swaddle the infant with hips flexed and abducted Key measures include: - Proper swaddling technique - infants should be swaddled with their hips bent up (flexion) and out (abduction), allowing room for hip movement (Option 3) - Choosing infant carriers or car seats with wide bases - infant seats should allow for proper hip positioning in an abducted manner - Avoiding any positioning device, seat, or carrier that causes hip extension with the knees straight and together

The nurse taught the caregiver of a child with a ventriculoperitoneal (VP) shunt about when to contact the health care provider (HCP). The caregiver shows understanding of the instructions by contacting the HCP about which symptom? Ventriculoperitoneal shunting is surgery to treat excess cerebrospinal fluid (CSF) in the cavities (ventricles) of the brain (hydrocephalus). A ventriculoperitoneal (VP) shunt is a cerebral shunt that drains excess cerebrospinal fluid (CSF) when there is an obstruction in the normal outflow or there is a decreased absorption of the fluid. Cerebral shunts are used to treat hydrocephalus. Increased ICP may occur with VP shunt malfunctions. The caregiver must recognize symptoms of vomiting, headaches, vision changes, and changes in mental status. Early intervention by the HCP will decrease the risk of damage to the brain tissue.

3. The child vomits after awakening from a nap and 1 hour later The caregiver of a child with a VP shunt must understand symptoms of increased intracranial pressure (ICP), which indicate shunt malfunction. Vomiting may be a sign of increased ICP and would require that the HCP be contacted. The inability to remember one meal would not indicate a change of mental status. A VP shunt is tunneled under the scalp and can be palpated.

The summer camp nurse and parent of a 9-year-old with juvenile idiopathic arthritis (JIA) are discussing appropriate physical activities for the child. Which of the following activities should be included? Select all that apply.

3.Stationary bicycling 4.Swimming 5.Yoga In general, low-impact, weight-bearing, and non-weight-bearing exercises that involve range of motion and stretching to preserve joint mobility and strengthen muscles are best. High-impact activities and those that cause overtiring and joint pain should be avoided. Swimming is often considered the ideal activity for children with JIA as it allows for exercising a large number of joints with minimal gravitational pull. Other recommended activities include riding a stationary bike, throwing or kicking a ball, low-impact aerobic dancing, walking, and yoga.

cephalohematoma vs caput succedaneum Caput Succedaneum = Cross, Sutures & Symmetrical

Cephalohematoma - swelling caused by bleeding between the osteum and periosteum of the skull DOES NOT CROSS SUTURE LINE - Cephalohematoma occurs when blood collects between the skull and periosteum (ie, outer membrane layer of bone) due to the rupture of blood vessels during delivery, often from forceps- or vacuum-assisted deliveries. Caput Succedaneum - Edematous swelling on the scalp caused by pressure during birth, this swelling may cross suture lines, usually disappears in a few days -Caput succedaneum is benign scalp swelling superficial to the periosteum that is present at birth. Infants with caput succedaneum often have poorly demarcated edema that crosses suture lines.

The client's findings are most likely caused by

Hydrocephalus Hydrocephalus results in the buildup of cerebrospinal fluid (CSF) in the brain due to overproduction, outward flow obstruction (eg, tumor, infection), or decreased reabsorption of CSF. Accumulation of CSF causes the ventricles to become dilated (ie, ventriculomegaly) and to compress the brain tissue against the bony cranium, resulting in increased intracranial pressure. If hydrocephalus is suspected, an MRI or CT scan can confirm the diagnosis. Daily measurements of head circumference should be performed to monitor cranial expansion over time (eg, 2-4 weeks).

The nurse is caring for the client after ventriculoperitoneal shunt placement. For each intervention, click to specify if the intervention is indicated or not indicated for the care of the infant.

Indicated: Assess for abdominal tenderness, Report a temperature ≥100.4 F (38 C), Test the surgical site drainage for the presence of glucose - Assessing for abdominal tenderness:The infant is at risk for postoperative ileus, constipation, and peritonitis because the shunt terminates into the peritoneum. -Infection is one of the most common complications of a VP shunt, especially during the first month following the procedure. Fever may also indicate increasing intracranial pressure. -Testing the surgical site drainage for the presence of glucose: Leaking cerebrospinal fluid contains glucose, whereas normal serous drainage does not. Not Indicated: Place the infant on the affected side -ecause this increases the amount of pressure on the VP shunt valve. Instead, the child should be placed on the unaffected side opposite of the shunt.

The infant is admitted to the hospital. The nurse is preparing the infant for ventriculoperitoneal shunt placement. For each potential intervention, click to specify if the intervention is indicated or not indicated for the care of the client. ventriculoperitoneal (VP) shunt drains excess cerebrospinal fluid (CSF) from the ventricles of the brain into the peritoneum, where the CSF is reabsorbed into the bloodstream. When preparing an infant for VP shunt placement, the nurse should initiate seizure precautions, shave the hair on the infant's head, mark the location where the head circumference was measured, and verify informed consent.

Indicated: Initiate seizure precautions, Shave the hair on the infant's head, Mark the location where the head circumference was measured, Verify the parents' understanding of the indication, risks, alternatives, and right to refuse the procedure Not Indicated: Insert an IV catheter in a scalp vein - For an infant requiring surgical placement of a VP shunt due to hydrocephalus, inserting an IV catheter into a scalp vein is not indicated due to the risk for accidental insertion into the brain

A child in the emergency department had a cast placed on the right arm for a nondisplaced fracture. The client is being discharged home with pain medications. Which statement by the parent indicates that additional teaching is required? Parents of children with casts are taught to check for emergency signs of circulatory impairment, including changes in sensation and motor function, which could indicate early signs of compartment syndrome due to swelling within the confined space of the cast. However, some swelling is expected, so this symptom alone is not indicative of compartment syndrome. An itching sensation under the cast is expected, clients and parents are taught to avoid inserting anything into the cast to scratch the skin. Instead, they should use a hair dryer on the cold setting.

The 6 Ps of compartment syndrome include: - Pain: Increasing despite elevation, analgesics, and ice. Pain will also increase with passive stretching/movement. Increasing pain is an early sign and indicates muscle ischemia (Option 3). - Pressure: Affected extremity or digits are firm and tense; skin is tight and appears shiny. - Paresthesia: Tingling, numbness, or burning sensation, which is also an early sign and indicates nerve ischemia (Option 1). - Pallor: Skin appears pale; capillary refill is >3 seconds. These indicate poor perfusion. - Pulselessness: Pulse distal to injury or compartment is impalpable. Absent pulses are a late sign. - Paralysis: Loss of function or inability to move extremity or digits. Muscle weakness occurs before paraly

Osteomyelitis is a bone infection that occurs in pediatric clients due to hematogenous spread of bacteria through the bloodstream into the well-vascularized metaphysis of long bones (eg, tibia). Inflammation compromises skeletal blood flow, forcing the infectious exudate into cortical and periosteal bone, causing necrosis. Eventually, the areas of dead bone separate from living bone, forming sequestra. Manifestations include fever, pain, tachycardia erythema, and swelling at the affected site.

Without treatment, sepsis can develop. The nurse should obtain a specimen for blood culture and sensitivity to determine the causative pathogen (typically Staphylococcus aureus) and administer antibiotics. Long bone fractures = Cast placement that is too tight can cause compartment syndrome, a limb-threatening emergency caused by decreased perfusion. h sickle cell disease (SCD) may experience acute pain episodes in any part of the body (eg, bone, lungs [acute chest syndrome]) due to vasoocclusion. --> Hydroxyurea increases production of hemoglobin for long-term treatment of SCD. Juvenile idiopathic arthritis is a pediatric autoimmune disorder that causes chronic joint inflammation. Interventions include managing joint pain and inflammation (eg, NSAIDs, corticosteroids) and encouraging daily exercise to reduce joint stiffness and prevent flexion contractures.