Chapter 47: Nursing Care of the Child With an Alteration in Immunity/Immunologic Disorder

A pregnant client who is HIV positive asks the nurse if she will be able to breastfeed the newborn. Which response by the nurse is most appropriate?

"Breastfeeding will increase your newborn's risk of contracting HIV." Rationale: HIV can be transmitted by breastfeeding. A newborn who received the recommended plan of drug treatment has a reduced risk for contracting the infection. Contracting HIV is not an absolute for this newborn. The client should be discouraged from breastfeeding to limit exposure to the newborn. Breastfeeding does provide immunity when the mother is free of infection but not in this scenario. Telling the mother to speak to the health care provider is not the best response as the nurse is able to provide this education to the client.

The parent of a school-age child comments to the nurse, "Every time my child eats enchiladas at our local Mexican restaurant the child gets a rash. It just does not make sense to me." How should the nurse respond?

"Has your child ever been tested for a peanut allergy?" Rationale: Enchilada sauce is an unexpected food that may contain a form of peanuts (such as peanut oil) that may be causing an allergic reaction in the child.

A nurse is conducting a physical examination of a 12-year-old girl with suspected systemic lupus erythematosus (SLE). How would the nurse best interview the girl?

"Have you noticed any hair loss or redness on your face?" Rationale: Alopecia and the characteristic malar rash (butterfly rash) on the face are common clinical manifestations of SLE. Rhinorrhea, wheezing, and an enlarged spleen are not hallmark manifestations of SLE. Petechiae and purpura are more commonly associated with hematological disorders, not SLE.

The nurse is caring for a child with HIV currently taking zidovudine. Which statement by the parent would be the most concerning?

"Zidovudine decreases the chance my child will transmit HIV to others." Rationale: Zidovudine inhibits the replication of HIV and reduces the possibility of maternal-fetal transmission of HIV, but not from person to person. Although side effects like nausea/vomiting, headache, paresthesia, and altered taste are concerning, the parent's lack of understanding that the child can transmit HIV to others is most concerning because this increases risk of exposure to others.

Food allergies have become more and more common in the last few decades. What are some common food allergies of childhood? Select all that apply.

-Milk -Eggs -Peanuts Rationale: Allergies to eggs, peanuts, and milk are common in childhood. Cheerios are made of oats and are not known to be allergenic. Apples also are not allergenic, unlike bananas, which can cause problems for children who have latex allergies.

A nurse is providing education to pregnant women diagnosed with HIV. Which statement indicates the need for further teaching?

Pregnancy will accelerate the progression of the disease. Rationale: Of the nearly 1,000,000 people in the United States infected with HIV, 25% are female. There isn't any research showing pregnancy accelerates the progression of the disease. Women with HIV should not breastfeed, because they could transmit the virus to the baby via the breastmilk. Early use of antiretroviral medications are effective in reducing transmission, and a cesarean birth may be scheduled to reduce potential transmission to the newborn.

The nurse is preparing a care plan for a 4-year-old client newly diagnosed with severe combined immune deficiency. What is the priority goal for this client?

The client will remain free from infection. Rationale: While all of these are goals for the client, the highest priority for the immunocompromised client is to remain free from infection since the client is at a high risk for development of an infection. In the immunocompromised client any infection can be life threatening. Performing hygiene care helps promote cleanliness and decrease infection rates. This age group can do some tasks, but still need assistance. The client is old enough to have a basic understanding of the disorder. The primary goal is focused on remaining infection free and not on activities after discharge at this time.

The nurse is explaining patterns of incidence and transmission of HIV to a group of adolescent girls. She explains that the risks for this population are much higher because of the possibility of both vertical and horizontal transmission. Horizontal transmission refers to transmission of the disease during:

sexual contact. Rationale: Horizontal transmission refers to person-to-person transfer of the virus. Transmission by feeding with breast milk, birthing, and pregnancy are all examples of vertical transmission.

The nurse is caring for a 6-month-old infant with Wiskott-Aldrich syndrome. Which teaching does the nurse provide the parent?

"Do not insert anything in the rectum." Rationale: Children with Wiskott-Aldrich syndrome should not be given rectal suppositories or temperatures since these children are at a high risk for bleeding. Tub baths are not contraindicated. Pacifiers are not contraindicated in Wiskott-Aldrich but should be kept as sanitary as possible to avoid oral infections.

To avoid anaphylactic reactions in children, which question would be most important to ask a parent before administering penicillin to her infant?

"Has she ever had penicillin before?" Rationale: Penicillin is a drug frequently involved in allergic reactions. The reaction occurs after the child has first been sensitized to the drug.

The nursing instructor has completed a presentation on normal immune function. Which statement by a student would suggest a need for further education?

"Humoral immunity is generally functional at birth." Rationale: Normal immune function is a complex process involving phagocytosis (process by which phagocytes swallow up and break down microorganisms), humoral immunity (immunity mediated by antibodies secreted by B cells), cellular immunity (cell-mediated immunity controlled by T cells), and activation of the complement system. Cellular immunity is generally functional at birth, and as the infant is exposed to various substances over time, humoral immunity develops.

The nurse is caring for a young child with HIV. Which nursing intervention is priority for this child?

Administer prescribed medications. Rationale: Although assisting with activities, assessing pain, and reviewing CD4 counts are all important, the priority when caring for a child with HIV is to administer prescribed medications. Prescribed medications prevent progressive deterioration of the immune system and provide prophylaxis against opportunistic infections.

A school-aged child, who is allergic to bee stings, states, "I think I was stung by a bee outside." Which intervention by the school nurse is most appropriate?

Assess the client for signs of anaphylactic shock Rationale: First, the nurse will assess the client for signs of anaphylactic shock and then administer epinephrine if warranted. Epinephrine counteracts histamine release to decrease bronchospasm and difficulty breathing. If there were no signs of anaphylactic shock, the nurse would determine if the child was actually stung. The nurse would apply ice to promote vasoconstriction once the client was stable.

The nurse is helping the parents of a toddler identify foods that are causing allergic symptoms in the child. Which strategy should the nurse encourage the parents to use?

Elimination diet Rationale: An elimination diet is a traditional method to detect food allergens. Parents feed the child only foods that rarely cause allergy, such as rice, lamb, carrots, peas, and sweet potatoes, for about 7 days. Then they add, one by one, at 2- to 3-day intervals, foods that are suspected of causing allergy. When a food is introduced this way, the child must be encouraged to eat a lot of it that day. If symptoms occur, the food is then eliminated from the child's meals on a permanent basis. If no symptoms occur, the child can continue to eat the food. Hyposensitivity testing is unreliable with food allergies. Corticosteroids delay hypersensitivity reactions. It is difficult to totally eliminate protein from the diet, and this is not a method to determine the cause of food allergies in the toddler.

When describing anaphylaxis to a group of parents whose children have experienced anaphylaxis from insect stings, the nurse integrates knowledge that this response is related to which immunoglobulin?

IgE Rationale: Anaphylaxis is an acute IgE-mediated response to an allergen that involves many organ systems and may be life-threatening.

The nurse is caring for a school-age child recently diagnosed with an allergy to peanuts. Which nursing action is a priority?

Include the child when discussing foods that contain peanuts. Rationale: Involving school-age children in education related to their allergy helps them play an active role in their own care. Involving the child in teaching also helps to plan nursing care that meets QSEN competencies and also best meets the family's needs. Although advising parents the child may benefit from skin testing of other allergies, informing the child's school of the peanut allergy, and offering information about community support groups are important, involving the child in education is the best method to prevent exposure to the allergen.

The nurse is providing teaching for the parents of a child with a latex allergy. The nurse tells the client to avoid which food?

bananas Rationale: The nurse should instruct children and their families to avoid foods with a known cross-reactivity to latex, such as bananas.

When providing discharge instructions to a child who was admitted to the hospital following stridor, wheezing, and urticaria after taking penicillin, which nursing action is priority?

Encourage the child to wear a medical alert bracelet for penicillin. Rationale: Oral medications most likely to cause an allergic reaction include antibiotics, acetylsalicylic acid (aspirin), and NSAIDs. Children experiencing stridor, wheezing, and urticaria after taking a medication most likely have an allergy to that medication. The priority nursing action for discharge education is to prevent the child from being exposed to penicillin again, which could be accomplished by encouraging the child to wear a medical alert bracelet. Although children with atopic diseases are more likely to have medication allergies, requesting parents have the child evaluated is not a priority. Questioning the child about the amount of penicillin taken and educating parents about the side effects of penicillin is not a priority.

The nurse in the emergency department is examining an 18-month-old child who recently received a first dose of penicillin. The nurse notes lip edema, urticaria, stridor, and tachycardia. Which action will the nurse take next?

Administer epinephrine. Rationale: The nurse would suspect the child is experiencing anaphylaxis and administer epinephrine. Lip edema, urticaria, stridor, and tachycardia are common clinical manifestations of anaphylaxis. CPR is not indicated; the child is still breathing and has a heart rate at this time. The nurse would want to ensure IV access is obtained and have intubation equipment at hand; however, these are not priority.

The nurse is caring for a child who is receiving a skin test to determine the presence of allergies. A positive skin test for one particular allergen shows the mediation of which type of immune globulin?

IgE Rationale: Skin testing is done to detect the presence of IgE in the skin that responds to a particular allergen. IgM is part of the body's primary response, and IgG is part of the body's secondary response to infection. IgA is present in the mucous membranes of the body to fight against infection.