Chapter 51: Nursing Care During a Pediatric Emergency

The child presents to the emergency department via ambulance in uncompensated SVT at a rate of 262 beats per minute. The nurse receives an order to administer adenosine IV. In addition to adenosine, what would the nurse bring to the bedside in preparation to administer the adenosine? a consent form for the child or parent to sign a blood pressure cuff in the appropriate size an emesis basin for the child to use if vomiting a generous saline flush to follow the IV medication

a generous saline flush to follow the IV medication RATIONALE: Adenosine IV is given rapidly (over 1 or 2 seconds) and is followed by a generous saline flush followed by a rapid (to ensure the medication has entered the vessel). The nurse would assess the child's blood pressure but not specifically in relation to the administration of adenosine. The parents would not sign a consent form for this medication. Vomiting is not a side effect of adenosine.

The nurse is conducting an educational class regarding the use of the intraosseous site for administration of fluid to the pediatric client experiencing an emergency, such as shock. What would the nurse include in this educational presentation? The intraosseous site is used only for crystalloid fluids such as normal saline. The intraosseous site is preferred if peripheral access cannot be attained rapidly. The nurse will utilize a small gauge catheter for children, such as a 25 gauge. The child must be in a left-side lying position with the spine flexed to access properly.

The intraosseous site is preferred if peripheral access cannot be attained rapidly. RATIONALE: The intraosseous site is preferred if peripheral access cannot be obtained in 90 seconds. The child would be positioned so the nurse can readily access the bone rather than in a position with the spine flexed. The access site is not related to the spine. The intraosseous needles are generally 15 to 18 gauge. Any fluids or medications that can be infused via a peripheral site can be given via an intraosseous site.

The nurse is planning to provide education on injury prevention to caregivers of toddlers. Which information will the nurse include in the session? Select all that apply. sports safety burn prevention poisoning prevention car seat safety water safety

burn prevention poisoning prevention car seat safety water safety RATIONALE: Common causes of unintentional injuries and death in the toddler age group include motor vehicle crashes, drowning, burns, and poisoning. Sports safety and the use of protective equipment are more important for older children.

The nurse is attempting to establish peripheral vascular access in a child requiring pediatric advanced life support. The decision to use the intraosseous route would be made if the nurse were unsuccessful after how many attempts within 90 seconds? five four two three

three RATIONALE: No more than three attempts should be made within 90 seconds to obtain peripheral vascular access.

The nurse has completed teaching a CPR course for a local day care. Which statement by a participant indicates a need for further education? "I will compress 30 times and then give 2 breaths if I have to give CPR to an infant." "I will place the heel of my hand on the sternum of a 9-month-old when performing CPR." "I will use one hand to compress the chest of a toddler." "I will compress 30 times and then give 2 breaths if I am giving CPR to a child or infant."

"I will place the heel of my hand on the sternum of a 9-month-old when performing CPR." RATIONALE: The correct hand placement for an infant is two fingers placed one fingerbreadth below the nipple line. Placing the heel of one hand on the sternum is the correct placement for a child.

The nurse is assessing the respiratory status and lungs of a 6-year-old child. What finding would the nurse report immediately? Low-pitched bronchial sounds over the periphery High-pitched breath sounds over the trachea Resonance over the lungs on percussion Minimal air movement through the lungs

Minimal air movement through the lungs RATIONALE: Minimal or no air movement requires immediate intervention because this child's status is severely compromised. Breath sounds over the trachea typically are high pitched. Breath sounds over the peripheral lung fields are lower pitched. Normally percussion over air-filled lungs reveals resonant sounds.

A nurse is preparing discharge instructions for a child treated for ingestion of an unknown amount of ibuprofen. The child was treated with an activated charcoal gastric lavage. Which piece of information should the nurse include to provide anticipatory guidance to the parent? The child will continue taking the chelating agent. The mouth sores will heal over several weeks. Blood tests will be needed to check liver function. Stools will be black in color for the next few days.

Stools will be black in color for the next few days. RATIONALE: Activated charcoal is a gritty black substance that binds with the ingested substance in the bowel and is excreted in the stools. It is important to give parents this information so they do not mistake the color for tarry stools, which indicate blood. The child would return for liver function tests if acetaminophen had been ingested. A chelating agent is treatment for lead poisoning and is not associated with ibuprofen ingestion or treatment with activated charcoal. Mouth sores are not associated with ibuprofen ingestion or activated charcoal. However, they are associated with the ingestion of corrosive agents such as batteries and some household cleaners.

The nurse receives shift report from the previous shift on several pediatric clients. For which child would the nurse further assess the electrolyte levels immediately following report? the 10-year-old preparing for discharge following a near-drowning 4 days ago the 18-month-old experiencing unrelenting pain from a fractured femur the 15-year-old who had a resolved episode of ventricular tachycardia the previous shift the 5-year-old post-op day #3 following repair of a traumatic injury to her spleen

the 15-year-old who had a resolved episode of ventricular tachycardia the previous shift RATIONALE: Abnormalities of potassium and hypokalemia have been associated with the development of ventricular tachycardia in children. The other clients' electrolyte levels would require monitoring but there would be no expected deviation.

The health care team prepares to intubate a child. Prior to insertion of the endotracheal tube, what drug should the nurse administer to reduce the risk of increased intracranial pressure during intubation? opioid medication anticholinergic drug neuromuscular blocking agent anesthetic agent

opioid medication RATIONALE: Premedicating a child for pain prior to endotracheal intubation is important to decrease intracranial pressure, minimize vagal stimulation causing bradycardia, prevent hypoxia, and minimize the effects of passing the tube. An anticholinergic medication such as atropine decreases respiratory secretions and the vagal effects of the intubation. An anesthetic agent such as lidocaine can increase intracranial pressure. Neuromuscular blocking agents such as rocuronium and vecuronium prevent movements during the intubation and are especially useful when there is a precarious airway, such as in the child with epiglottitis or facial trauma.

A 12-year-old boy has broken his arm and is showing signs and symptoms of shock. Which action should the nurse take first? Provide oral analgesics as ordered. Establish a suitable IV site. Begin hyperventilation. Draw blood for type and cross-match.

Establish a suitable IV site. RATIONALE: The goal of treating shock is to restore circulating blood volume. This requires that vascular access be obtained to administer fluids and vasoactive drugs. Hyperventilation is reserved for temporary treatment of severe intracranial pressure. Analgesics should not be administered prior to neurologic and cardiovascular examination being performed. Chelation therapy is a treatment for metallic poisoning.

A nurse is providing care to a child with a depressed skull fracture. The child has fluid draining from the nose. The nurse confirms the fluid is cerebrospinal fluid based on which finding? The fluid is light yellow in color. The fluid is thick with red specks. The fluid tests positive for glucose. The fluid is clear and watery.

The fluid tests positive for glucose. RATIONALE: To confirm if the fluid is CSF or rhinitis from nasal secretions, the nurse would test the fluid with a glucose reagent strip. CSF will test positive for glucose, whereas the clear, watery drainage from an upper respiratory tract infection or allergy will not. The color of the fluid does not confirm if it is CSF. Cerebrospinal fluid is thin and watery, not thick.

The nurse is caring for a child in an emergency situation. When placing a cardiac monitor on the child, the nurse notes wide QRS complexes with no P waves. The child does not have a pulse. What interventions should be performed on this child? Select all that apply. adenosine defibrillation epinephrine CPR atropine

defibrillation epinephrine CPR RATIONALE: A child presenting with no pulse and an ECG monitor showing wide QRS complexes with no P waves is in pulseless ventricular tachycardia. Treatment for this arrhythmia includes CPR, defibrillation, epinephrine, and treatment of the underlying cause. Atropine is used to treat bradycardias. Adenosine is used to treat supraventricular tachycardias.

The nurse is preparing an in-service program on pediatric cardiopulmonary resuscitation. The nurse would include a discussion that cardiopulmonary arrest in infants and children is most likely the result of: respiratory failure. underlying heart disease. neurologic trauma. lethal arrhythmia.

respiratory failure. RATIONALE: Cardiopulmonary arrest in infants and children typically results from disorders that lead to respiratory failure and shock. In adults, the most common causes of cardiopulmonary arrest are lethal arrhythmias secondary to heart disease. Although neurologic trauma can lead to respiratory failure, it alone is not the most likely factor.

A nurse is assessing a child brought to the emergency department. The child has a fever of 102.4°F. (39.1°C). The nurse continues the assessment, integrating knowledge that which of the following reflects the effect of fever on the basal metabolic rate? bradycardia tachypnea decreased oxygen demand bradypnea

tachypnea RATIONALE: Fever increases the basal metabolic rate, resulting in tachycardia, tachypnea, and increased oxygen demand.

The nurse is caring for a 7-year-old client who suffered extensive burns from a house fire. Which finding in the client's history most concerns the nurse? The child appears withdrawn and frightened. The child was home alone when the fire started. The child was trapped in a burning bedroom. The child's clothing was burned when exiting the home.

The child was trapped in a burning bedroom. RATIONALE: When a child is confined in a closed space during a fire, the child can inhale a great deal of smoke, causing respiratory tract burns or irritation. This would lead the nurse to further assess for respiratory complications, which is a priority at this time. Burned clothing could indicate burns of the child's body and requires further assessment. However, this is not a priority over assessing the client's airway and ability to breathe. The client appearing withdrawn and frightened and being home alone at such a young age would be concerning to the nurse and warrant follow-up once the client is determined to be stable.

The nurse is collecting a brief health history from the parents of a 3-year-old child brought to the emergency department experiencing a cardiac emergency. What questions are appropriate for inclusion? Select all that apply. "What foods or drugs is your child allergic to?" "Tell me about any coughing or wheezing you may have noticed when your child has been playing lately." "Has your child had any recent illnesses?" "How many children live in the home?" "What activities does your child like to do?"

"What foods or drugs is your child allergic to?" "Tell me about any coughing or wheezing you may have noticed when your child has been playing lately." "Has your child had any recent illnesses?" RATIONALE: When a child is being treated for a cardiac emergency a brief health history is needed. This history must highlight possible problems and causes of the illness being experienced. Questions about recent illnesses can show possible links to the cardiac emergency. Information about drug and food allergies is needed as this child will likely need to receive medications and knowing potential allergies is of importance. Wheezing and coughing may signal cardiac or respiratory concerns and should be investigated. The number of children in the home and activities the child enjoys are of interest but are not of emergent value.

A child is to undergo synchronized cardioversion. The child weighs 44 lb (20 kg). The nurse would expect how many joules to be delivered? 10 to 20 joules 2 to 4 joules 30 to 40 joules 5 to 10 joules

10 to 20 joules RATIONALE: Energy for cardioversion is delivered at 0.5 to 1 joule/kg. The child weighs 44 lb or 20 kg. Therefore, the child would receive 10 to 20 joules.

The nurse is assessing a child with a suspected head injury. The child opens the eyes only in response to the nurse placing pressure in the child's nail bed. What score on the Glasgow coma scale for eye opening should the nurse assign based on this assessment finding? 4 3 1 2

2 RATIONALE: In the eye opening section of the Glasgow coma scale, eye opening only in response to painful stimuli would be a score of 2. Spontaneous eye opening is a 4, opening in response to speech is a 3, and no eye opening in response to painful stimuli is a 1.

A 4-year-old girl has been admitted to the emergency department after accidently ingesting a cleaning product. Which treatment is most likely appropriate in the immediate treatment of the girl's poisoning? Inducing vomiting Administration of activated charcoal Gastric lavage Intravenous rehydration

Administration of activated charcoal RATIONALE: Activated charcoal is the most common treatment for many poisonings and is more effective and safe than induced vomiting or gastric lavage. Rehydration is likely necessary, but this does not actively treat the girl's poisoning.

The nurse notes tachycardia on the cardiac monitor of the pediatric client. What would the nurse further assess for this child? Select all that apply. fluid volume status constipation oxygen saturation pain body temperature

fluid volume status oxygen saturation pain body temperature RATIONALE: Pain, fever, hypoxia, and hypovolemia are common reasons for the child to be tachycardic. Diarrhea, not constipation, would lead to increased fluid loss and thus be considered as a reason for tachycardia.

A nurse is providing care to a child hospitalized after an accident that resulted in a substantial loss of blood. The nurse is preparing to administer IV fluids using a 60-milliliter syringe attached to the child's IV site. The child's parent asks the nurse why there is no IV bag hanging. What is the best response for the nurse to make? "I need to administer small amounts of fluid as quickly as possible." "Your child is too young to receive IV fluids by that method." "Children need much less fluid than adults." "Hanging an IV bag would cause the infusion to flow too quickly."

"I need to administer small amounts of fluid as quickly as possible." RATIONALE: Children who require fluid resuscitation should receive several small boluses over short periods of time (20 ml/kg over 5 to 10 minutes). Infusing the fluid via gravity would be too slow for resuscitation purposes. Children are not too young to receive IV infusions via a more traditional method. Children may need less fluid overall than adults but that is not the rationale for using a syringe for fluid resuscitation.

The nursing instructor is speaking with a group of nursing students about rapid cardiopulmonary assessment. Which statement by a student would indicate a need for further education? "An interosseous needle will need to be inserted if a peripheral IV access cannot be obtained within 90 seconds in a child." "I will place the child on a cardiac monitor. I will use this to assess the child's heart rate." "If a child receiving 100% oxygen by mask does not improve, I will need to perform assisted ventilation with a bag-valve-mask device." "For an infant, I use the brachial artery to check for a pulse."

"I will place the child on a cardiac monitor. I will use this to assess the child's heart rate." RATIONALE: Always evaluate the presence of a heart rate by auscultation of the heart or by palpation of central pulses. Never use the cardiac monitor to determine if the child has a heart rate. The presence of a cardiac rhythm is not a reliable method for evaluation of the ability to perfuse the body. If a child does not improve with 100% oxygen, the next step is to administer oxygen via a bag-valve-mask. The brachial artery is the correct place to check for a pulse in an infant. Establishment of IO access should be attempted if a peripheral IV is not able to be obtained within 3 attempts or 90 seconds.

A 6-year-old girl who is being treated for shock is pulseless with an irregular heart rate of 32 bpm. Which intervention is priority? Give three doses of epinephrine. Initiate cardiac compressions. Administer two consecutive defibrillator shocks. Defibrillate once followed by three cycles of cardiopulmonary resuscitation (CPR).

Initiate cardiac compressions. RATIONALE: The American Heart Association (AHA) emphasizes the importance of cardiac compressions in pulseless clients with arrhythmias, making this the priority intervention in this situation. Current AHA recommendations are for defibrillation to be administered once followed by five cycles of CPR. The AHA now recommends against using multiple doses of epinephrine because they have not been shown to be helpful and may actually cause harm to the child.

The nurse plans to educate the parents of a child experiencing septic shock about the purpose of administering dobutamine intravenously to their child. What would the nurse include in this educational plan? Dobutamine will work to eliminate the bacteria causing the infection. Dobutamine is used to provide vasodilation, thus increasing blood pressure. Dobutamine will work to dry secretions and inhibit serotonin and histamine. Dobutamine is used to improve cardiac contractility.

Dobutamine is used to improve cardiac contractility. RATIONALE: Dobutamine improves the contractility of the heart muscle during shock. The medication is not an antibiotic. Vasodilation would result in lower blood pressure. Atropine (anticholinergic) increases cardiac output, dries secretions, and inhibits serotonin and histamine.

A 10-year-old child comes to the emergency department as a victim of abuse. The child's parent reports that the child was hit repeatedly with a baseball bat a few hours prior. The initial assessment indicates the child's blood pressure is 84/40 mm Hg. The nurse would further assess the child for what finding? allergies, specifically any history of anaphylactic reactions injuries resulting in ongoing blood loss signs of septic shock resulting from infection history of cardiac structural heart disease or arrhythmias

injuries resulting in ongoing blood loss RATIONALE: The child has a lower than normal blood pressure and is in hypovolemic shock, secondary to blood loss from a major injury. The nurse would further assess the child for sources of blood loss, including obvious external injuries that are bleeding and those that may not be visible, causing internal blood loss. The child's body should be assessed for malformation (ex: fractured femur), swelling, redness, and pain of the extremities. The child's abdomen should be assessed for signs of internal injury/blood loss in the abdominal cavity (distention, skin discoloration, redness, bowel sounds). The child was injured a few hours prior, so it is unlikely the source of the low blood pressure would be a septic shock, as the injuries are too recent for infection to be present yet. The child's history indicates obvious injuries sustained from a baseball bat, so the nurse would not immediately assess for cardiogenic shock (usually caused by structural heart disease) or anaphylaxis (caused by allergies).

The nurse is caring for a child who is critically ill and requiring fluid resuscitation. Which intravenous fluids are appropriate for use? Select all that apply. 10% dextrose in water 5% lactated Ringer's 5% dextrose in water lactated Ringer's normal saline

lactated Ringer's normal saline RATIONALE: If the circulation or perfusion is compromised, then fluid resuscitation is necessary. Establish large-bore intravenous (IV) access immediately and administer isotonic fluid rapidly. Lactated Ringer's solution and normal saline are isotonic solutions. 5% and 10% dextrose in water and 5% lactated Ringer's solutions are hypertonic and not appropriate for use in this scenario.

The nursing instructor is speaking with a group of nursing students about defibrillation and cardioversion. Which statement by a student would indicate a need for further education? "The initial energy amount for defibrillation is 4 joules/kg." "Defibrillation uses electricity to depolarize the cells of the myocardium to help stop abnormal life-threatening cardiac rhythms." "During synchronized cardioversion, the electrical current is applied on the R wave of the electrocardiogram." "Medications may be used along with medications to treat supraventricular tachycardia."

"The initial energy amount for defibrillation is 4 joules/kg." RATIONALE: The initial energy amount for defibrillation is 2 joules/kg; it can be increased up to 4 joules/kg for defibrillation for subsequent shocks. Defibrillation uses electricity to depolarize the cells of the myocardium to help stop life-threatening cardiac rhythms. The electrical current is applied to the R wave during synchronized cardioversion. Medications may be used to enhance cardioversion.

A community health nurse is planning a class on water safety for families. What information is important for the nurse to include in the class? Select all that apply. It is important for adult supervision at poolside at all times. Children who have learned to swim require less supervision. Small inflatable wading pools are safe options for toddlers. Personal floatation devices are recommended for children riding in boats. The family needs to maintain fencing around pools to deter unsupervised swimming

It is important for adult supervision at poolside at all times. Personal floatation devices are recommended for children riding in boats. The family needs to maintain fencing around pools to deter unsupervised swimming RATIONALE: Information that is important for the nurse to include in a water safety class includes the importance of adult supervision for children at poolside, maintaining fencing around pools, and the use of personal floatation devices for children riding in boats. Toddlers can easily drown in a few inches of water so inflatable wading pools can be as hazardous as a full sized pool. Parents and children sometimes misjudge the child's swimming abilities, so children will still require supervision.

The nurse cares for a child injured in an automobile accident. Based on the principles of emergency pediatric care, the nurse will initiate which action? applying a cardiac monitor to determine heart rate assessing the carotid pulse for 10 to 20 seconds preparing to use defibrillation to treat asystole using the jaw-thrust technique to position the airway

using the jaw-thrust technique to position the airway RATIONALE: The principles of pediatric emergency care place emphasis on maintaining the child's airway before moving on to breathing and cardiac function. Because children usually have healthy hearts, they often suffer cardiopulmonary arrest from deterioration of respiratory status. The child was involved in an automobile accident and cervical spine injury has not been ruled out. Thus, a jaw-thrust maneuver is utilized first to position the airway. The nurse will assess the pulse after airway and breathing, but for no more than 10 seconds. The nurse will evaluate the presence of a heart rate by auscultation or palpation, and not by using a cardiac monitor (due to pulseless rhythms). Asystole is treated with cardiopulmonary resuscitation (CPR) and epinephrine after lead placement is verified, and not with defibrillation.