Exam 202 Exam 4 SATA

When teaching the parents of a child diagnosed with tetralogy of Fallot about the cardiac defects involved with this condition, which defects should the nurse describe? Select all that apply. A. right ventricular hypertrophy B. aortic valve stenosis C. ventricular septal defect D. overriding aorta E. atrial septal defect F. pulmonary stenosis

A. right ventricular hypertrophy C. ventricular septal defect D. overriding aorta F. pulmonary stenosis Tetralogy of Fallot involves four defects: right ventricular hypertrophy, ventricular septal defect, overriding aorta, and pulmonary stenosis. Aortic valve stenosis and atrial septal defect are not components associated with this condition.

A nurse is caring for a 3-year-old child with viral meningitis. Which signs and symptoms does the nurse expect to find during the initial assessment? Select all that apply. A. bulging anterior fontanel B. fever C. nuchal rigidity D. petechiae E. irritability F. photophobia

B. fever C. nuchal rigidity E. irritability F. photophobia Common signs and symptoms of viral meningitis include fever, nuchal rigidity, irritability, and photophobia. A bulging anterior fontanel is a sign of hydrocephalus, which isn't likely to occur in a toddler because the anterior fontanel typically closes by age 24 months. A petechial, purpuric rash may be seen with bacterial meningitis.

A 15-month-old has just received routine immunizations, including DTaP, IPV, and MMR. What information would the nurse give to the parents before they leave the office? Select all that apply. A. Minor symptoms can be treated with acetaminophen. B. Analgesics for discomfort are suggested following arrival home. C. Call the office if the toddler develops a temperature above 103°F (39.4°C), seizures, or difficulty breathing. D. Discomfort at the immunization site and mild fever are common. E. The immunizations prevent the toddler from contracting associated diseases. F. The toddler should restrict activity for the remainder of the day.

A. Minor symptoms can be treated with acetaminophen. C. Call the office if the toddler develops a temperature above 103°F (39.4°C), seizures, or difficulty breathing. D. Discomfort at the immunization site and mild fever are common. Minor symptoms, such as soreness at the immunization site and mild fever, can be treated with acetaminophen or ibuprofen. While some infants may experience discomfort, not all do; thus, analgesics are only given per healthcare provider guidelines and not routinely suggested to all. The parents would notify the clinic if serious complications (such as a fever above 103°F [39.4°C], seizures, or difficulty breathing) occur. Minor discomforts, such as soreness and mild fever, are common after immunizations. Immunizing the child decreases the health risks associated with contracting certain diseases; it does not prevent the toddler from acquiring them. Although the child may prefer to rest after immunizations, it is not necessary to restrict activity.

Parents bring a 10-month-old boy with myelomeningocele and hydrocephalus with a ventriculoperitoneal shunt to the emergency department. His symptoms include vomiting, poor feeding, lethargy, and irritability. What interventions by the nurse are appropriate? Select all that apply. A. Weigh the child. B. Listen to bowel sounds. C. Palpate the posterior fontanel. D. Obtain vital signs. E. Assess pitch and quality of the child's cry.

A. Weigh the child. B. Listen to bowel sounds. D. Obtain vital signs. E. Assess pitch and quality of the child's cry. Common shunt complications are obstruction, infection, and disconnection of the tubing. The signs presented by the child indicate increased intracranial pressure from a shunt malfunction, which could be caused by an infection, such as peritonitis or meningitis. By listening to bowel sounds, the nurse will note if peritonitis might be a possibility. Intracranial pressure manifests as a bulging or taut anterior fontanel, but the posterior fontanel is typically closed. Obtaining vital signs would assess for signs of infection, such as elevated temperature or, possibly, Cushing's triad (elevated blood pressure, slow pulse, and depressed respirations). A high-pitched cry is a sign of increased intracranial pressure. Weighing the child, while it would not help identify the cause of the problem, would help determine the severity of the dehydration from vomiting.

Which assessment findings should lead the nurse to suspect that a toddler is experiencing respiratory distress? Select all that apply. A. coughing B. respiratory rate of 35 breaths/minute C. heart rate of 95 beats/minute D. restlessness E. malaise F. diaphoresis

A. coughing B. respiratory rate of 35 breaths/minute D. restlessness F. diaphoresis Coughing, especially at night and in the absence of an infection, is a common symptom of asthma. Early signs of respiratory distress include restlessness, tachypnea, tachycardia, and diaphoresis. Other signs also include hypertension, nasal flaring, grunting, wheezing, and intercostal retractions. A heart rate of 95 bpm is normal for a toddler. Malaise typically does not indicate respiratory distress.

The nurse is monitoring an infant with meningitis for signs of increased intracranial pressure (ICP). The nurse should assess the infant for which signs and symptoms? Select all that apply. A. irritability B. headache C. mood swings D. bulging fontanel E. emesis

A. irritability D. bulging fontanel E. emesis Irritability, bulging fontanel, and emesis are all signs of increased ICP in an infant. A headache may be present in an infant with increased ICP; however, the infant has no way of communicating this to the parent. A headache is an indication of increased ICP in a verbal child. An infant cannot exhibit mood swings; this is indicative of increased ICP in a child or adolescent.

Which signs and symptoms would lead the nurse to suspect a child has tetralogy of Fallot (TOF)? Select all that apply. A. murmur B. history of squatting C. bounding pulse D. cyanosis E. faint pulse F. tachypnea

A. murmur B. history of squatting D. cyanosis F. tachypnea TOF is a heart condition with four defects: pulmonic stenosis, right ventricular hypertrophy, ventricular septal defect, and an overriding aorta. A systolic murmur, cyanosis, and tachypnea are all symptoms of TOF. Toddlers with uncorrected defects instinctively squat (knee-chest position) to decrease the return of systemic venous blood to the heart. Coaractation of the aorta is a narrowing in the descending aorta, obstructing the systemic blood outflow. Infants with severe constriction may present with faint pulse in lower extremities and bounding upper extremities pulses.

A nurse is reviewing an infant's progress notes. Progress notes: Four-month-old infant admitted last evening. Wt: 4.95 kg. (10%) Ht: 66 cm (95%), Frequent episodes of bradycardia, tachypnea. Breastfeeding every 4 hours for 30 minutes on each side. What notations would lead the nurse to suspect that this infant has a ventricular septal defect? Select all that apply. A. tachypnea B. plots at 95th percentile for height on growth chart C. plots at the 10th percentile for weight on growth chart D. bradycardia E. increased length of time to finish breastfeeding

A. tachypnea C. plots at the 10th percentile for weight on growth chart E. increased length of time to finish breastfeeding Children with a ventricular septal defect usually present with symptoms of heart failure, poor growth and development, and failure to thrive. They also have difficulty feeding due to their decreased cardiac output and tachypnea.

A parent brings her 6-year-old daughter to the pediatrician's office for evaluation. The child recently started wetting the bed and running a low-grade fever. A urinalysis is positive for bacteria and protein. A urinary tract infection (UTI) is diagnosed, and the child is prescribed antibiotics. Which nursing interventions are appropriate? Select all that apply. A. Limit fluids for the next few days to decrease the frequency of urination. B. Assess the parent's understanding of UTI and its causes. C. Instruct the parent to administer the antibiotic as prescribed, even if the symptoms diminish. D. Provide instructions only to the parent, not the child. E. Tell the parent to have the child wipe the back to the front after voiding and defecation.

B. Assess the parent's understanding of UTI and its causes. C. Instruct the parent to administer the antibiotic as prescribed, even if the symptoms diminish. Assessing the parent's understanding of UTI and its causes provides the nurse with a baseline for teaching. The full course of antibiotics must be taken to eradicate the organism and prevent recurrence, even if the child's signs and symptoms decrease. Fluids should be encouraged, not limited, to prevent urinary stasis and help flush the organism from the urinary tract. Instructions should be given at the child's level of comprehension to help the child better understand the treatment and promote compliance. The child should wipe from the front to the back, not back to front, to minimize the risk of contamination after elimination.

A toddler admitted in respiratory distress keeps pulling at the oxygen mask, trying to remove it. Which interventions are indicated? Select all that apply. A. Restrain the child. B. Have the parent read to the child. C. Administer a sedative. D. Encourage the parent to hold the child. E. Tell the child the mask will help him breathe better. F. Ask the parent to leave the child's bedside.

B. Have the parent read to the child D. Encourage the parent to hold the child. Children in respiratory distress need to be kept as quiet as possible to decrease respiratory and heart rates. Toddlers need a parent with them for security. The best way to quiet toddlers is to read to or hold them. Restraints increase heart and respiratory rates. A sedative will mask the signs of further respiratory distress. Although you could tell toddlers that a mask will help with breathing, they cannot understand the rationale and thus fully comprehend its importance. Asking the parents to leave the bedside will most likely result in greater upset, further contributing to respiratory distress.

A client is born with severe tetrology of Fallot and transferred to a pediatric hospital. The nurse caring for the client anticipates administering which medications during, or to prevent, a "tet spell?" Select all that apply. A. indomethacin B. morphine sulfate C. propranolol hydrochloride D. prednisone E. digoxin

B. morphine sulfate C. propranolol hydrochloride The nurse would expect to administer propranolol as a preventive measure, and morphine sulfate during a tet spell to decrease infundibular spasm. Indomethacin is used to relieve pain, swelling, and joint stiffness; prednisone is used for suppressing the immune system and inflammation; and digoxin is a drug used to treat congestive heart failure.

A nurse is completing a physical assessment of a neonate following birth. When completing the musculoskeletal assessment, which findings would indicate developmental dysplasia of the hip (DDH)? Select all that apply. A. negative Ortolani test B. positive Barlow test C. asymmetrical leg skin folds D. limitation in adduction of the affected leg E. lengthening of the affected leg

B. positive Barlow test C. asymmetrical leg skin folds Developmental dysplasia (dislocation) of the hip is an abnormal formation of the hip joint in which the ball on the top of the femur is not held firmly in the socket. A neonate with DDH will have a positive Ortolani test, a positive Barlow test, and asymmetrical skin folds in the thigh. The affected leg has limited abduction and appears shorter than the unaffected leg in a neonate with DDH.