Passpoint: Toddler
When teaching the mother of a 17-month-old child about toilet training, which instruction would initially be most appropriate? Be sure the child is ready before starting to toilet train. Offer a reward every time the child has a bowel movement in the potty chair. Remove the diaper and use training pants to begin the process. Place the toddler on the potty chair every 2 hours for 10 minutes.
Be sure the child is ready before starting to toilet train. All of the instructions are appropriate, but knowing whether the child is ready to toilet train is initially most appropriate. Many 17-month-old children don't have the neuromuscular control to be able to be trained. Waiting a few more months until the child is closer to age 2 years allows the child to develop more control. The mother should be taught the signs of readiness for toilet training.
For a child with a circumferential chest burn, what is the most important factor for the nurse to monitor? Heart rate Body temperature Breathing pattern Wound characteristics
Breathing pattern All of the options are important. However, breathing pattern is the most important factor to monitor because eschar impedes chest expansion in a child with a circumferential chest burn, causing breathing difficulty.
The nurse is caring for a toddler hospitalized with a diagnosis of croup (laryngotracheobronchitis). The health care provider prescribes treatment with a mist tent. As the parent attempts to put the toddler in the crib, the toddler cries and clings to the parent. What would be the best approach for the nurse to take to gain the child's cooperation with the treatment? Let the toddler sit on the parent's lap next to the mist tent. Encourage the parent to stand next to the crib and stay with the child. Turn off the mist so the noise does not frighten the toddler. Put the side rail down so the toddler can get into and out of the crib unaided.
Encourage the parent to stand next to the crib and stay with the child. By encouraging the parent to stand next to the crib and stay with the child, the nurse promotes compliance with treatment while minimizing the toddler's separation anxiety. Because the mist helps thin secretions and makes them easier to clear, turning off the mist or letting the toddler with croup sit next to the mist tent defeats the treatment's purpose. To prevent falls, the nurse should keep the side rails up and should not permit the toddler to climb into or out of the crib.
A parent calls the health clinic and tells the nurse that the toddler was found with an open and empty bottle of acetaminophen. The parent asks the nurse what to do. What is the nurse's priority intervention? Tell the parent to get the child to drink a glass of milk. Determine whether the parent knows cardiopulmonary resuscitation (CPR). Give the parent instructions on how to call poison control. Have the parent give the child syrup of ipecac.
Give the parent instructions on how to call poison control. The parent should call poison control and ask what immediate steps should be taken to treat this ingestion. Home administration of syrup of ipecac is no longer recommended. Milk is not an antidote for acetaminophen toxicity. Asking about CPR is not appropriate since it would distract from the immediate interventions needed.
A child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. On entering the examination room, the child is crying and clinging to his mother. Which data should the nurse obtain first? Heart rate, respiratory rate, and blood pressure Recent exposure to communicable diseases Height and weight Number of immunizations received
Heart rate, respiratory rate, and blood pressure The most important data to obtain on a child's arrival in the emergency department are vital sign measurements. The nurse should gather the other data later.
During a well-child visit, the nurse is reinforcing education with the parents of a 2-year-old child. What is the best recommendation a nurse can give to the parents regarding frequent temper tantrums? Ignore the behavior when it happens. Allow the toddler more choices. Move the toddler to a different setting. Give into the toddler's demands.
Ignore the behavior when it happens. The nurse should instruct the parents of a 2-year-old to ignore the tantrums because paying attention to this undesirable behavior reinforces it. Changing the toddler's setting can increase the tantrum behavior. Allowing the toddler more choices may increase tantrum behavior if the toddler is unable to follow through with choices. The toddler should be offered only allowable and reasonable choices. Giving in to the toddler's demands is not recommended because doing so promotes tantrum behavior.
A client is admitted to the hospital for an asthma exacerbation. The nursing history reveals this client was exposed to varicella (chickenpox) 1 week ago. When, if at all, would this client require isolation? Isolation would be required 10 days after exposure. Isolation would be required 12 days after exposure. Immediate isolation in a private room is required . Isolation is not required at this time.
Immediate isolation in a private room is required . The incubation period for varicella (chickenpox) is 2 to 3 weeks, usually 13 to 17 days. A client is commonly isolated 1 week after exposure to avoid the risk of a breakout. A person is infectious from 1 day before eruption of lesions to 6 days after the vesicles have formed crusts.
The nurse is caring for a toddler who is visually impaired. What is the most important action for the nurse to take to ensure the safety of the child? Request that the parent stay with the child. Use visual aids to facilitate communication. Avoid startling the child by limiting excess noise. Maintain a tidy environment around the child.
Maintain a tidy environment around the child. Children with visual impairment explore the environment by feel. A tidy and organized environment can support this and promote the child's safety. It is a priority to make sure all items that could potentially injure the child are removed from the environment. This includes meal trays and supplies for procedures. It is not reasonable to expect the parent to be available at all times or to expect the parent to take on the nurse's responsibility. Visual aids won't be effective for a child with visual impairment. While limiting noise volume is helpful to avoid startling the child, this does not promote safety as effectively as establishing and maintaining an environment free of dangerous objects and obstacles.
The nurse is caring for a one-day post-surgical toddler. What is the best method for the nurse to evaluate pain in this client? Have the child use the FACES scale. Observe for behavioral changes. Ask the parents if the child's behavior is normal. Take the child's vital signs.
Observe for behavioral changes. Behavioral changes and facial expressions are common signs of pain. These signs are especially valuable indicators in a toddler because the child has limited verbal skills. In clients of this age group, look for signs such as narrowing of the eyes, grimacing or fearful appearance, frequent and longer bouts of crying, reduced receptiveness to comforting by parents, and protection of the painful area. The FACES scale can be used but a young toddler may not be able to make a distinction between the faces or think it is a game instead of an assessment. It should be used as an adjunct to an objective assessment. The parents' assessment may not be correct as they may want the child to be comfortable and have pain medication. Vital signs are not a good indicator of pain. The blood pressure generally does not change.
A 2-year-old with laryngotracheobronchitis is experiencing severe respiratory distress. What nursing action would be a priority? Administer frequent sedatives. Provide an atmosphere of cool mist and high humidity. Offer frequent, oral feedings. Stimulate the child to keep him awake.
Provide an atmosphere of cool mist and high humidity. An atmosphere of cool mist and high humidity reduces mucosal edema and prevents drying of secretions, thus helping to maintain an open airway. Keeping the child calm, not stimulated, helps to reduce oxygen need. Oral feedings may need to be withheld in a child experiencing respiratory distress because eating may interfere with his ability to breathe. Sedation is generally contraindicated because it may cause respiratory depression and mask anxiety, a sign of respiratory distress.
A nurse is caring for a toddler with Down syndrome. What can the nurse do to help the toddler cope with painful procedures? Select all that apply. Provide physical comfort to the child after the procedure. Encourage the parent to remain with the child during the procedure. Use atraumatic pain management techniques. Refer the child to a Child Life Specialist. Establish a time limit to get ready for the procedure.
Refer the child to a Child Life Specialist; Provide physical comfort to the child after the procedure; Encourage the parent to remain with the child during the procedure; Use atraumatic pain management techniques. A child with Down syndrome may have difficulty coping with painful procedures and may regress during illness. Having the parent present will decrease separation anxiety during painful procedures. Holding, rocking, and giving the child a security object may comfort the child. An older child or a child without Down syndrome may benefit from positive self-talk, time limits, and diversionary tactics, such as counting and singing, but these tactics may be ineffective for a child with Down syndrome. The best intervention for this child is a referral to the Child Life Specialist. Atraumatic pain management techniques such as topical anesthetics and aids such as the Busy Bee product will help provide comfort.
A toddler is hospitalized with multiple injuries. Although the parent states that the child fell down the stairs, the child's history and physical findings suggest abuse as the cause of the injuries. What is the nurse's first responsibility in caring for this child? Document all the areas of injuries. Report the incident to the proper authorities. Place the child in a monitored room. Restrict the parent from the child's room.
Report the incident to the proper authorities. The nurse is required by law to report all incidents of abuse whether they be proven or suspected. In the hospital setting there is usually protocol as to the chain of command for reporting. In some facilities the nurse and/or healthcare provider should share the information about the injuries with the hospital social worker and the social worker contacts the police, Child Protective Services, or a children's aid society. In other facilities, the person seeing the abuse would report directly to the authorities. The healthcare provider and the nurse should document each of the injuries on the child, such as size and locations of bruises or open wounds, what stages of healing they are in, and if there is evidence of any broken bones or teeth. Once the case is investigated, the authorities will determine if monitoring is needed or if parents can visit with the child. Until abuse is proven, the parents are allowed to stay with the child.
The parent of an 18-month-old reports that the child seems tired and fussy even though the child naps twice per day and sleeps through the night. The nurse observes that the child is pale and clings to the parent during the health history and evaluation. Which finding should lead the nurse to suspect iron-deficiency anemia? The child drinks 40 to 48 oz. (1.2 to 1.4 L) of pasteurized cow's milk daily. The child is often constipated. The child weighed 8 lb, 9 oz. (3.9 kg) at birth. The child is in the 50th percentile for height and the 60th percentile for weight.
The child drinks 40 to 48 oz. (1.2 to 1.4 L) of pasteurized cow's milk daily. A dietary history of a child suspected of having iron-deficiency anemia typically reveals abnormally high milk intake (more than 32 oz. [0.9 L] of cow's milk daily). Preterm infants are at greater risk for iron-deficiency anemia than babies born at full term. Young children with chronic diarrhea are more likely to develop iron-deficiency anemia due to inadequate absorption. Constipation is not associated with iron-deficiency anemia. From 30% to 56% of children with iron-deficiency anemia are below the 10th percentile for weight when diagnosed.
A nurse is reinforcing education with parents on providing adequate nutrition for their toddler who has cerebral palsy. Which observation by the nurse indicates that the education has been effective? The child eats finger foods independently. The toddler finishes the meal within a specified period of time. The toddler stays neat while eating. The child lies down to rest after eating.
The child eats finger foods independently. A child with cerebral palsy should be encouraged to be as independent as possible. Finger foods allow the toddler to self-feed. Because spasticity affects coordinated chewing and swallowing, as well as the ability to bring food to the mouth, it is difficult for a child with cerebral palsy to eat neatly. Independence in eating should take precedence over neatness. A child with cerebral palsy may require more time to bring food to the mouth; thus, chewing and swallowing should not be rushed to finish a meal by a specified time. A child with cerebral palsy may vomit after eating due to a hyperactive gag reflex. Therefore, the child should remain in an upright position after eating to prevent aspiration and choking.
The nurse is caring for a child with a fractured leg. The child's mother becomes concerned when she visits her son and notices him sucking his thumb, a behavior that he had previously given up. What does this behavior indicate? The child is in pain. The child is responding to stress. The child wants attention. The child is depressed.
The child is responding to stress. Regression (reverting back to previously outgrown behaviors) is a common response to stressful situations. The nurse should reassure the parents that thumb sucking and other regressive behaviors should disappear after the stressful situation is resolved. Thumb sucking isn't a sign of depression or pain or an attention-seeking behavior.
A nurse on the pediatric floor is caring for a toddler. What should the nurse keep in mind about toddlers? They have little fear. They express negativism. They have reliable verbal responses to pain. They have a good concept of danger.
They express negativism. Toddlers' increasing autonomy is commonly expressed by negativism. They're unreliable in expressing pain; they respond just as strongly to painless procedures as they do to painful ones. They have little concept of danger and have common fears.
Parents tell the nurse that they want to begin toilet training their 22-month-old child. What is the most important factor regarding toilet training that the nurse should stress to the parents? developmental readiness of the child the parents' positive attitude consistency in approach developmental level of the child's peers
developmental readiness of the child If the child is not developmentally ready, the child and parent will become frustrated during toilet training. Consistency is important once toilet training has started, but it is not the most important factor. The parent's positive attitude is also important but only after the child is determined to be ready. A child's developmental level is individualized, so comparison to peers is not useful.
A parent expresses concern over a toddler's eating habits, stating the toddler eats very little and consumes only a single type of food for weeks on end. Which instruction is most appropriate? "The feeding pattern is a form of control and indicates a behavioral pattern." "The health care provider will assess for a nutrient deficiency." "This is indicative of an eating disorder." "This is normal toddler behavior."
"This is normal toddler behavior." Erratic eating is typical of toddlers. The physiologic need for food decreases at about age 18 months as growth declines from the rapid rate characteristic of infancy. The toddler also develops strong food and taste preferences, sometimes eating just one type of food for days or weeks and then switching to another. The child should not be forced to eat. Typically, the child switches to another food spontaneously after a while, correcting any nutritional imbalances. Parents may encourage the child to eat other foods by offering items from the various food groups at each meal. Erratic eating habits in toddlers are not characteristic of an eating disorder, a nutrient deficiency, or a behavioral problem.
Which intervention prevents a 17-month-old child with spastic cerebral palsy from going into a scissoring position? Place the child on the hip. Keep the child in leg braces 23 hours per day. Try to keep the child as quiet as possible. Let the child lie down as much as possible.
Place the child on the hip. To interrupt the scissoring position, flex the knees and hips. Placing the child with spastic cerebral palsy on the hip is an easy way to stop this common spastic positioning. This child needs stimulation and movement to reach the goal of development to the fullest potential. Wearing leg braces 23 hours per day is inappropriate and doesn't allow the child to move freely. Trying to keep the child quiet and lying flat are inappropriate measures.
A nurse observes a parent in a class performing chest compressions on a simulated 2-year-old child. The nurse knows the parent is doing compression correctly when the nurse observes the compressions being administered approximately how many inches in depth? 2 in (5 cm) 2 1/2 in (6 cm) 1 in (2.5 cm) 1 1/2 in (4 cm)
2 in (5 cm) The chest compressions should compress at least one-third of the anteroposterior diameter of the chest or approximately 2 in (5 cm). For infants, compress 1½ in (3.8 cm), and compress at least 2 in (5 cm) for adults.
A 3-year-old child is being discharged from the emergency department after receiving three sutures for a scalp laceration. The nurse should tell the family to return for suture removal in how many days? 10 to 14 days 5 to 7 days 8 to 10 days 1 to 3 days
5 to 7 days The recommended healing time for a scalp laceration is 5 to 7 days. Sutures need longer than 1 to 3 days to form an effective bond. Sutures of the fingertips and feet need 8 to 10 days, and 10 to 14 days is the recommended healing time for extensor surfaces of the knees and elbows.
A toddler is ordered 350 mg of amoxicillin and clavulanate by mouth four times per day. The pharmacy sends a bottle with a concentration of 250 mg/5 ml. How many milliliters should the nurse administer per dose? 9 5 8 7
7 The following formula is used to calculate drug dosages: Dose on hand/Quantity on hand = Dose desired/X. In this example, the equation is 250 mg/5 ml = 350 mg/X. X = 7 ml.
An 18-month-old Hispanic toddler admitted to the hospital with bronchitis has red marks on his upper chest over both sides of his body. The mother states that she has been treating him at home. Which treatment has the mother most likely been administering to her toddler? Coin rubbing Acupuncture Reflexology Rolfing
Coin rubbing Coin rubbing, also known as Cao Gío, is used by many cultures to relieve pain. Bruising commonly occurs with the rubbing and can be easily mistaken for child abuse. The other options are examples of alternative therapies used by a variety of other cultures.
A nurse is caring for a 3-year-old child diagnosed with viral meningitis. Which signs and symptoms does the nurse anticipate finding when gathering data? Select all that apply. bulging anterior fontanel fever nuchal rigidity petechiae irritability photophobia
fever, nuchal rigidity, irritability, photophobia
A 3-year-old child with Down syndrome is admitted to the pediatric unit with asthma. During assessment, it is noted that the child does not enunciate words well and holds onto furniture when walking. Which assessment question regarding development is most helpful? Does your child have social difficulty? Is this normal behavior for your child? Have you been referred to a developmental specialist? Has your child met the developmental milestones?
Is this normal behavior for your child? Identifying normal behavior for the child is helpful for the nurse assessing the child's current status. Asking if the child has met the developmental milestones is inappropriate for a child with Down syndrome who may need longer to accomplish social and physical tasks. Asking about specialist referral indicates a nursing concern before the nursing assessment has been completed.
What should the nurse do to ensure a safe hospital environment for a toddler? Place the child in a youth bed. Move the equipment out of reach. Pad the crib rails. Move stacking toys out of reach.
Move the equipment out of reach. Toddlers are curious and may try to play with items such as equipment that is within their reach. Doing so is dangerous. Toddlers in a strange hospital environment still need the security of a crib. Padded crib rails are necessary if seizure activity is present. Stacking toys are appropriate for this age-group and don't present a safety hazard.
A child, age 2, with a history of recurrent ear infections is brought to the clinic with a fever and irritability. To elicit the most pertinent information about the child's ear problems, the nurse should ask the parent: "Does your child have any hearing problems?" "Does your child tug at either ear?" "Does your child's ear hurt?" "Does anyone in your family have hearing problems?"
"Does your child tug at either ear?" Although all of the options are appropriate questions to ask when collecting data on a young child's ear problems, questions about the child's behavior are most useful because a young child usually can't describe symptoms accurately.
When assisting in developing a plan of care for a toddler with a seizure disorder, which of the following would be inappropriate? Padded side rails Cardiorespiratory monitoring Oxygen mask and bag system at bedside Arm restraints while asleep
Arm restraints while asleep Restraints should never be used on a child with a seizure disorder because they could harm the child if a seizure occurs. Padded side rails will prevent the child from being injured during a seizure. The bag and mask system should be present in case the child needs oxygen during a seizure. Cardiopulmonary monitoring should be readily available for checking vital signs during a seizure.
A pediatric nurse preceptor working on an oncology floor goes to see if the new graduate nurse caring for a 3-year-old terminally ill child requires assistance. The preceptor finds the new nurse in the lounge crying. What is the preceptor's best action? Ask the graduate what has caused the crying. Let the nurse manager know about the situation. Offer to call the chaplain to offer the graduate support. Give the graduate some privacy.
Ask the graduate what has caused the crying. Caring for acute or chronically ill children can be emotionally and physically stressful. A preceptor to a new nurse should be supportive and empathetic by asking about the new nurse's feelings. It is not appropriate for the preceptor to make judgments about the new nurse, and it is not acceptable for the preceptor to talk with the nurse manager about the issue at this time. It is not unusual for a nurse to need time to emotionally adjust to a new situation or new client population. Many times the chaplain can offer emotional and spiritual support that the nurse needs, but the preceptor offering support is the primary need.
The nurse is planning a health teaching session for parents of a toddler. When describing a toddler's typical eating pattern, the nurse should mention that many children of this age exhibit: a preference for eating alone. strong food preferences. consistent table manners. an increased appetite.
strong food preferences. A toddler typically exhibits strong food preferences, eating one type of food for several days and excluding others. A toddler can't be expected to use consistent table manners. Generally, the appetite decreases during the toddler stage because of a slowed growth rate. A toddler typically enjoys socializing during meals and often imitates others.
A toddler is diagnosed with iron deficiency anemia. When teaching the parents about using supplemental iron elixir, the nurse should provide which instruction? "Give the iron preparation with milk." "Give the elixir with water or juice." "Give the iron preparation before meals." "Monitor the child for episodes of diarrhea."
"Give the elixir with water or juice." Because iron preparations may stain the teeth, the nurse should instruct the parents to give the elixir with water or juice. The iron preparation shouldn't be given with milk because milk impedes iron absorption. This preparation may darken the stools and cause constipation; parental instruction regarding increased fluid intake and fiber intake can prevent constipation. To prevent GI upset, the nurse should instruct the parents to mix the iron preparation with water or fruit juice and have the child take it with meals. (Giving it with fruit juice may be preferable because vitamin C enhances iron solubility and absorption.)
The nurse has performed as assessment on a 2-year-old client. Which assessment finding(s) does the nurse associate with possible abuse? Select all that apply. mixture of multiple old and new bruises scar on the forehead fever of 100.9°F (38.3°C) several small, circular burn marks on the torso grabbing at nurse's stethoscope
mixture of multiple old and new bruises; scar on the forehead; several small, circular burn marks on the torso
The nurse in the pediatrician's office is teaching the mother of a 3-year-old about car seat safety. The mother questions the nurse as to why her son requires a car seat when he weighs 35 lb (15.9 kgs). Which response by the nurse is best? "He should ride in a rear-facing car seat." "He doesn't need to be in a car seat; he can be seat-belted into a regular seat." "He should ride in the car seat until he's at least 40 pounds (18 kgs) and 4 years old." "He can ride in a booster seat with a seat belt around him.
"He should ride in the car seat until he's at least 40 pounds (18 kgs) and 4 years old." Children should remain in car seats while riding in cars until they reach 4 years of age and weigh at least 40 lb (18 kgs); at that time they can be switched to a booster seat. Infants should be restrained in rear-facing car seats. Using a seat belt for children at this age is dangerous.
The nurse is gathering data regarding the physical development of a 33-month-old who is playing. Which of the following activities would the nurse anticipate the toddler being able to complete with minimal assistance? Select all that apply. coloring a detailed picture washing and drying hands riding a bicycle using a spoon for eating removing his or her jacket
washing and drying hands; removing his or her jacket; using a spoon for eating Normal growth and development for children entering the preschool years is to be able to follow directions on hand washing, remove one article of clothing, and feed themselves with a spoon. Riding a bicycle (two wheels) typically requires more coordination; coloring a detailed picture requires more fine motor ability.
A 2-year-old child has been diagnosed with asthma. The parents ask about the most common asthma triggers. What is the nurse's response? the cat next door one parent with asthma peanut butter weather
weather Excessively cold air, wet or humid changes in weather and seasons, and air pollution are some of the most common asthma triggers. Food allergens are rarely responsible for airway reactions in children. Household pets are a trigger. Evidence suggests that asthma is partly hereditary in nature, but heredity isn't an allergen.
A 3-year-old child is receiving ampicillin for acute epiglottitis. Which sign would lead the nurse to suspect that the child is experiencing a common adverse effect of this drug? constipation low-grade temperature generalized rash increased appetite
generalized rash Some children with epiglottitis may develop an erythematous or maculopapular rash after 3 to 14 days of therapy; however, this complication doesn't necessitate discontinuing the drug. Nausea, vomiting, epigastric pain, diarrhea, and respiratory symptoms of anaphylaxis are adverse effects that may necessitate discontinuation of the drug.
An 18-month-old toddler is admitted to the emergency department with dehydration. The nurse concludes that this child's crying when the parent leaves the room to complete the admission process is related to which major developmental stressor? stranger anxiety fear of pain fear of being alone separation from the family
separation from the family For infants through preschoolers, separation from the family is the major stressor posed by hospitalization. This starts at about 8 months, peaks at about 18 months, and decreases after that. To minimize the effects of separation, the nurse may suggest that a family member stays with the child as much as possible. Reducing this stressor may help a young child withstand other stressors of hospitalization, such as fear of bodily injury, loss of control, and fear of pain. Stranger anxiety happens more in infancy.
A 2-year-old child with status asthmaticus is admitted to the pediatric unit and begins to receive continuous treatment with albuterol, given by nebulizer. The nurse should observe for which adverse reaction? bradycardia tachycardia tachypnea lethargy
tachycardia Albuterol is a rapid-acting bronchodilator. Common adverse effects include tachycardia, nervousness, tremors, insomnia, irritability, and headache.
A registered nurse (RN) has been "care-paired" with a licensed practical nurse (LPN) during the evening shift. Whose care should the RN assign to the LPN? a 12-month-old infant who has a white blood cell (WBC) count of 34/μl and a fever a 22-month-old infant with type 1 diabetes who has a blood glucose level of 277 mg/dl (15.37 mmol/L). the 2-year-old child who has started eating soft, solid foods following a tonsillectomy a 17-month-old infant with a contusion as a result of a motor vehicle accident 4 hours earlier
the 2-year-old child who has started eating soft, solid foods following a tonsillectomy The nurse can delegate care of the child who had the tonsillectomy to the LPN because that child is stable and likely preparing for discharge. The infant with a WBC count of 34/μl and fever requires close monitoring for additional signs of infection. Infection could lead to sepsis or septic shock. Although the infant with contusions from the motor vehicle accident may be stable, children sometimes experience delayed reactions to injury. This infant requires close monitoring for signs or injury or shock. The RN should care for the infant with type 1 diabetes, who could become ill very quickly.
A 1-year-old underwent hypospadias repair yesterday; he has a urethral catheter in place and an IV. Which rationale is appropriate for administering propantheline on an as-needed basis? to increase urine flow from the kidney to the ureters to decrease the chance of infection at the suture line to decrease the number of organisms in the urine to prevent bladder spasms while the catheter is present
to prevent bladder spasms while the catheter is present Propantheline is an antispasmodic that works effectively on children. It prevents bladder spasms while the catheter is in place. It isn't an antibiotic and therefore won't decrease the chance of infection or the number of organisms in the urine. The drug has no diuretic effect and won't increase urine flow.
The physician prescribes acetaminophen elixir, 160 mg every 4 hours, for a 14- month-old child who weighs 20 lb (9.08 kg). This drug, supplied in a bottle labeled 160 mg/tsp, has a safe dosage of 10 mg/kg/dose. The nurse should administer how many milliliters? 5 ml 7.5 ml None because this isn't a safe dose 2.5 ml
None because this isn't a safe dose For this client, the safe dose of this drug is 90.8 mg (9.08 kg × 10 mg/kg = 90.8 mg). Therefore, the prescribed dose isn't safe.
During a well-baby visit, a toddler's parent states that the parent keeps all medications out of the toddler's reach in the kitchen cabinet. Which is an appropriate response by the nurse? "Medications should be kept out of the toddler's sight." "Medications should be kept in a locked location." "Keeping medications out of reach is a good idea." "Medications should be kept in the bathroom medicine cabinet."
"Medications should be kept in a locked location." Most toddler deaths are accidental. Medications should be kept in a locked location to prevent accidental ingestion by the toddler. Toddlers are curious and are beginning to climb and explore. Keeping medications out of sight and/or out of reach is not enough to prevent the toddler from finding/reaching and accidentally ingesting medication.
The nurse is teaching parents about otitis media. When discussing why children are predisposed to this disorder, the nurse should mention the significance of which anatomical feature? External ear canal Eustachian tubes Tympanic membrane Nasopharynx
Eustachian tubes In a child, the eustachian tubes are short and lie in a horizontal plane, promoting entry of nasopharyngeal secretions into the tubes and thus setting the stage for otitis media. The nasopharynx, tympanic membrane, and external ear canal have no unusual features that would predispose a child to otitis media.
A 2-year-old is brought to the emergency department with suspected croup. The child appears frightened and cries as the nurse approaches. The nurse needs to auscultate the child's breath sounds. What is the most appropriate way for the nurse to approach the child? Allow the child to handle the stethoscope before listening to the lungs. Expose the child's chest quickly, and auscultate breath sounds as quickly and efficiently as possible. Tell the child that the nurse is going to listen to his chest with the stethoscope. Ask the parent to wait outside until the examination is over.
Allow the child to handle the stethoscope before listening to the lungs. Toddlers are naturally curious about their environment, and letting them handle minor equipment is distracting, helps allay their fears, and allows them to gain trust with the nurse. The nurse should only expose one area at a time during evaluation and should approach the child slowly and unhurriedly. The caregiver should be encouraged to hold and console the child. Telling the child about listening to the child's chest at first approach may increase the child's fear.
A toddler is brought to the emergency department with sudden onset of abdominal pain, vomiting, and stools that look like red currant jelly. To confirm intussusception, the suspected cause of these findings, the nurse expects the physician to order: suprapubic aspiration. nasogastric (NG) tube insertion. indwelling urinary catheter insertion. a barium enema.
a barium enema. A barium enema commonly is used to confirm and correct intussusception. Performing a suprapubic aspiration or inserting an NG tube or an indwelling urinary catheter wouldn't help diagnose or treat this disorder.
A 2-year-old child is brought to the emergency department with a history of upper airway infection that has worsened over the last 2 days. The nurse suspects the child has croup. Signs of croup include a hoarse voice, inspiratory stridor, and: dysphagia. a barking cough. a high fever. sudden onset.
a barking cough. Croup is an acute viral respiratory illness characterized by a barking cough. Fever is usually low grade. Croup has a gradual onset, and dysphagia isn't a symptom.
The nurse is caring for a child whose mother is deaf and untrusting of staff. She frequently cries at the bedside, but refuses intervention from the social worker or the chaplain. Which issue is most important for the nurse to address with the mother to promote a trusting relationship? communication barriers between the mother and staff lack of knowledge about the child's illness and treatment the mother's fear that the staff do not respect her the mother's feelings of loss of control over her child
communication barriers between the mother and staff The communication barrier is the most significant and would require immediate attention. Strategies need to be implemented that include taking the time to share information via the written word with all new members of the healthcare team and the mother. Fear, loss of control, and lack of knowledge about the illness of the child may contribute to the overall stress of the situation.
The nurse is reinforcing education for the parents of a toddler with congenital heart disease. Which information should the nurse include when reinforcing education regarding care? "Try to maintain your child's usual lifestyle to promote normal development." "Make sure your child avoids contact with small children to reduce overstimulation." "Relax discipline and limit-setting to prevent crying." "Reduce your child's caloric intake to decrease cardiac demand."
"Try to maintain your child's usual lifestyle to promote normal development." Parents of a child with a congenital heart defect should treat the child normally and allow self-limited activity. Reducing the child's caloric intake would not necessarily reduce cardiac demand. Altering disciplinary patterns and deliberately preventing crying or interactions with other children could foster maladaptive behaviors. Contact with peers promotes normal growth and development.
An emergency department nurse suspects neglect in a 3-year-old child admitted for failure to thrive. What behavior in the child should the nurse look for that might indicate signs of neglect? loud crying and screaming pulling hair and hitting slapping, kicking, and punching others poor hygiene and weight loss
poor hygiene and weight loss Neglect can involve failure to provide food, bed, shelter, health care, or hygiene. Poor hygiene and weight loss are indicative of neglect in a child with failure to thrive. A child who slaps, kicks, pulls hair, hits, and punches may be the victim of physical abuse. Loud crying and screaming are not abnormal findings in a 3-year-old.
A 2-year-old child is admitted to the pediatric unit with the diagnosis of bacterial meningitis. Which nursing action would be appropriate for the nurse to perform first? Place the toddler in respiratory isolation. Draw ordered laboratory tests. Explain the treatment plan to the parents. Obtain a urine specimen.
Place the toddler in respiratory isolation. Nurses should take necessary precautions to protect themselves and others from possible infection from the bacterial organism causing meningitis. The affected child should immediately be placed in respiratory isolation; then the parents can be informed about the treatment plan. This should be done before laboratory tests are performed.
A 2-year-old is brought to the clinic by his mother for his annual examination. Which statement by the mother alerts the nurse to the toddler's risk for malnutrition? "He loves cheese, crackers, and all kinds of fruit." "He eats peanut butter and jelly sandwiches every day." "He drinks a bottle of whole milk several times a day." "He's so busy at meal time so I give him frequent snacks of a variety of foods throughout the day."
"He drinks a bottle of whole milk several times a day." A 2-year-old should consume 2% milk with meals from a cup, not a bottle. Drinking whole milk several times per day prevents the toddler from consuming other foods that are essential to his diet, leaving him at risk for malnutrition. Toddlers commonly develop preferences for foods that they consume on a regular basis, such as peanut butter and jelly sandwiches. This food preference doesn't place the toddler at risk for malnutrition. Toddlers are typically unable to sit still for meals; therefore, small, frequent feedings are recommended. Cheese, crackers, and fruit are good food choices for toddlers.
A young client develops a fever and rash and is diagnosed with rubella. The client's mother has just given birth to another child. Which statement by the mother best indicates that she understands the implications of rubella? "I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my children." "I'll ask the physician about giving the baby an immunization shot." "I told my partner to give the client aspirin for the fever." "I don't have to worry because I've had the measles."
"I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my children." By saying she'll call her pregnant neighbor, the mother demonstrates that she understands the implications of rubella. Fetal defects can occur during the first trimester of pregnancy if the pregnant woman contracts rubella. Aspirin shouldn't be given to young children because aspirin has been implicated in the development of Reye's syndrome. Acetaminophen should be used instead of aspirin. Rubella immunization isn't recommended for children until ages 12 to 15 months. Having the measles (rubeola) won't provide immunity for rubella.
Which statement by the mother of a toddler with nephrotic syndrome indicates that the nurse's discharge teaching was effective? "I'm sure that my child will be back to normal soon." "I've been checking the urine for protein so I'll be able to do it at home." "I just went out and bought all I'll need for the special diet." "I know that I'll need to keep my child as quiet as possible."
"I've been checking the urine for protein so I'll be able to do it at home." Protein in urine is an indication of the progression of nephrotic syndrome, so parents are taught to test the child's urine. The child doesn't need to be kept quiet and usually isn't on a specific diet. How the child feels will dictate the child's activity level. Most children return to normal soon but may relapse.
A nurse is reinforcing education to the parents of an 18-month-old infant diagnosed with bilateral otitis media about the prescribed medication amoxicillin and clavulanate potassium. Which statement by the parents indicates the education has been effective? "It can cause a rash." "It can cause headache." "It can cause diarrhea." "It can cause petechiae."
"It can cause diarrhea." Diarrhea is a common adverse effect of amoxicillin and clavulanate potassium suspension. Red rash and petechiae occur less commonly. Headache is not a common adverse effect and would be difficult to determine in an 18-month-old infant.
A 15-month-old child is being discharged after treatment for severe otitis media and bacterial meningitis. Which statement by the parents indicates effective discharge teaching? "We should have gone to the physician sooner. Next time, we will." "We'll take our child to the physician's office every week until everything is okay." "We'll go to the physician if our child pulls on his ears or won't lie down." "We're just so glad this is all behind us."
"We'll go to the physician if our child pulls on his ears or won't lie down." The parents indicate full understanding of discharge teaching by repeating the specific, common signs of otitis media in toddlers, such as pulling on his ears and refusing to lie down, and by verbalizing the need for immediate follow-up care if these signs arise. Option 1 implies a sense of guilt. Option 2 addresses only weekly follow-up care. Option 4 is unrealistic because the child's condition may recur.
The nurse is preparing a toddler for a lumbar puncture. For this procedure, the nurse should place the child in which position? lying prone, with the feet higher than the head lying prone, with the neck flexed lying on one side, with the back curved sitting up, with the back straight
lying on one side, with the back curved Lumbar puncture involves placing a needle between the lumbar vertebrae into the subarachnoid space. For this procedure, the nurse should position the client on one side with the back curved; curving the back maximizes the space between the lumbar vertebrae, facilitating needle insertion. Prone and seated positions don't achieve maximum separation of the vertebrae.
A 2-year-old child with a tracheostomy suddenly becomes diaphoretic and has an increased heart rate, an increased respiratory rate, and a decreased oxygen saturation level. Which of the following should be the nurse's first action? Turn the child to a side-lying position. Perform chest physiotherapy. Administer pain medication. Suction the tracheostomy.
Suction the tracheostomy. Diaphoresis, increased heart rate, increased respiratory effort, and decreased oxygen saturation are signs that mucus is partially occluding the airway. The child needs suctioning immediately to prevent full occlusion. Turning the child to a side-lying position won't remove mucus from the airway. The child may require pain medication after his airway has been cleared if his condition warrants it. Chest physiotherapy will help drain excess mucus from the lungs but not from a tracheostomy.
A 3-year-old child has had surgery to remove a Wilms tumor. Which action should the nurse take first when the parent asks for pain medication for the child? Get the pain medication ready for administration. Check for the last time pain medication was administered. Gather data regarding the child's pain using a pain scale of 1 to 10. Gather data regarding the child's pain using a smiley face pain scale.
Gather data regarding the child's pain using a smiley face pain scale. The first action by the nurse should be to gather data from the child regarding pain. A 3-year-old child is too young to use a pain scale from 1 to 10, but can easily use the smiley face pain scale. After gathering data regarding the child's pain, the nurse should then investigate the time the pain medication was last given and administer the medication accordingly.
The parents of a 2-year-old child with chronic otitis media are concerned that the disorder has affected their child's hearing. Which behavior suggests that the child has a hearing impairment? Babbling continuously Using gestures to express desires Stuttering Playing alongside rather than interacting with peers
Using gestures to express desires Using gestures instead of verbal communication to express desires — especially in a child older than 15 months — may indicate a hearing or communication impairment. Stuttering is normal in children ages 2 to 4, especially boys. Continuous babbling is a normal phase of speech development in young children; its absence, not presence, would be cause for concern. Parallel play — playing alongside peers without interacting — is typical of toddlers. However, in an older child, difficulty interacting with peers or avoiding social situations may indicate a hearing deficit.
The nurse is preparing to administer morning care to a 24-month-old admitted with respiratory syncytial virus bronchiolitis. Keeping in mind the extent to which a child in this age-group can help to meet his own hygiene needs, the nurse can expect to: provide total care because the toddler is too young to assist. place the toddler in a bathtub and check on him frequently. allow the toddler to bathe himself using a basin with water at the bedside. allow the toddler to bathe as much of himself as he can with supervision.
allow the toddler to bathe as much of himself as he can with supervision. A toddler should be encouraged to bathe himself as much as he can, with supervision. When he's finished, the nurse should bathe the areas that the toddler was unable to wash. Doing so fosters independence, which is important to toddlers, but maintains their safety. Toddlers should never be left unattended near water, whether contained in a bathtub or basin, to prevent accidental drowning.
The nurse is caring for a 30-month-old client in the pediatrician's office. The client is being assessed for autism spectrum disorder. While assessing the client with the health care provider, which clinical characteristics does the nurse anticipate documenting in the medical record? Select all that apply. talking with an imaginary playmate avoiding eye-to-eye contact with others sitting on the lap of the office staff displaying separation anxiety when the parent leaves the room using repetitive behaviors throughout the session
avoiding eye-to-eye contact with others; using repetitive behaviors throughout the session Autism spectrum disorder is a group of complex disorders of brain development. These disorders are characterized, in varying degrees, by difficulties in social interaction, verbal and nonverbal communication, and repetitive behaviors. When assessing for symptoms of autism spectrum disorder, the nurse would anticipate documenting avoiding eye-to-eye contact and using repetitive behaviors. Talking with an imaginary playmate, sitting on the lap of office staff, and experiencing separation anxiety are common characteristics in the toddler/early preschooler age.
The nurse is gathering data regarding the physical development of a 33-month-old who is playing. Which of the following activities would the nurse anticipate the toddler being able to complete with minimal assistance? Select all that apply. riding a bicycle washing and drying hands coloring a detailed picture removing his or her jacket using a spoon for eating
washing and drying hands; removing his or her jacket; using a spoon for eating Normal growth and development for children entering the preschool years is to be able to follow directions on hand washing, remove one article of clothing, and feed themselves with a spoon. Riding a bicycle (two wheels) typically requires more coordination; coloring a detailed picture requires more fine motor ability.
An 18-month-old child comes to the primary health care provider's office for a well-baby checkup. Which foods should the nurse recommend as providing the best sources of dietary iron for the child? cheese, yogurt, and fresh fish peanut butter, green vegetables, and raisins yellow vegetables, citrus fruits, and white bread berries, turkey, and cheese
peanut butter, green vegetables, and raisins Peanut butter, legumes, green vegetables, and dried fruits are sources high in iron. Cheese, yogurt, fresh fish, yellow vegetables, citrus fruits, white bread, berries, turkey, and cheese are lower in iron content.
A nurse is obtaining data from a 3-year-old child with nuchal rigidity. Which sign would be documented on the chart to support this condition? positive Kernig's sign positive Homans sign negative Kernig's sign negative Brudzinski's sign
positive Kernig's sign A positive Kernig's sign indicates nuchal rigidity, caused by an irritative lesion of the subarachnoid space. A positive Brudzinski's sign also is indicative of the condition. A positive Homans sign may indicate venous inflammation of the lower leg. Negative signs mean that the condition is not present.
The nurse is caring for a child in the early stages of burn recovery. Which nursing diagnosis does the nurse prioritize? disturbed body image impaired skin integrity constipation impaired physical mobility
impaired skin integrity Impaired skin integrity is a serious problem for the burned child. The open skin causes fluid to leak and can contribute to fluid and electrolyte issues. Also, because the skin is open there is a portal for infectious organisms. The diagnoses of impaired physical mobility, disturbed body image, and constipation are relevant in the care of the child with burns, but they are concerns for later in the recovery process.
In addition to an increasing respiratory rate, which sign in a 3-year-old child with acute epiglottitis indicates that respiratory distress is increasing? increasing heart rate productive cough progressive, barking cough increasing irritability
increasing heart rate Increasing heart rate is an early sign of hypoxia. A progressive, barking cough is characteristic of spasmodic croup. A child in respiratory distress will be irritable and restless. As distress increases, the child will become lethargic related to the work of breathing and impending respiratory failure. A productive cough shows that secretions are moving and the child can effectively clear them.
The nurse is caring for a toddler with right lower lobe pneumonia. In order to improve gas exchange, which position should the child be placed in? supine right side-lying prone left side-lying
left side-lying The child with right lower lobe pneumonia should be placed on the left side. This places the unaffected left lung in a position that allows gravity to promote blood flow though the healthy lung tissue and improve gas exchange. Placing the child on the right side, back, or stomach does not promote circulation to the unaffected lung.
A 2-year-old child is being treated with rifampin for tuberculosis. Which finding does the nurse expect to find in the client? decreased bilirubin levels hyperactivity orange body secretions decreased levels of liver enzymes
orange body secretions Rifampin and its metabolites will turn urine, feces, sputum, tears, and sweat an orange color. This is not a serious adverse effect. Rifampin may also cause GI upset, headache, drowsiness, dizziness, vision disturbances, and fever. Liver enzyme and bilirubin levels increase because of hepatic metabolism of the drug. Parents should be taught the signs and symptoms of hepatitis and hyperbilirubinemia, such as jaundice of the sclera or skin.
The nurse is caring for a toddler admitted to the hospital with nephrotic syndrome. The nurse carefully monitors the toddler's fluid intake and output and checks urine specimens regularly with a reagent strip. Which finding is the nurse most likely to report? polyuria glucosuria proteinuria ketonuria
proteinuria In nephrotic syndrome, the glomerular membrane of the kidneys becomes permeable to proteins. This condition results in massive proteinuria, which the nurse can detect with a reagent strip. Nephrotic syndrome typically does not cause glucosuria or ketonuria. Because the syndrome causes fluids to shift from plasma to interstitial spaces, it is more likely to decrease urine output than to cause polyuria (excessive urine output).
