Pediatric: Toddler practice ?s
The nurse caring for a 2-year-old client offers the child the choice to hold the syringe and squirt the medication in the mouth or have the nurse give the medication. According to Erikson, what does this help the child achieve? trust autonomy industry initiative
autonomy Explanation: According to Erikson's theory of development, a 2-year-old child is at the stage of autonomy versus shame and doubt. Offering the child choices about some aspects of care encourages autonomy. An infant is at the stage of trust versus mistrust, a school-age child is industry versus inferiority, and a preschooler is at the stage of initiative versus guilt.
A 15-month-old client is being discharged after treatment for severe otitis media and bacterial meningitis. Which statement by the caregivers indicates effective discharge teaching? A. "We should have gone to the physician sooner. Next time, we will." B. "We'll take our child to the physician's office every week until everything is okay." C. "We'll go to the physician if our child pulls on the ears or won't lie down." D. "We're just so glad this is all behind us."
Correct response: "We'll go to the physician if our child pulls on the ears or won't lie down." Explanation: The caregivers indicate full understanding of discharge teaching by repeating the specific, common signs of otitis media in toddlers, such as pulling on the ears and refusing to lie down, and by verbalizing the need for immediate follow-up care if these signs arise. Expressing that they should have gone to the physician sooner doesn't indicate effective teaching because it implies a sense of guilt - a feeling not promoted through teaching. Stating that they'll take the client to the physician's office every week addresses only weekly follow-up care and expressing that they're happy the problem is behind them is unrealistic because the client's condition may recur.
The nurse is caring for a 2-year-old child with cancer. The parents have been told that the child will need an allogeneic bone marrow transplant and want to know what this means. What is the best response by the nurse? A. The donor for this type of transplant must have the same DNA as your child." B. A donor is determined after testing for similar human leukocyte antigens." C. This type of transplant uses the child's own stem cells for the procedure." D. The donor bone marrow can be accepted from anyone who volunteers."
Correct response: B. A donor is determined after testing for similar human leukocyte antigens." Explanation: An allogeneic transplant is one in which the donor and the recipient are related or unrelated but share similar human leukocyte antigens (HLA).
A parent calls the pediatric clinic to express concern over the child's eating habits. The parent says the child eats very little and consumes only a single type of food for weeks on end. The nurse knows that this behavior is characteristic of: toddlers. preschool-age children. school-age children. adolescents.
Correct response: toddlers. Explanation: The nurse knows that erratic eating is typical of toddlers because the physiologic need for food decreases at about age 18 months as growth declines from the rapid rate 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.
A child with a poor nutritional status and weight loss is at risk for a negative nitrogen balance. To help diagnose this problem, the nurse anticipates that the physician will order which laboratory test? total iron-binding capacity hemoglobin (Hb) total protein sweat test
Correct response: total protein Explanation: The nurse anticipates the physician will order a total protein test because negative nitrogen balance may result from inadequate protein intake. Measuring total iron-binding capacity and Hb levels would help detect iron deficiency anemia, not a negative nitrogen balance. The sweat test helps diagnose cystic fibrosis, not a negative nitrogen balance.
A parent calls the pediatric clinic to express concern over the child's eating habits. The parent says the child eats very little and consumes only a single type of food for weeks on end. The nurse knows that this behavior is characteristic of: A. toddlers. B. preschool-age children. C. school-age children. D. adolescents.
Correct response: A. toddlers. Explanation: The nurse knows that erratic eating is typical of toddlers because the physiologic need for food decreases at about age 18 months as growth declines from the rapid rate 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.
As two toddlers play side by side, their parents note that they are not sharing their toys with each other and one cries when a toy is taken by the other child. The nurse hears the parents telling their children to share. Which is the nurse's best response? A. Do nothing as this is normal behavior for a toddler. B. Encourage the parents to teach their children to share. C. Separate the children so that they cannot fight. D. Sit between the children and encourage them to play together.
Correct response: Do nothing as this is normal behavior for a toddler. Explanation: Toddlers participate in parallel play. They play beside each other but not together. They are not ready to "share" their toys. No intervention is needed for this normal developmental behavior.
The nurse teaches the mother of a toddler who has had cleft palate repair that her child is at risk for developing which problem in the future? hearing problems poor self-concept a speech defect chronic sinus infections
Correct response: a speech defect Explanation: The most common long-term problem experienced by children with cleft palate repair is speech problems. These children frequently need speech therapy for a period of time. Hearing problems may occur as a result of chronic ear infections and the placement of myringotomy tubes. A poor self-concept may develop in any child. However, if a child with a cleft palate receives adequate parenting and support, this should not occur. Chronic sinus infections are more commonly associated with asthma, not with this defect.
A nurse discussing injury prevention with a group of workers at a daycare center is focusing on toddlers. When discussing this age-group, the nurse should stress that A. accidents are the leading cause of death among toddlers. B. the risk for homicide is highest among toddlers. C. toddlers can distinguish right from wrong. D. toddlers will always chase a ball that rolls into the street.
Correct response: accidents are the leading cause of death among toddlers. Explanation: The leading cause of death in toddlers is accidents, so it's important for parents, family members, and childcare providers to understand the importance of accident prevention. Toddlers don't have the highest risk for homicide. Toddlers are just beginning to understand right from wrong, but don't understand the consequences of their actions. Although many children will chase balls or toys into the street, not all children will do so.
When assessing a toddler's growth and development, the nurse understands that a child in this age group displays behavior that fosters which developmental task? A. initiative B. autonomy C. trust D. industry
Correct response: autonomy Explanation: The toddler's developmental task is to achieve autonomy while overcoming shame and doubt. Developing initiative is the preschooler's task whereas developing trust is the infant's task. Developing industry is the task of the school-age child.
A mother brings a 15-month-old child to the well-baby clinic. She states the child has been taking approximately 18 to 20 oz (540 to 600 mL) of whole milk per day from a bottle with meals and at bedtime. The nurse should suggest that she begin weaning the child from the bottle to avoid risking: malnutrition. anemia. dental caries. malocclusion.
Correct response: dental caries. Explanation: Nursing bottle caries occur when a child is routinely given a bottle of milk or juice at nap and bedtime. When teeth become coated in sugar before sleep, the lack of activity in the child's mouth for several hours during sleep allows the sugar to convert to acid, leading to decay. A child drinking 18 to 20 oz of whole milk in a day should not be malnourished, although she may lack essential vitamins and iron. Anemia may occur if she is only drinking milk because it contains no iron; however, the mother indicates she is eating meals. Regardless, children of this age should be taking no more than 16 oz of milk per day, and most children at this age should be drinking from a cup. The mother should be instructed to wean the child to a cup one feeding at a time until the child is completely weaned to a cup for all feedings. The last bottle-feeding to be replaced is usually the night bottle. Malocclusion of the teeth does not occur at 15 months. If the child were to continue to suck on a bottle until age 4 years or later, then malocclusion may occur.
Which assessment finding is an early sign of heart failure in a client? increased respiratory rate increased urine output decreased weight decreased heart rate
Correct response: increased respiratory rate Explanation: Increased respiratory and heart rates are the earliest signs of heart failure. Decreased urine output and increased weight are later signs.
The inability of an 18-month-old child to perform what activity would cause the nurse to be concerned? copying a circle playing with pull toys playing tag with other children building a tower of eight blocks
Correct response: playing with pull toys Explanation: Playing with pull toys is a typical task of a normally developed 18-month-old child. Inability of the toddler to do so would be a concern.Copying a circle and building a tower of eight or more blocks is a behavior typical of a 3-year-old child.Playing tag with other children requires cooperative play and the ability to follow rules; this behavior develops at about age 5 years.
Which assessment would be the priority for a 2-year-old child after a bronchoscopy? heart rate respiratory quality sputum color pulse pressure changes
Correct response: respiratory quality Explanation: After bronchoscopy, airway obstruction secondary to laryngeal edema may occur. Therefore, assessment of the child's respiratory quality is the priority. The child should be observed for signs and symptoms of respiratory distress including tachypnea, increased stridor and retractions, and tachycardia.Assessing cardiac rate and rhythm is important and should be done once the child's respiratory status is assessed.Although observing the color of the sputum is an important assessment, it is not the priority. The sputum may be bloody after bronchoscopy.A change in pulse pressure is not associated with bronchoscopy but rather with changes in intracranial pressure and shock. A pulse deficit is associated with some arrhythmias.
The nurse teaches the parents of a 2-year-old child how to instill antibiotic eardrops. Which statement about the direction to pull on the earlobe indicates that the child's father has understood the teaching? "I should pull the earlobe up and forward." "I should pull the earlobe up and backward." "I should pull the earlobe down and outward." "I should pull the earlobe down and backward."
Correct response: "I should pull the earlobe down and backward." Explanation: For children aged 3 years and younger, the external auditory canal is straightened by gently pulling the earlobe down and backward.For an older child or an adult, the earlobe is gently pulled up and backward.
A nurse is caring for a toddler with Down syndrome. To help the toddler cope with painful procedures, the nurse can A. prepare the child by positive self-talk. B. establish a time limit to get ready for the procedure. C. hold and rock the child and give the child a security object. D. count and sing with the child.
Correct response: C. hold and rock the child and give the child a security object. Explanation: The toddler with Down syndrome may have difficulty coping with painful procedures and may regress during illness. Holding, rocking, and giving the child a security object is helpful because it may be comforting to 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; however, the success of these tactics depends on the child.
Which toxic adverse reaction should the nurse monitor in a toddler taking digoxin? A. weight gain B. tachycardia C. nausea and vomiting D. seizures
Correct response: nausea and vomiting Explanation: Digoxin toxicity in infants and children may present with nausea, vomiting, anorexia, or a slow, irregular heart rate. Weight gain, tachycardia, and seizures are not findings in digoxin toxicity.
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? A. "I told my partner to give the client aspirin for the fever." B. "I'll ask the physician about giving the baby an immunization shot." C. "I don't have to worry because I've had the measles." D. "I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my children."
Correct response: D. "I'll call my neighbor who's 2 months pregnant and tell her not to have contact with my children." Explanation: 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.
What should a nurse do to ensure a safe hospital environment for a toddler? A. Place the toddler in a youth bed. B. Move stacking toys out of reach. C. Pad the crib rails. D. Move the equipment out of reach.
Correct response: Move the equipment out of reach. Explanation: Moving the equipment out of reach ensures a safe environment because toddlers are curious and may try to play with items within their reach. Toddlers in a strange hospital environment still need the security of a crib. Stacking toys don't need to be moved out of reach because they don't present a safety hazard and are appropriate for this age-group. Padded crib rails are necessary only if seizure activity is present.
The father of a 2-year-old phones the emergency department on a Sunday night and informs the nurse that his son put a bead in his nose. What is the most appropriate recommendation by the nurse? A. "Try removing the bead at home as soon as possible. You might try using a pair of tweezers." B. "Be sure to take your child to the pediatrician in the morning so the pediatrician can remove the bead in the office." C. "You should bring your child to the emergency department tonight so the bead can be removed as soon as possible." D. "Ask your child to blow his nose several times; this should dislodge the bead."
Correct response: "You should bring your child to the emergency department tonight so the bead can be removed as soon as possible." Explanation: The bead should be removed by a health care professional as soon as possible to prevent the risk of aspiration and tissue necrosis. Unskilled individuals should not attempt to remove an object from the nose as they may push the object further increasing the risk for aspiration. Two-year-old children are not skilled at blowing their nose and may breathe in, further increasing the risk of aspiration.
The mother of a toddler who has just been admitted with severe dehydration secondary to gastroenteritis says that she cannot stay with her child because she has to take care of her other children at home. Which response by the nurse would be most appropriate? A. "You really shouldn't leave right now. Your child is very sick." B. "I understand, but feel free to visit or call anytime to see how your child is doing." C. "It's really not necessary to stay with your child. We will take very good care of him." D. "Can you find someone to stay with your children? Your child needs you here."
Correct response: " I understand, but feel free to visit or call anytime to see how your child is doing." Explanation: The nurse's best course of action would be to support the mother. This is best done by conveying understanding and encouraging the mother to visit or call. Telling the mother that she should not leave and that the child is very sick is critical and insensitive. Additionally, it implies guilt should the mother leave. Commenting that the child does not need anyone is not appropriate or true. Toddlers, in particular, need family members present because of the stresses associated with hospitalization. They experience separation anxiety, a normal aspect of development, and need constancy in their environment. Asking the mother to find someone else to stay with her children is inappropriate. The children at home also need the support of the mother and/or other family members to minimize the disruptions in family life resulting from the toddler's hospitalization and to maintain consistency.
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? A. "Keeping medications out of reach is a good idea." B. "Medications should be kept in the bathroom medicine cabinet." C. "Medications should be kept in a locked location." D. "Medications should be kept out of the toddler's sight."
Correct response: " Medications should be kept in a locked location." Explanation: 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.
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: A. "Does your child's ear hurt?" B. "Does your child have any hearing problems?" C. "Does your child tug at either ear?" D. "Does anyone in your family have hearing problems?"
Correct response: "Does your child tug at either ear?" Explanation: Although all of the options are appropriate questions to ask when assessing a young child's ear problems, questions about the child's behavior, such as "Does your child tug at either ear?" are most useful because a young child usually can't describe symptoms accurately.
A parent brings a child to the clinic with symptoms of weight loss, paleness, fatigue, and not growing. What question about the child's environment should the nurse ask the parent based on these symptoms? A. "Do you have pets in your home?" B. "How old is the house that you live in?" C. "Do you live near a hydroelectric facility?" D. "Are you a single parent?"
Correct response: "How old is the house that you live in?" Explanation: The nurse should suspect lead poisoning in this situation. Many of the symptoms are the same as other illnesses, but the key is living in the older home. Lead poisoning occurs through older lead pipes and drinking water from those pipes. Lead is also found in the dirt in areas surrounding homes where lead pipes and lead paint have been used. The symptoms of lead poisoning include weight loss, being tired all the time, difficulty concentrating, and abdominal pain. The concern for living near a hydroelectric facility would be methylmercury poisoning. The symptoms of this would include lack of coordination, speech impairments and muscle weakness. The type of pets in the home could indicate symptoms of a disease such as asthma. The concern for being a single parent would be one of financial need and not being able to purchase nutritious foods for the child.
The parents of a toddler do not want their child to have a varicella immunization, stating, "My child will have better immunity if he or she gets the disease now." Which is the nurse's best response? A. "You are correct and chicken pox is not fatal." B. The antibodies in the vaccine are good for other communicable diseases as well." C. "If the child contracts the disease, it could be very serious, even life threatening." D. "Chicken pox is not very contagious, so it is unlikely your child will contract it naturally."
Correct response: "If the child contracts the disease, it could be very serious, even life threatening." Explanation: The varicella vaccine protects the child from chicken pox. Although most cases of chicken pox are not life threatening, children can die from the disease. It is highly contagious, and other children, or immunocompromised adult and children, may be exposed to the unvaccinated child. The vaccine is specific for chicken pox disease.
A preschool-age child with a history of being abused has blood drawn. The child lies very still and makes no sound during the procedure. Which comment by the nurse would be most appropriate? "It's okay to cry when something hurts." "That really didn't hurt, did it?" "We are mean to hurt you that way." "You were very good not to cry with the needle."
Correct response: "It's okay to cry when something hurts." Explanation: It is not normal for a preschooler to be totally passive during a painful procedure. Typically, a preschooler reacts to a painful procedure by crying or pulling away because of the fear of pain. However, an abused child may become "immune" to pain and may find that crying can bring on more pain. The child needs to learn that appropriate emotional expression is acceptable. Telling the child that it really did not hurt is inappropriate because it is untrue. Telling the child that nurses are mean does not build a trusting relationship. Praising the child will reinforce the child's response not to cry, even though it is acceptable to do so.
Two toddlers are arguing over a toy in the playroom. What should the nurse should say to the children? A. "If you can't play together, I'll have to put you back in your rooms." B. "Give the toy to me. Now neither of you will have it." C. "Let me see if I can get both of you a similar toy." D. "Let one of you play with it for a while, and then give it to the other."
Correct response: "Let me see if I can get both of you a similar toy." Explanation: A toddler has not developed the concept of sharing, so two similar toys must be provided to prevent disagreements. Playing together in harmony is not the developmental level of a toddler. They play side by side, but not together. Threatening to put the children in their rooms does not solve the problem, nor does taking away the toy.
A nurse is giving discharge instructions to a parent of a 13-month-old infant who weighs 18 lb (8.2 kg). Which statement by the parent demonstrates understanding of car seat safety? A. "My infant may ride in a front-facing car seat at 1 year of age." B. "My infant may ride in a front-facing car seat when weighing 30 lb (13.6 kg)." C. "My 13-month-old infant is very tall so I need to change to a front-facing car seat." D. "My infant will need to ride in a rear-facing car seat until 3 years old."
Correct response: "My infant may ride in a front-facing car seat when weighing 30 lb (13.6 kg)." Explanation: The American Academy of Pediatrics in 2018 recommended that children stay in rear-facing car seats as long as possible or until the highest weight and height allowed by the seat is reached. Generally this is 3 ft (1 m) tall and 30 to 35 lb (13.6 to 16 kg). Changing from rear- to front-facing is based on weight and height, not age. The parent would have to know the infant's height before changing positions of the car seat. Just stating the infant is "very tall" may not meet car seat guidelines.
The parent of a toddler hospitalized for episodes of diarrhea reports that when the toddler cannot have things the way she wants, she throws her legs and arms around, screams, and cries. The mother says, "I don't know what to do!" After the nurse teaches the parent about ways to manage this behavior, which statement by the parent indicates that the nurse's teaching was successful? A. "Next time she screams and throws her legs, I'll ignore the behavior." B. "I'll allow her to have what she wants once in a while." C. "I'll explain why she cannot have what she wants." D. "When she behaves like this, I'll tell her that she is being a bad girl."
Correct response: "Next time she screams and throws her legs, I'll ignore the behavior." Explanation: The child is demonstrating behavior associated with temper tantrums, which are relatively frequent normal occurrences during toddlerhood as the child attempts to develop a sense of autonomy. The development of autonomy requires opportunities for the child to make decisions and express individuality. Ignoring the outbursts is probably the best strategy. Doing so avoids rewarding the behavior and helps the child to learn limits, promoting the development of self-control. However, the mother should intervene in a temper tantrum if the child is likely to injure herself. Allowing the child to have what she wants occasionally would typically add to the problems associated with temper tantrums because doing so rewards the behavior and prevents the child from developing self-control. Toddlers do not possess the capacity to understand explanations about behavior. Expressing disappointment in the child's behavior or telling her that she is being a bad girl reinforces feelings of guilt and shame, thus interfering with the child's ability to develop a sense of autonomy.
A 2-year-old child is prescribed cyclosporine. The parent says the child doesn't like taking the liquid medication. Which statement by the nurse is most appropriate? A. "Give your child some control over what time the medication is taken during the day." B. "Offer the medication diluted with chocolate milk or orange juice to make it more palatable." C. "We can inquire about inserting a nasogastric (NG) tube to administer the medication." D. "Give the ordered dose in small amounts over 2 hours to make it less unpleasant."
Correct response: "Offer the medication diluted with chocolate milk or orange juice to make it more palatable." Explanation: Because liquid cyclosporine has a very unpleasant taste, diluting it with chocolate milk or orange juice will lessen the strong taste and help the child take the medication as ordered. It is not acceptable to miss a dose, because the drug's effectiveness is based on therapeutic blood levels, and skipping a dose could lower the level. It is also very important that the dosage be given at the same time every day. If it is given in the morning, it should always be given in the morning. Unfortunately, the child does not get to pick and choose when they will take the medication. Cyclosporine should not be given by NG tube, because it adheres to the plastic tube and, thus, some of the drug may not be administered. Taking the medication over a period of time could negatively affect the blood level. Cyclosporine comes in pill form, but a 2 year old is generally too young to swallow pills.
A boy, age 2, is diagnosed with hemophilia. The nurse explains to the father how the gene for hemophilia is transmitted. Which statement by the father indicates an understanding of gene transmission? A. "Our newborn daughter may be a carrier of the trait." B. "If we have more sons, all of them will have hemophilia." C. "All of our offspring will carry the trait for hemophilia." D. "Our daughter will develop hemophilia when she gets older."
Correct response: "Our newborn daughter may be a carrier of the trait." Explanation: The father stating that his newborn daughter may be a carrier of the trait demonstrates understanding of X-linked recessive disorders. X-linked recessive genes behave like other recessive genes. A normal dominant gene hides the effects of an abnormal recessive gene. However, the gene is expressed primarily in male offspring because it's located on the X chromosome. Male offspring of a carrier mother and an unaffected father have a 50% chance of expressing the trait, whereas female offspring are more likely to carry the trait than express it. These parents may produce offspring who neither express nor carry the trait for hemophilia.
A boy, age 2, is diagnosed with hemophilia. The nurse explains to the father how the gene for hemophilia is transmitted. Which statement by the father indicates an understanding of gene transmission? A. "Our newborn daughter may be a carrier of the trait." B. "If we have more sons, all of them will have hemophilia." C. "All of our offspring will carry the trait for hemophilia." D. "Our daughter will develop hemophilia when she gets older."
Correct response: "Our newborn daughter may be a carrier of the trait." Explanation: The father stating that his newborn daughter may be a carrier of the trait demonstrates understanding of X-linked recessive disorders. X-linked recessive genes behave like other recessive genes. A normal dominant gene hides the effects of an abnormal recessive gene. However, the gene is expressed primarily in male offspring because it's located on the X chromosome. Male offspring of a carrier mother and an unaffected father have a 50% chance of expressing the trait, whereas female offspring are more likely to carry the trait than express it. These parents may produce offspring who neither express nor carry the trait for hemophilia.
While interviewing a preschool-age girl who has been sexually abused about the event, which approach would be most effective? A. Describe what happened during the abusive act. B. Draw a picture and explain what it means. C. "Play out" the event using anatomically correct dolls. D. Name the perpetrator.
Correct response: "Play out" the event using anatomically correct dolls. Explanation: A 3-year-old child has limited verbal skills and should not be asked to describe an event, explain a picture, or respond verbally or nonverbally to questions. More appropriately, the child can act out an event using dolls. The child is likely to be too fearful to name the perpetrator or will not be able to do so.
Which statement by a parent indicates the best understanding of why raisins should be limited as a snack food in toddlers? A. "Raisins are low in nutritional value." B. "Raisins can increase tooth decay." C. "Raisins are easy to choke on." D. "Raisins are hard to digest entirely."
Correct response: "Raisins can increase tooth decay." Explanation: Raisins are high in nutritional value but are sticky and have a high sugar content. The raisin can stick to the teeth and act like high-sugar foods in promoting tooth decay. Although anything can be aspirated, round, hard, smooth foods are more easily aspirated than raisins, which are soft and chewy. Raisins need to be chewed thoroughly for maximum nutritional value.
A nurse in a clinic finds the mother of a 15-month-old child in tears. The mother states that her child doesn't love her, because the child says "no" to everything. Which response is appropriate? A. "This is unusual. Toddlers are usually very agreeable." B. "This is normal at this age. It's best to ignore the behavior." C. "Explain to your child what the word 'no' means." D. "Saying 'no' is part of toddler development and is normal at this age."
Correct response: "Saying 'no' is part of toddler development and is normal at this age." Explanation: Telling the mother that saying "no" is normal for a 15-month-old child is an appropriate response. The child's behavior doesn't mean that the child doesn't love the mother; it means the child is attempting to exert independence. Saying that it's best to ignore the behavior is inappropriate because the child needs to learn about limits. Saying that saying "no" is unusual is incorrect and may further frighten the mother that something is wrong with her child. A 15-month-old child already has a concrete understanding of the word "no."
A toddler is admitted to the emergency department with a suspected seizure disorder. When informing the parents about necessary diagnostic procedures, which statement is most appropriate for the nurse? A. "We will prepare your child to have spinal fluid withdrawn and analyzed." B. "The best way to diagnose seizures is through a computed tomography (CT) scan." C. "It's important to confirm a previous history of seizures for the child." D. "The child will need to have skull X-rays performed to verify the seizures."
Correct response: "The best way to diagnose seizures is through a computed tomography (CT) scan." Explanation: CT scans provide the most benefit of the list provided in determining irregular brainwave activity. None of the other options would be used to measure brain wave activity.
A parent of a 2-year-old child states the child cries when being dropped off at daycare but seems happy when being picked up later in the day. What is the best advice the nurse can give the parent related to this behavior? A. "This is a normal stage of development that toddlers go through." B. "Your child is likely afraid of something at the daycare." C. "Send your child's favorite toy to daycare as a comfort object." D. "It would help if you make a game of going to daycare."
Correct response: "This is a normal stage of development that toddlers go through." Explanation: Separation anxiety starts as early as 5 months old and is most evident in toddlers and preschoolers. It occurs after the child has gained an understanding of object permanence. Once the toddler learns the parent is really gone, crying and temper tantrums ensue. Because the toddler has a short attention span, once their attention is diverted to another activity the anxiety is reduced. Taking a favorite toy or blanket with the child may be helpful but does not solve the child's anxiety. It might be good for the parent to discuss the situation with the daycare personnel, but it still does not prevent the child from having separation anxiety.
What would be the nurse's best response to the parents of a child being discharged from the day surgery center after insertion of tympanostomy tubes when they ask, "What will happen to the tubes in my child's ears?" A. "The tubes usually dissolve on their own in about 1 year." B. "You will see them fall out in about 6 months." C. "The tubes must remain permanently in place." D. "Call for an appointment to have them removed in about 6 months."
Correct response: "You will see them fall out in about 6 months." Explanation: The tympanostomy tubes, made of a polyurethane material that does not change in structure or composition while in the ear, usually remain in place for about 6 months and then are spontaneously ejected from the ear. Parents should be told about the tubes' appearance so they can observe them if they fall out.The tubes do not dissolve, and they do not need to be surgically removed.
A 2-year-old is being seen in the outpatient department for a minor injury. The nurse places the child on the examining table, and the child begins to scream and cry. No attempts to comfort the toddler are effective. Which is the nurse's best action? A. Allow the parents to hold the child in their lap for the assessment. B. Allow the toddler to play on the floor until ready to start the assessment. C. Ask for help from another nurse to hold the child during the assessment. D. Ask the parents to hold their child tightly while the assessment is performed.
Correct response: Allow the parents to hold the child in their lap for the assessment. Explanation: Do not attempt to hold a toddler still for an assessment. Let the child sit in a parent's lap so that the nurse can perform the assessment. The child may play until ready to start the assessment, but once the assessment begins, the child should be placed in a parent's lap to maximize the sense of security that the parent provides.
A parent asks the nurse about the nutritional needs of her toddler. Which response by the nurse would be most appropriate? A. "Toddlers usually don't have a good appetite." B. "Toddlers have definite food preferences." C. "Toddlers usually consume large quantities of milk." D. "Toddlers are inquisitive, willing to try new foods."
Correct response: B. "Toddlers have definite food preferences." Explanation: Toddlers have definite food preferences, typically wanting the same food item for several days in a row.Because toddlers experience a slow and steady growth rate, they usually have a good appetite.Toddlers should consume 2 to 3 servings of milk per day.The majority of their nutrients should come from table foods. Toddlers typically are not interested in trying new foods.
When caring for a toddler with epiglottitis, the nurse should first A. examine the client's throat. B. place a tracheotomy tray at the bedside. C. administer I.V. fluids. D. administer antibiotics.
Correct response: B. place a tracheotomy tray at the bedside. Explanation: Placing a tracheotomy tray at the bedside should take priority because acute epiglottitis is an emergency situation in which inflammation can cause the epiglottis to swell, totally obstructing the airway. This situation may require tracheotomy or endotracheal intubation. The nurse should never depress the tongue of a child with a tongue blade to examine the throat if signs or symptoms of epiglottitis are present because this maneuver can cause the swollen epiglottis to completely obstruct the airway. Because the child can't swallow, I.V. fluids are necessary; however, airway concerns are the priority. Only after a patent airway is secured can antibiotics be given to treat Haemophilus influenzae, a common cause of acute epiglottitis.
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? A. stuttering B. using gestures to express desires C. babbling continuously D. playing alongside rather than interacting with peers
Correct response: B. using gestures to express desires Explanation: Using gestures instead of verbal communication to express desires — especially in a child older than age 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. In fact, 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.
When teaching a caregiver of a 17-month-old about toilet training, which instruction would initially be most appropriate? A. Place the toddler on the potty chair every 2 hours for 10 minutes. B. Offer a reward every time the toddler has a bowel movement in the potty chair. C. Remove the diaper and use training pants to begin the process. D. Be sure the toddler is ready before starting to toilet train.
Correct response: Be sure the toddler is ready before starting to toilet train. Explanation: All of the instructions are appropriate, but knowing whether the toddler is ready to toilet train is initially most appropriate. Many 17-month-olds do not have the neuromuscular control to be able to be trained. Waiting a few more months until the toddler is closer to age 2 years allows the toddler to develop more control. The caregiver should be taught the signs of readiness for toilet training.
x A toddler with hemophilia is hospitalized with multiple injuries after falling off a sliding board. X-rays reveal no bone fractures. When caring for the child, what is the nurse's highest priority? A. administering platelets as ordered B. taking measures to prevent infection C. assessing the child's level of consciousness (LOC) frequently D. discussing a safe play environment with the parents
Correct response: C. assessing the child's level of consciousness (LOC) frequently Explanation: In hemophilia, one of the factors required for blood clotting is absent, significantly increasing the risk of hemorrhage after injury. Therefore, the nurse must assess the child frequently for signs and symptoms of intracranial bleeding, such as an altered LOC, slurred speech, vomiting, and headache. To manage hemophilia, the absent blood clotting factor is replaced via I.V. infusion of factor, cryoprecipitate, or fresh frozen plasma; this may be done prophylactically or after a traumatic injury. Platelet transfusions aren't necessary. Clients with hemophilia aren't at increased risk for infection. Discussing a safe play environment with the parents is important but isn't the highest priority.
What should the nurse teach the parent of a 3-year-old child with eczema to remove from the child's environment at home? A. metal toy trucks B. plastic figures C. stuffed animals D. wooden blocks
Correct response: C. stuffed animals Explanation: For the child with eczema, which is commonly related to an allergic response, stuffed animals should be avoided because they tend to collect dust and are difficult to clean. Metal toy trucks, plastic figures, and wooden blocks are suitable toys for a 3-year-old child. They are easy to keep clean.
A toddler is receiving an infusion of total parenteral nutrition via a Broviac catheter. As the child plays, the I.V. tubing becomes disconnected from the catheter. What should the nurse do first? Turn off the infusion pump. Position the child on the side. Clamp the catheter. Flush the catheter with heparin.
Correct response: Clamp the catheter. Explanation: First, the nurse must clamp the catheter to prevent air entry, which could lead to air embolism. If an air embolism occurs, the nurse should position the child on the side after clamping the catheter. The nurse may turn off the infusion pump after ensuring the child's safety. If blood has backed up in the catheter, the nurse may need to flush the catheter with heparin; however, this isn't the initial priority.
A nurse is caring for a toddler admitted for long-term treatment of a chronic illness. Which action should the nurse take to promote normal childhood growth and development? A. Allow the child to sleep for at least 12 hours per night. B. Consult with a play therapist about activities in which the child can participate. C. Make sure the child is continuously isolated because of the chronic illness and risk of infection. D. Maintain a diet high in carbohydrates and low in fats.
Correct response: Consult with a play therapist about activities in which the child can participate. Explanation: Play is an important part of a child's growth and development. A nurse should facilitate play even when a child has a chronic illness. Consulting a play therapist is one way of facilitating such play. Although it's important for children to get adequate sleep, it isn't necessary for a toddler to get 12 hours' sleep per night. A child with a chronic illness may need to be temporarily isolated, but he should still have interaction with family members. A diet high in carbohydrates and low in fat isn't indicated for every toddler with a chronic illness.
The nurse meets with the family of a 3-year-old child who is seriously ill. What is the most important role of the nurse as collaborator? A. Addresses financial concerns and coordinates resources. B. Collaborates with facility clergy to provide spiritual care. C. Coordinates the multidisciplinary services and provides information about them. D. Orders consults with other specialties to help in treating the child's diagnosis.
Correct response: Coordinates the multidisciplinary services and provides information about them. Explanation: Coordinating the multidisciplinary services and providing information about them demonstrate collaboration because the nurse will be explaining the functions of social service, case management, and so forth. Providing parents with information about financial assistance programs is the responsibility of social services, not a nursing role. It is the healthcare provider's responsibility to order consults with other specialties. Collaborating with facility clergy to provide spiritual care is part of the nurse's role, but it is not the most important.
Twelve hours after cardiac surgery, the nurse is assessing a 3-year-old who weighs 15 kg. The nurse should notify the surgeon about which clinical finding? A. A Urine output of 60 mL in 4 hours B. strong peripheral pulses in all four extremities C. fluctuations of fluid in the collection chamber of the chest drainage system D. alterations in levels of consciousness
Correct response: D. alterations in levels of consciousness Explanation: Clinical signs of low cardiac output and poor tissue perfusion include pale, cool extremities, cyanosis or mottled skin, delayed capillary refill, weak, thready pulses, oliguria, and alterations in level of consciousness. An adequate urine output for a child over 1 year should be 1 mL/kg/h. Therefore 60 mL/4 h is satisfactory. Strong peripheral pulses indicate adequate cardiac output. Drainage from the chest tube should show fluctuation in the drainage compartment of the chest drainage system. The fluid level normally fluctuates as proof that the apparatus is airtight. On about the 3rd postoperative day, the fluctuation ceases indicating the lungs have fully expanded.
In an initial screening for lead poisoning, a toddler is found to have a minimally elevated lead level. What is the most important action the nurse should take? A. Arrange a follow-up appointment in 6 months. B. Obtain a consultation for chelation therapy. C. Educate parents on ways to reduce lead in the environment. D. Assure the parents this is not an unexpected finding.
Correct response: Educate parents on ways to reduce lead in the environment. Explanation: Treatment for children with minimally elevated lead levels should include family lead education, follow-up testing, and a social service consultation if needed. Waiting 6 months for a follow-up screening is too long because the effects of lead are irreversible. Oral chelation therapy is not begun until levels approach high levels, 45 mcg/dL (2.2 μmol/L). There is no such thing as a "normal" lead level because there is no beneficial action in the body.
Which nursing intervention will promote successful achievement of Erikson's stage of development for the 3-year-old toddler? A. Allow the toddler to choose what time to take an antibiotic. B. Encourage the toddler to assist in removing a dressing on the leg. C. Allow the toddler to work on an art project. D. Encourage friends to visit the toddler in the hospital.
Correct response: Encourage the toddler to assist in removing a dressing on the leg. Explanation: Toddlers are in Erikson's stage of autonomy versus shame and doubt. They want to do things on their own and experience despair when they are not allowed to be independent in areas which they are capable. Allowing the toddler to participate in the dressing change promotes their independence. Medications must be administered on a schedule to maintain therapeutic levels. Toddlers have short attention spans and would not likely complete an art project. Toddlers commonly engage in parallel play. Having another toddler visit will not aid in the achievement of Erikson's stage of development.
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? A. Isolation is not required at this time. B. Immediate isolation in a private room is required C. Isolation would be required 10 days after exposure. D. Isolation would be required 12 days after exposure.
Correct response: Immediate isolation in a private room is required. Explanation: 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.
After insertion of bilateral tympanostomy tubes in a toddler, which instruction should the nurse include in the child's discharge plan for the parents? A. Insert ear plugs into the canals when the child bathes. B. Gently clean the ear canal with cotton swabs. C. Administer antibiotics daily while the tubes are in place. D. Disregard any drainage from the ear after 1 week.
Correct response: Insert ear plugs into the canals when the child bathes. Explanation: Placing ear plugs in the ears will prevent contaminated bathwater from entering the middle ear through the tympanostomy tube and causing an infection. Inserting cotton swabs into the ear canal is not recommended. Antibiotics may be given for a short period after insert and are appropriate only when an ear infection is present. Tympanostomy tubes may remain in place for several years. It is not necessary to administer antibiotics continuously to a child with a tympanostomy tube. Drainage from the ear may be a sign of middle ear infection and should be reported to the health care provider (HCP).
When assessing for pain in a toddler, which method would be the most appropriate? Ask the child about the pain. Observe the child for restlessness. Use a numeric pain scale. Assess for changes in vital signs.
Correct response: Observe the child for restlessness. Explanation: Toddlers usually express pain through such behaviors as restlessness, facial grimaces, irritability, and crying. It is not particularly helpful to ask toddlers about pain. In most instances, they would be unable to understand or describe the nature and location of their pain because of their lack of verbal and cognitive skills. However, preschool and older children have the verbal and cognitive skills to be able to respond appropriately. While the FACES pain scale can be used in young children numeric rating pain scales are more appropriate for children who are of school age or older. Changes in vital signs do occur as a result of pain, but behavioral changes usually are noticed first.
When developing the postoperative plan of care for a child who is scheduled to have a tympanostomy tube inserted into the right ear, which intervention should the nurse identify to facilitate drainage? Apply warm compresses to the right ear. Position the child to lie on the right side. Apply a gauze dressing to the left ear. Apply an ice pack to the left ear.
Correct response: Position the child to lie on the right side. Explanation: Positioning the child on the affected side, in this case the right side, will promote drainage from the middle ear by gravity.Application of heat, such as in the form of warm compresses, may facilitate drainage of exudate from the ear but only if the child is lying on the affected side.A gauze dressing is not applied after surgery. However, a loose wick may be inserted into the external ear canal to absorb drainage from the right, not left, ear.Application of an ice bag may help reduce pressure and edema. However, the ice bag would be applied to the right ear.
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.
Correct response: Report the incident to the proper authorities. Explanation: 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.
A toddler with croup is given a racemic epinephrine treatment because of increasing respiratory distress. Which finding indicates that the treatment has been effective? Color is normal. Retractions are less severe. Heart rate is 100 bpm. Pulse oximeter reads 90.
Correct response: Retractions are less severe. Explanation: Epinephrine in an inhalant form can be given to decrease inflammation in the upper airway through vasoconstriction. It also has bronchodilator effects. In the case of croup, epinephrine is used to increase the opening of the narrowed airway. A decrease in the severity of retractions is the only answer indicating a change that reflects an increase in the airway opening.Children with croup may not manifest with color change. A heart rate of 100 is normal for a toddler and tells the nurse very little about a child's degree of respiratory distress. While no data is given to show that the pulse oximeter reading was improving, a oxygen saturation of less than 92% in room air reflects suboptimal oxygenation.
At 0300 the mother of a 3-year-old child calls the emergency department nurse and reports the child has a temperature of 101° F (38° C), a runny nose, and a barky cough that "gets going and will not stop." The mother states that she just gave the child acetaminophen. What should the nurse recommend next? A. Sit with the child in a steamy, warm bathroom. B. Run a steam vaporizer near the child's bedside. C. Give the child an over-the-counter decongestant. D. Administer aspirin in 2 hours.
Correct response: Sit with the child in a steamy, warm bathroom. Explanation: Based on the mother's description, the child most likely is exhibiting signs and symptoms of laryngotracheal bronchitis. The mother should try to decrease the inflammation in the upper airway by exposing her child to a warm, steamy environment. The safest method is to steam up the bathroom and stay with the child.Steam vaporizers work by boiling water. Their use is to be avoided because they can cause severe burns if the child comes in close contact with the steam or if the vaporizer spills.A decongestant may assist in decreasing the rhinorrhea (runny nose) but it will not decrease the inflammation in the upper airway.Laryngotracheal bronchitis is caused by a virus. Aspirin is contraindicated in children with viral infections because this combination is implicated in Reye's syndrome.
Which observation by the nurse should suggest that a 15-month-old toddler has been abused? The child appears happy when personnel work with him. The child plays alongside others contentedly. The child is underdeveloped for his age. The child sucks his thumb.
Correct response: The child is underdeveloped for his age. Explanation: An almost universal finding in descriptions of abused children is underdevelopment for age. This may be reflected in small physical size or in poor psychosocial development. The child should be evaluated further until a plausible diagnosis can be established. A child who appears happy when personnel work with him is exhibiting normal behavior. Children who are abused often are suspicious of others, especially adults. A child who plays alongside others is exhibiting normal behavior, that of parallel play. A child who sucks his thumb contentedly is also exhibiting normal behavior.
When developing the teaching plan for the mother of a toddler diagnosed with scabies, what information should the nurse expect to include? Disinfect all hard surfaces in the home. The child should be held frequently. Itching should cease in a few days. The entire family should be treated.
Correct response: The entire family should be treated. Explanation: Scabies is caused by the scabies mite, Sarcoptes scabiei. The mite burrows into the stratum corneum of the epidermis, where the female deposits eggs and fecal material. These burrows are linear. Scabies is highly contagious. The length of time from infestation to physical symptoms is 30 to 60 days, so everyone in close contact with the child will need to be treated. The bed linens and the child's clothing should be washed in hot water and dried on the hot setting. Disinfect all hard surfaces to prevent the spread of scabies. The child should be held minimally until treatment is completed. Family members should wash their hands after contact with the child. Itching lasts for 2 to 3 weeks until the stratum corneum is replaced.
A parent tells the nurse that the primary discipline method used in the home is corporal punishment. What should the nurse tell the parent about corporal punishment? A. It does not physically harm the child. B. Use can result in children becoming accustomed to spanking. C. It reinforces the idea that violence is not acceptable. D. Use can be beneficial in teaching children what they should do.
Correct response: Use can result in children becoming accustomed to spanking. Explanation: Corporal punishment is an aversion technique that teaches children what not to do. Children can commonly become accustomed to physical punishment, so the punishment must be more severe to get the same results. Parents commonly use physical punishment when they are in a rage; injury to the child can result. Corporal punishment, such as spanking, can reinforce the idea that violence is acceptable in certain circumstances. Corporal punishment is not beneficial. It causes children to be fearful and may lead children to redirect their anger in destructive ways.
Before administering a tube feeding to a toddler, which method should the nurse use to check the placement of a nasogastric (NG) tube? A. abdominal X-rays B. injection of a small amount of air while C. listening with a stethoscope over the abdominal area D. a check of the pH of fluid aspirated from the tube E. visualization of the measurement mark on the tube made at the time of insertion
Correct response: a check of the pH of fluid aspirated from the tube Explanation: Intestinal, gastric, and respiratory fluids have different pH values. Therefore, checking the pH of fluid aspirated from the tube is the most reliable technique for checking proper NG tube placement without taking X-rays before each feeding. X-rays can't be performed multiple times a day on a daily basis. Because auscultation of air can be heard when the tube is in the esophagus as well as in the stomach, this isn't the best test for checking placement. Observing the insertion measurement mark isn't a good check either because the mark may remain the same even though the tube has migrated up or down into the esophagus, lungs, or intestines.
These pediatric clients are in the triage area awaiting assessment. Which client will the nurse assess first? A. a crying 3-year-old whose parent is holding a cloth on the child's head covering a scalp laceration B. a lethargic 15-month-old with pink cheeks whose parent reported temperature of 38.4°C (101.2°F) C. a quiet 2-year-old with nasal flaring who is sitting in a tripod position D. a pale 6-month-old with a frequent cough and audible wheezing
Correct response: a quiet 2-year-old with nasal flaring who is sitting in a tripod position Explanation: The nurse identifies the nasal flaring and particularly the tripod position as indications of respiratory distress. This pediatric client needs rapid assessment and intervention and will be seen first. The other pediatric clients are not in immediate danger and will be seen as soon as possible by a healthcare professional.
After undergoing a tetralogy of Fallot repair, a preschool child is transferred to the pediatric floor. Which intervention does the nurse tells the family to expect? a reduced sodium diet an activity restriction for several days assignment to an isolation room limiting visitation to parents only
Correct response: a reduced sodium diet Explanation: Because of the hemodynamic changes that occur with open heart surgery repair, particularly with septal defects, transient congestive heart failure may develop. Therefore, the child's sodium intake typically is restricted to 2 to 3 g/day. Activity restrictions are inappropriate. Typically the child is encouraged to walk the halls and unit. Risk for infection after the repair is the same as any postoperative client, therefore isolation is not necessary. The child may be placed in a room with other children who are not contagious. Visitors are not restricted unless the pediatric unit has restrictive visiting policies.
A nurse is teaching a new mother about intussusception. Which signs and symptoms should the nurse include? A. abdominal distension and vomiting B. hard black stools C. high fever and loss of appetite D. loss of bowel sounds
Correct response: abdominal distension and vomiting Explanation: Intussusception occurs when a portion of the bowel slides into the next, like the pieces of a telescope. When this occurs it can create a blockage in the bowel, with the walls of the intestines pressing against one another. This leads to abdominal swelling, inflammation, and decreased blood flow to the part of the intestines involved. Additional symptoms include vomiting, passing of stools mixed with blood and mucus, and grunting due to pain.
A young child with sickle cell anemia prefers a side-lying position with the knees sharply flexed. The nurse should assess further for: nausea. backache. abdominal pain. emotional regression.
Correct response: abdominal pain. Explanation: The child's self-positioning on the side with the knees sharply flexed strongly suggests the possibility of abdominal pain. The child assumes this position to decrease the discomfort. Thus, the nurse should assess for further evidence of abdominal pain.Nausea usually causes a young child to refuse nourishment.A backache would most probably cause the young child to lie supine to relieve discomfort.Regression is common in acutely ill hospitalized children, but insufficient data are given to confirm regression.
Which behavior in a 20-month-old would lead the nurse to suspect that the child is being abused? absence of crying during the examination clinging to the parent during the examination playing with toys on the examination room floor talking easily with the nurse
Correct response: absence of crying during the examination Explanation: Children who are being abused may demonstrate behaviors such as withdrawal, apparent fear of parents, and lack of an appropriate reaction, such as crying and attempting to get away when faced with a frightening event (an examination or procedure).
Twelve hours after cardiac surgery, the nurse is assessing a 3-year-old who weighs 15 kg. The nurse should notify the surgeon about which clinical finding? A. a urine output of 60 mL in 4 hours B. strong peripheral pulses in all four extremities C. fluctuations of fluid in the collection chamber of the D. chest drainage system E. alterations in levels of consciousness
Correct response: alterations in levels of consciousness Explanation: Clinical signs of low cardiac output and poor tissue perfusion include pale, cool extremities, cyanosis or mottled skin, delayed capillary refill, weak, thready pulses, oliguria, and alterations in level of consciousness.An adequate urine output for a child over 1 year should be 1 mL/kg/h. Therefore 60 mL/4 h is satisfactory.Strong peripheral pulses indicate adequate cardiac output.Drainage from the chest tube should show fluctuation in the drainage compartment of the chest drainage system. The fluid level normally fluctuates as proof that the apparatus is airtight. On about the 3rd postoperative day, the fluctuation ceases indicating the lungs have fully expanded.
When assessing speech development, the nurse should refer which child for further revaluation? a 4-month-old who laughs out loud a 10-month-old who says "dada" and "mama" a 1-year-old who says 3 to 5 words an 18-month-old who only says "no"
Correct response: an 18-month-old who only says "no" Explanation: An 18-month-old child should be able to say 10 or more words. Lack of speech development may indicate a lack of social stimulation, a hearing deficiency, or developmental delay. Referring the child for an evaluation may increase the child's chance of reaching the child's potential. A 4-month-old child with a healthy central nervous system and normal mental development should be able to laugh out loud if the child's environment has been caring and the child's needs are met safely and consistently. Children at age 10 months should be able to say the words "dada" and "mama" in response to the appropriate person. A 1-year-old child should have the ability to speak three to five words plus "mama" and "dada."
For a client with a Wilms' tumor, which preoperative nursing intervention takes highest priority? A. restricting oral intake B. monitoring acid-base balance C. avoiding abdominal palpation D. maintaining strict isolation
Correct response: avoiding abdominal palpation Explanation: Because manipulating the abdominal mass may disseminate cancer cells to adjacent and distant sites, the most important intervention for a client with a Wilms' tumor is to avoid palpating the abdomen. Restricting oral intake and monitoring acid-base balance are routine interventions for all preoperative clients; they have no higher priority in one with a Wilms' tumor. Isolation isn't required because a Wilms' tumor isn't infectious.
A toddler with a ventricular septal defect is receiving digoxin to treat heart failure. Which assessment finding should be the nurse's priority concern? bradycardia tachycardia hypertension hyperactivity
Correct response: bradycardia Explanation: Digoxin enhances cardiac efficiency by increasing the force of contraction and decreasing the heart rate. An early sign of digoxin toxicity is bradycardia (an abnormally slow heart rate). To help detect digoxin toxicity, the nurse always should measure the apical heart rate before administering each digoxin dose. Other signs and symptoms of digoxin toxicity include arrhythmias, vomiting, hypotension, fatigue, drowsiness, and visual halos around objects. Tachycardia, hypertension, and hyperactivity aren't associated with digoxin toxicity.
Which is a priority nursing action for a child with croup? A. continually assessing respiratory status B. giving antipyretics to alleviate fever C. encouraging parents to stay with their child D. delivering oxygen as prescribed
Correct response: continually assessing respiratory status Explanation: Respiratory status should be assessed continually as the child may have laryngeal spasms without notice. Antipyretics may be given as well as oxygen, but respiratory status takes priority. Parents would be encouraged to stay with their child but this is not an immediate priority.
After teaching the parents of a toddler about commonly aspirated foods, which food, if identified by the parents as easily aspirated, would indicate the need for additional teaching? popcorn raw vegetables round candy crackers
Correct response: crackers Explanation: Crackers, because they crumble and easily dissolve, are not commonly aspirated. Because children commonly eat popcorn hulls or pieces that have not popped, popcorn can be easily aspirated. Toddlers frequently do not chew their food well, making raw vegetables a commonly aspirated food. Round candy is often difficult to chew and comes in large pieces, making it easily aspirated.
A mother brings a 15-month-old child to the well-baby clinic. She states the child has been taking approximately 18 to 20 oz (540 to 600 mL) of whole milk per day from a bottle with meals and at bedtime. The nurse should suggest that she begin weaning the child from the bottle to avoid risking: A. malnutrition. B. anemia. C. dental caries. D. malocclusion.
Correct response: dental caries. Explanation: Nursing bottle caries occur when a child is routinely given a bottle of milk or juice at nap and bedtime. When teeth become coated in sugar before sleep, the lack of activity in the child's mouth for several hours during sleep allows the sugar to convert to acid, leading to decay. A child drinking 18 to 20 oz of whole milk in a day should not be malnourished, although she may lack essential vitamins and iron. Anemia may occur if she is only drinking milk because it contains no iron; however, the mother indicates she is eating meals. Regardless, children of this age should be taking no more than 16 oz of milk per day, and most children at this age should be drinking from a cup. The mother should be instructed to wean the child to a cup one feeding at a time until the child is completely weaned to a cup for all feedings. The last bottle-feeding to be replaced is usually the night bottle. Malocclusion of the teeth does not occur at 15 months. If the child were to continue to suck on a bottle until age 4 years or later, then malocclusion may occur.
A nurse observes two 2-year-old children playing. The nurse documents what form of play as normal for this age group? A. playing a game of catch with a ball B. pretending to "race" toy cars with each other C. digging side-by-side in a sandbox D. riding tricycles near each other
Correct response: digging side-by-side in a sandbox Explanation: Two-year-old children exhibit parallel play. They engage in similar activity, side by side. Two-year-old children have very short attention spans, so they change toys easily when playing. Taking turns in games does not occur until age 3 years, and playing catch is a "take turns" activity. Pretending to "race" toy cars is more suggestive of cooperative play, in which the children work together. Cooperative play is more typical of children 4 to 5 years of age. Riding tricycles near each other represents independent play. While the children are performing the same activity, they do not maintain the constant proximity ("side-by-side") exhibited in the parallel play that is common among 2-year-olds.
After teaching the mother of a toddler with iron deficiency anemia about diet modifications, the nurse determines that the teaching was initially effective when the mother verbalizes she will make which dietary change? A. ingestion of equal amounts of iron-rich solids and milk products B. increased intake of iron-rich solids and C. decreased milk intake provision of several meals per day to the child D. twice-daily offerings of dairy food snacks to the child
Correct response: increased intake of iron-rich solids and decreased milk intake Explanation: In iron deficiency anemia, the child's intake of iron-rich solids needs to be increased, while the intake of milk, which is low in iron, needs to be decreased to just two servings a day. Decreasing milk intake will increase the child's hunger for and tolerance of solids that contain higher amounts of iron.It is impossible to obtain the needed iron from milk alone, but milk does contain essential minerals and vitamins. Providing the child with several meals per day does not ensure that the solid foods will be consumed.Offering the child snacks is appropriate if they are iron-rich. Even then, a decrease is milk intake is still necessary.
A nurse is caring for a 2-year-old child with tetralogy of Fallot (TOF) who is scheduled for surgery in 24 hours. What intervention is the most important for the nurse to include in the plan of care? A. meperidine for pain B. positioning the child with knees to the chest C. oxygen at 2 L/nasal cannula D. encouraging activity in the playroom
Correct response: positioning the child with knees to the chest Explanation: TOF consists of four congenital anomalies: pulmonic stenosis, intraventricular septal defect, overriding aorta, and right ventricular hypertrophy. Interventions for care include high flow oxygen, morphine, beta-blockers and positioning with knees to chest.
A toddler who has been treated for a foreign body aspiration begins to fuss and cry when the parents attempt to leave the hospital for an hour. The parents will be returning to take the toddler home. As the nurse tries to take the child out of the crib, the child pushes the nurse away. The nurse interprets this behavior as indicating which stage of separation anxiety? protest despair regression detachment
Correct response: protest Explanation: Young children have specific reactions to separation and hospitalization. In the protest stage, the toddler physically and verbally attacks anyone who attempts to provide care. Here, the child is fussing and crying and visibly pushes the nurse away. In the despair stage, the toddler becomes withdrawn and obviously depressed (e.g., not engaging in play activities and sleeping more than usual). Regression is a return to a developmentally earlier phase because of stress or crisis (e.g., a toddler who could feed himself before this event is not doing so now). Denial or detachment occurs if the toddler's stay in the hospital without the parent is prolonged because the toddler settles in to the hospital life and denies the parents' existence (e.g., not reacting when the parents come to visit).
The nurse conducts a developmental screening of a 15-month-old child with cerebral palsy. Which milestones would the nurse expect a typically developing toddler of this age to have achieved? walking up steps using a spoon copying a circle putting a block in cup
Correct response: putting a block in cup Explanation: Delay in achieving developmental milestones is a characteristic of children with cerebral palsy. Ninety percent of typically developing 15-month-old children can put a block in a cup. Walking up steps typically is accomplished at 18 to 24 months. A child usually is able to use a spoon at 18 months. The ability to copy a circle is achieved at approximately 3 to 4 years of age.
The mother of a toddler diagnosed with iron deficiency anemia asks what foods she should give her child. The nurse should evaluate the teaching as successful when the mother later reports that she feeds the toddler which foods? A. milk, carrots, and beef B. raisins, chicken, and spinach C. beef, lettuce, and juice D. eggs, cheese, and milk
Correct response: raisins, chicken, and spinach Explanation: Good sources of dietary iron include red meats, poultry, green leafy vegetables, and dried fruits such as raisins. Milk products are poor sources of iron. Carrots are high in vitamin A.
A nurse is caring for a young client with tetralogy of Fallot (TOF). The client is upset and crying. The nurse observes that the client is dyspneic and cyanotic. Which position would help relieve the client's dyspnea and cyanosis? sitting in bed with the head of the bed at a 45-degree angle squatting lying flat in bed lying on his right side
Correct response: squatting Explanation: Placing the child in a squatting position sequesters a large amount of blood to the legs, reducing venous return. Sitting with the head of the bed at a 45-degree angle, lying flat, and lying on the right side don't reduce venous return; therefore, they won't relieve the client's dyspnea and cyanosis. A client with TOF may also assume a knee-chest position to reduce venous return to the heart.
The nurse is caring for a toddler who has been diagnosed with pernicious anemia. Which of the following should the nurse include in the health teaching about pernicious anemia for the parents? A. how to increase dietary intake of iron B. the importance of immediately reporting a fever C. how to prepare the child for bone marrow transplant D. the need to comply with lifelong injections of vitamin B12
Correct response: the need to comply with lifelong injections of vitamin B12 Explanation: Pernicious anemia requires lifelong monthly intramuscular injections of vitamin B12. All other choices refer to other types of anemia.
The mother asks the nurse for advice about discipline for her 18-month-old. Which discipline strategy should the nurse suggest that the mother use? A. reprimand B. spanking C. reasoning D. time-out
Correct response: time-out Explanation: Time-out is the most appropriate discipline for toddlers. It helps to remove them from the situation and allows them to regain control. Structuring interactions with 3-year-olds helps minimize unacceptable behavior. This approach involves setting clear and reasonable rules and calling attention to unacceptable behavior as soon as it occurs. Reprimanding a young child can reinforce undesirable behavior over time because it provides attention. Physical punishment, such as spanking, has limited effectiveness and serious negative effects. Reasoning is more appropriate for older children, such as preschoolers and those older, especially when moral issues are involved. Unfortunately, reasoning combined with scolding often takes the form of shame or criticism and children take such remarks seriously, believing that they are "bad."
