PEDS Chapter 23

A nurse must do a venipuncture on a 6-year-old child. What consideration is important in providing atraumatic care? Use an 18-gauge needle if possible. Show the child the equipment to be used before the procedure. If not successful after four attempts, have another nurse try. Restrain the child completely.

Sow the child the equipment to be used before the procedure. To provide atraumatic care the child should be able to see the equipment to be used before the procedure begins. Use the smallest gauge needle that permits free flow of blood. A two-try-only policy is desirable, in which two operators each have only two attempts. If insertion is not successful after four punctures, alternative venous access should be considered. Restrain the child only as needed to perform the procedure safely; use therapeutic hugging.

Guidelines for intramuscular administration of medication in school-age children include what standard? Inject medication as rapidly as possible. Insert needle quickly, using a dartlike motion. Have the child stand if at all possible and if the child is cooperative. Penetrate the skin immediately after cleansing the site while the skin is moist.

Insert needle quickly, using a dartlike motion The needle should be inserted quickly in a dartlike motion at a 90-degree angle unless contraindicated. Inject medications slowly. Allow skin preparation to dry completely before the skin is penetrated. Place the child in a lying or sitting position.

The nurse has just collected blood by venipuncture in the antecubital fossa. What should the nurse do nextterm-23? Keep the child s arm extended while applying a Band-Aid to the site. Keep the child s arm extended and apply pressure to the site for a few minutes. Apply a Band-Aid to the site and keep the arm flexed for 10 minutes. Apply a gauze pad or cotton ball to the site and keep the arm flexed for several minutes.

Keep the child's arm extended and apply pressure to the site for a few minutes Applying pressure to the site of venipuncture stops the bleeding and aids in coagulation. Pressure should be applied before a bandage or gauze pad is applied.

A 14-year-old adolescent is hospitalized with cystic fibrosis. What nursing note entry represents best documentation of his breakfast meal? Tolerated breakfast well Finished all of breakfast ordered One pancake, eggs, and 240 ml OJ No documentation is needed for this age child.

One pancake, eggs, and 240mL OJ Specific information is necessary for hospitalized children. It is essential to be able to identify caloric intake and eating patterns for assessment and intervention purposes. That he tolerated breakfast well only provides information that the child did not become ill with the meal. Even if he finished all his breakfast, an evaluation cannot be completed unless the quantity of food ordered is known. Nutritional information is essential, especially for children with chronic illnesses.

An appropriate method for administering oral medications that are bitter to an infant or small child should be to mix them with which? Bottle of formula or milk Any food the child is going to eat One teaspoon of something sweet-tasting such as jam Carbonated beverage, which is then poured over crushed ice

One teaspoon of something sweet-tasting such as jam Mix the drug with a small amount (about 1 tsp) of sweet-tasting substance. This will make the medication more palatable to the child. The medication should be mixed with only a small amount of food or liquid. If the child does not finish drinking or eating, it is difficult to determine how much medication was consumed. Medication should not be mixed with essential foods and milk. The child may associate the altered taste with the food and refuse to eat this food in the future.

An 11-month-old hospitalized boy is restrained because he is receiving intravenous (IV) fluids. His grandmother has come to stay with him for the afternoon and asks the nurse if the restraints can be removed. What nurse s response is best? Restraints need to be kept on all the time. That is fine as long as you are with him. That is fine if we have his parents consent. The restraints can be off only when the nursing staff is present.

That is fine as long as you are with him. The restraints are necessary to protect the IV site. If the child has appropriate supervision, restraints are not necessary. The nurse should remove the restraints whenever possible. When parents or staff members are present, the restraints can be removed and the IV site protected. Parental permission is not needed for restraint removal.

A child who has cystic fibrosis is admitted to the pediatric unit with methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse recognizes that in addition to a private room, the child is placed on what precautions? Droplet Contact Airborne Standard

Contact MRSA is an increasingly significant source of hospital-acquired infections. This organism meets the criteria of being epidemiologically important and can be transmitted by direct contact. Gowns and gloves should be worn when exposed to potentially contagious materials, and meticulous hand washing is required. S. aureus is not an organism that is spread through airborne or droplet mechanisms. Additional precautions, beyond Standard Precautions, are needed to prevent spread of this organism.

Using knowledge of child development, what approach is best when preparing a toddler for a procedure? Avoid asking the child to make choices. Plan for a teaching session to last about 20 minutes. Demonstrate on a doll how the procedure will be done. Show the necessary equipment without allowing child to handle it.

Demonstrate on a doll how the procedure will be done Prepare toddlers for procedures by using play. Demonstrate on a doll but avoid the child s favorite doll because the toddler may think the doll is really feeling the procedure. In preparing a toddler for a procedure, the child is allowed to participate in care and help whenever possible. Teaching sessions for toddlers should be about 5 to 10 minutes. Use a small replica of the equipment and allow the child to handle it.

The nurse is preparing a 9-year-old boy before obtaining a blood specimen by venipuncture. The child tells the nurse he does not want to lose his blood. What approach is best by the nurse? Explain that it will not be painful. Suggest to him that he not worry about losing just a little bit of blood. Discuss with him how his body is always in the process of making blood. Tell the child that he will not even need a Band-Aid afterward because it is a simple procedure.

Discuss with him how his body is always in the process of making blood School-age children can understand that blood can be replaced. Explain the procedure to him using correct scientific and medical terminology. The venipuncture will be uncomfortable. It is inappropriate to tell him it will not hurt. Even though the nurse considers it a simple procedure, the boy is concerned. Telling him not to worry will not allay his fears.

The nurse gives an injection in a patient s room. How should the nurse dispose of the needle? Remove the needle from the syringe and dispose of it in a proper container. Dispose of the syringe and needle in a rigid, puncture-resistant container in the patient s room. Close the safety cover on the needle and return it to the medication preparation area for proper disposal. Place the syringe and needle in a rigid, puncture-resistant container in an area outside of the patient s room.

Dispose of the syringe and needle in a rigid, puncture-resistant container in the patient's room All needles (uncapped and unbroken) are disposed of in a rigid, puncture-resistant, tamper-proof container located near the site of use. Consequently, these containers should be installed in the patient s room. Needles and syringes are disposed of uncapped and unbroken. A used needle should not be transported to an area distant from use for disposal.

A 7-year-old is identified as being at risk for skin breakdown. What intervention should the nursing care plan include? Massaging reddened bony prominences Teaching the parents to turn the child every 4 hours Ensuring that nutritional intake meets requirements Minimizing use of extra linens, which can irritate the child s skin

Ensuring that nutritional intake meets requirements Children who are hospitalized and NPO (taking nothing by mouth) for several days are at risk for nutritional deficiencies and skin breakdown. If NPO status is prolonged, parenteral nutrition should be considered. Massaging bony prominences can cause deep tissue damage. This should be avoided. Although parents can participate, turning the child is the nurse s responsibility. If the child is alert and can move, position shifts should be done more frequently. If the child does not move, the nurse should reposition every 2 hours. The number of linens is not an issue. The child should not be dragged across the sheet. Children should be lifted and moved to avoid friction and shearing.

A 10-year-old child requires daily medications for a chronic illness. Her mother tells the nurse that the child continually forgets to take the medicine unless reminded. What nursing action is most appropriate to promote adherence to the medication regimen? Establish a contract with her, including rewards. Suggest time-outs when she forgets her medicine. Discuss with her mother the damaging effects of her rescuing the child. Ask the child to bring her medicine containers to each appointment so they can be counted.

Establish a contract with her, including rewards Many factors can contribute to the child s not taking the medication. The nurse should resolve those issues such as unpleasant side effects, difficulty taking medicine, and time constraints before school. If these factors do not contribute to the issue, then behavioral contracting is usually an effective method to shape behaviors in children. Time-outs provide negative reinforcement. If part of a contract, negative consequences can work, but they need to be structured. Discussing with her mother the damaging effects of her rescuing the child is not the most appropriate action to encourage compliance. For a school-age child, parents should refrain from nagging and rescuing the child. This child is old enough to partially assume responsibility for her own care. If the child brings her medicine containers to each appointment so they can be counted, this will help determine if the medications are being taken, but it will not provide information about whether the child is taking them by herself.

The practitioner has ordered a liquid oral antibiotic for a toddler with otitis media. The prescription reads 1 1/2 tsp four times per day. What should the nurse consider in teaching the mother how to give the medicine? A measuring spoon should be used, and the medication must be given every 6 hours. The mother is not able to handle this regimen. Long-acting intramuscular antibiotics should be administered. A hollow-handled medication spoon is advisable, and the medication should be equally spaced while the child is awake. A household teaspoon should be used and the medicine given when the child wakes up, around lunch time, at dinner time, and before bed.

A hollow-handled medication spoon is advisable, and the medication should be equally spaced when the child is awake A hollow-handled medication spoon allows the mother to measure the correct amount of medication. The order is written for four times a day; every 6 hours dosing is not necessary. There is no indication that the mother is not able to adhere to the medication regimen. She is asking for clarification so she can properly care for her child. Long-acting intramuscular antibiotics are not indicated. Household teaspoons vary greatly and should not be used.

A 4-year-old girl is admitted to outpatient surgery for removal of a cyst on her back. Her mother puts the hospital gown on her, but the child is crying because she wants to leave on her underpants. What is the most appropriate nursing action at this time? Allow her to wear her underpants. Discuss with her mother why this is important to the child. Ask her mother to explain to her why she cannot wear them. Explain in a kind, matter-of-fact manner that this is hospital policy.

Allow her to wear her underpants It is appropriate for the child to leave her underpants on. If necessary, the underpants can be removed after she has received the initial medications for anesthesia. This allows her some measure of control in this procedure. The mother should not be required to make the child more upset. The child is too young to understand what hospital policy means.

A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as acetaminophen. How should the nurse respond to the parents? Febrile seizures can result. Antipyretics may cause malignant hyperthermia. Correct Antipyretics are of no value in treating hyperthermia. Liver damage may occur in critically ill children.

Antipyretics are of no value in treating hyperthermia Unlike with fever, antipyretics are of no value in hyperthermia because the set point is already normal. Cooling measures are used instead. Antipyretics do not cause seizures. Malignant hyperthermia is a genetic myopathy that is triggered by anesthetic agents. Antipyretic agents do not have this effect. Acetaminophen can result in liver damage if too much is given or if the liver is already compromised. Other antipyretics are available, but they are of no value in hyperthermia.

Frequent urine tests for specific gravity are required on a 6-month-old infant. What method is the most appropriate way to collect small amounts of urine for these tests? Apply a urine collection bag to the perineal area. Tape a small medicine cup inside of the diaper. Aspirate urine from cotton balls inside the diaper with a syringe without a needle. Use a syringe without a needle to aspirate urine from a superabsorbent disposable diaper.

Aspirate urine from cotton balls inside the diaper with a syringe without a needle To obtain small amounts of urine, use a syringe without a needle to aspirate urine directly from the diaper. Diapers with superabsorbent gels absorb the urine; if these are used, place a small gauze dressing or cotton balls inside the diaper to collect the urine and aspirate the urine with a syringe. For frequent urine sampling, the collection bag would be too irritating to the child s skin. It is not feasible to tape a small medicine cup to the inside of the diaper; the urine will spill from the cup.

What is the best method to verify the placement of a nasogastric tube before each use? Radiologic confirmation Auscultation of injected air Aspiration of stomach contents Verification of tape placement on tube

Aspiration of stomach contents Visual inspection and pH check of stomach contents is a reliable method of determining placement before each use. Radiologic examination should be obtained after initial placement but would be too cumbersome to do before each use. Auscultation is an unreliable method to confirm tube placement because of the similarity of sounds produced by air in the bronchus, esophagus, or pleural space. Verification of tape placement on the tube can be inaccurate if the tube has moved within the tape or become dislodged from the stomach.

What is an advantage of the ventrogluteal muscle as an injection site in young children? Easily accessible from many directions Free of significant nerves and vascular structures Can be used until child reaches a weight of 9 kg (20 lb) Increased subcutaneous fat, which provides sustained drug absorption

Free of significant nerves and vascular structures Being free of significant nerves and vascular structure is one of the advantages of the ventrogluteal site. In addition, it is considered less painful than the vastus lateralis. The major disadvantage is lack of familiarity by health professionals and controversy over whether the site can be used before weight bearing. The vastus lateralis is a more accessible site. The ventrogluteal muscle site has safely been used from newborn through adulthood. Clinical guidelines address the need for the child to be walking. The site has less subcutaneous tissue, which facilitates intramuscular deposition of the drug rather than subcutaneous.

A 16-year-old girl comes to the pediatric clinic for information on birth control. The nurse knows that before this young woman can be examined, consent must be obtained from which source? Herself Her mother Court order Legal guardian

Herself Contraceptive advice is one of the conditions that is considered medically emancipated. The adolescent is able to provide her own informed consent.

A bone marrow biopsy will be performed on a 7-year-old girl. She wants her mother to hold her during the procedure. How should the nurse respond? Holding your child is unsafe. Holding may help your child relax. Hospital policy prohibits this interaction. Holding your child is unnecessary given the child s age.

Holding may help your child relax The mother s preference for assisting, observing, or waiting outside the room should be assessed, as well as the child s preference for parental presence. The child s choice should be respected. This will most likely help the child through the procedure. If the mother and child agree, then the mother is welcome to stay. Her familiarity with the procedure should be assessed and potential safety risks identified (mother may sit in chair). Hospital policies should be reviewed to ensure that they incorporate family-centered care.

When teaching a mother how to administer eye drops, where should the nurse tell her to place them? At the lacrimal duct On the sclera while the child looks to the outside In the conjunctival sac when the lower eyelid is pulled down Carefully under the eyelid while it is gently pulled upward

In the conjunctival sac when the lower eyelid is pulled down The lower eyelid is pulled down, forming a small conjunctival sac. The solution or ointment is applied to this area. The medication should not be administered directly on the eyeball. The lacrimal duct is not the appropriate placement for the eye medication. It will drain into the nasopharynx, and the child will taste the drug.

The nurse needs to take the blood pressure of a preschool boy for the first time. What action would be best in gaining his cooperation? Tell him that this procedure will help him get well faster. Take his blood pressure when a parent is there to comfort him. Explain to him how the blood flows through the arm and why the blood pressure is important. Permit him to handle the equipment and see the cuff inflate and deflate before putting the cuff in place.

Permit him to handle the equipment and see the cuff inflate and deflate before putting the cuff in place A preschooler is at the stage of preoperational thought. The nurse needs to explain the procedure in simple terms and allow the child to see how the equipment works. This will help allay fears of bodily harm. Blood pressure measurement is used for assessment, not therapy, and will not help him get well faster. Although the parent will be able to support the child, he may still be uncooperative. Also, the assessment of blood pressure may be needed before the parent is available. Explaining to a preschooler how the blood flows through the artery and why the blood pressure is important is too complex.

Parents are being taught how to feed their infant using a newly placed gastrostomy tube (G-tube). What is essential information for the parents to receive? Verify placement before each feeding. Use a syringe with a plunger to give the infant bolus feedings. Position the infant on the right side during and after the feeding. Beefy red tissue around the G-tube site must be reported to the practitioner.

Position the infant on the right side during and after the feeding Positioning on the right side during and after feedings helps minimize the risk of aspiration. It is not necessary to verify placement before each feeing. G-tubes are inserted into the stomach and sutured in place. If the tube is through the skin, it is in the stomach. Feedings should be given by gravity flow. The plunger may be used to initiate the feeding, but then the formula should be allowed to flow. Beefy red tissue around the G-tube site is normal granulation tissue that is expected.

A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When preparing for a lumbar puncture, what should the nurse do? Set up a tray with equipment the same size as for adults. Apply EMLA to the puncture site 15 minutes before the procedure. Prepare the child for conscious sedation being used for the procedure. Reassure the parents that the test is simple, painless, and risk free.

Prepare the child for conscious sedation being used for the procedure Because of the urgency of the child s condition, conscious sedation should be used for the procedure. Pediatric spinal trays have smaller needles than do adult trays. EMLA should be applied approximately 60 minutes before the procedure; the emergency nature of the spinal tap precludes its use. A spinal tap is not a simple procedure and does have associated risks; analgesia will be given for the pain.

A 5-year-old child returns from the pediatric intensive care unit after abdominal surgery. The orders state to monitor vital signs every 2 hours. On assessment, the nurse observes that the child s heart rate is 20 beats/min less than it was preoperatively. What should be the nurse s next action? Follow the orders and check in 2 hours. Ask the parents if this is the child s usual heart rate. Recheck the pulse and blood pressure in 15 minutes. Notify the surgeon that the child is probably going into shock.

Recheck the pulse and blood pressure in 15 minutes In a 5-year-old child, this is a significant change in vital signs. The nurse should assess the child to see if his condition mirrors a drop in heart rate. The assessment and vital signs should be redone in 15 minutes to determine whether the child s condition is stable. When a disparity in vital signs or other assessment data is observed, the nurse should reassess sooner. Most parents will not know their child s heart rate. It is important to determine how the child is recovering from surgery. The nurse should collect additional information before notifying the surgeon. This includes blood pressure, respiratory rate, and pain status.

A child, age 7 years, has a fever associated with a viral illness. She is being cared for at home. What is the principal reason for treating fever in this child? Relief of discomfort Reassurance that illness is temporary Prevention of secondary bacterial infection Avoidance of life-threatening complications

Relief of discomfort The principal reason for treating fever is the relief of discomfort. Relief measures include pharmacologic and environmental intervention. The most effective is the use of pharmacologic agents to lower the set point. Although the nurse can reassure the child that the illness is temporary, the child is often uncomfortable and irritable. Intervention helps the child and family minimize the discomfort. Most fevers result from viral, not bacterial, infections. Few life-threatening events are associated with fever. The use of antipyretics does not seem to reduce the incidence of febrile seizures.

A 6-year-old boy is hospitalized for intravenous antibiotic therapy. He eats very little on his regular diet trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. What nursing action is the most appropriate? Request these favorite foods for him. Identify healthier food choices that he likes. Explain that he needs fruits and vegetables. Reward him with ice cream at the end of every meal that he eats.

Request these favorite foods for him Loss of appetite is a symptom common to most childhood illnesses. To encourage adequate nutrition, the nurse should request favorite foods for the child. The foods he likes provide nutrition and can be supplemented with additional fruits and vegetables. Ice cream and other desserts should not be used as rewards or punishment.

A 6-year-old child needs to drink 1 L of GoLYTELY in preparation for a computed tomography scan of the abdomen. To encourage the child to drink, what should the nurse do? Give him a large cup with ice so it tastes better. Restrict him to his room until he drinks the GoLYTELY. Use little cups and make a game to reward him for each cup he drinks. Tell him that if he does not finish drinking by a set time, the practitioner will be angry.

Use little cups and make a game to reward him for each cup he drinks One liter of GoLYTELY is difficult for many children to drink. By using small cups, the child will find the amount less overwhelming. Then a game can be made in which some type of reward (sticker, reading another page of a book) is given for each cup. A large cup of ice would make it more difficult because the child would see it as too much and ice adds additional fluid to be consumed. Negative reinforcement may work if the child wishes to be out of his room. A practitioner may or may not be angry if he does not finish drinking by a set time; this is a threat that may or may not be true. If the child is having difficulty drinking, this would most likely not be effective.

A toddler is being sent to the operating room for surgery at 9 AM. As the nurse prepares the child, what is the priority intervention? Administering preoperative antibiotic Verifying that the child and procedure are correct Ensuring that the toddler has been NPO since midnight Informing the parents where they can wait during the procedure

Verifying that the child and procedure are correct The most important intervention is to ensure that the correct child is going to the operating room for the identified procedure. It is the nurse s responsibility to verify identification of the child and what procedure is to be done. If an antibiotic is ordered, administering it is important, but correct identification is a priority. Clear liquids can be given up to 2 hours before surgery. If the child was NPO (taking nothing by mouth) since midnight, intravenous fluids should be administered. Parents should be encouraged to accompany the child to the preoperative area. Many institutions allow parents to be present during induction.

A child has a central venous access device for intravenous (IV) fluid administration. A blood sample is needed for a complete blood count, hemogram, and electrolytes. What is the appropriate procedure to implement for this blood sample? Perform a new venipuncture to obtain the blood sample. Interrupt the IV fluid and withdraw the blood sample needed. Withdraw a blood sample equal to the amount of fluid in the device, discard, and then withdraw the sample needed. Flush the line and central venous device with saline and then aspirate the required amount of blood for the sample.

Withdraw a blood sample equal to the amount of fluid in the device, discard, and then withdraw the sample needed. The blood specimen obtained must reflect the appropriate hemodilution of the blood and electrolyte concentration. The nurse needs to withdraw the amount of fluid that is in the device and discard it. The next sample will come from the child s circulating blood. With a central venous device, the trauma of a separate venipuncture can be avoided. The blood sample will be diluted with either the IV fluid being administered or the saline.