Peds Exam 1

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Assessment of infant/child and parent:

"Goodness of fit": Are the parents' expectations of their child's behavior consistent with the child's temperament type?

Question 10 Type: MCSA A school-age child has epistaxis. Which intervention by the school nurse is the most appropriate? Tilting the child's head forward, squeezing the nares below the nasal bone, and applying ice to the nose Tilting the child's head back, squeezing the bridge of the nose, and applying a warm, moist pack to the nose Lying the child down and applying no pressure, ice, or warm pack Immediately packing the nares with a cotton ball soaked with Neo-Synephrine

Question 10 Type: MCSA The nurse is assessing a family's effective coping strategies and ineffective defensive strategies. Which family-social-system theory is the nurse using in this assessment of the family? Family-stress theory Family-development theory Family-systems theory Family life-cycle theory

Question 3 Type: MCSA The nurse suspects that an infant has a visual disorder caused by abnormal musculature. Which test will the nurse perform to detect this disorder? A cover/uncover test An ophthalmologic exam A vision-acuity exam A pupil-reaction-to-light test

Question 5 Type: MCSA A nurse is caring for a visually impaired 20-month-old who has not begun to walk. Which nursing diagnosis is the most appropriate for this client? Delayed growth and development Impaired physical mobility Self-care deficit Impaired home maintenance

Question 5 Type: MCSA Several children arrived at the emergency department accompanied only by their fathers. Which father may legally sign emergency medical consent for treatment? The divorced one from the binuclear family The stepfather from the blended or reconstituted family The divorced one when the single-parent mother has custody The nonbiologic one from the heterosexual cohabitating family

Question 7 Type: MCSA While inspecting a 5-year-old child's ears, the nurse notes that the right pinna protrudes outward and that there is a mass behind the right ear. In light of these findings, which vital-sign parameter would the nurse assess on priority? Temperature Heart rate Respirations Blood pressure

Question 8 Type: MCMA A 7-year-old child presents to the clinic with an exacerbation of asthma symptoms. On physical examination, the nurse would expect which assessment findings? Standard Text: Select all that apply. Wheezing Increased tactile fremitus Decreased vocal resonance Decreased tactile fremitus Bronchophony

1, 3, 4

CHAPTER 8 Question 1 Type: MCMA Which of these aspects of developmental health supervision should be included in each healthcare visit of young children? Standard Text: Select all that apply. Assessment Discipline Education Intervention Toilet training

1, 3, 4 rationale 1: The main recommendations for developmental health supervision of young children include assessment, education, intervention, and care coordination. This standard framework should be used as guidelines for each healthcare visit. Discipline and toilet training, while important to the care of children, are age specific and not part of the main developmental plans.

Question 10 Type: SEQ A new parent group inquires about the stages through which their children will progress as they grow older. The nurse is discussing Piaget's developmental stages. In what order would the nurse expect the child to progress through Piaget's stages of development? Standard Text: Click and drag the options below to move them up or down. Choice 1. Sensorimotor Choice 2. Formal operational Choice 3. Preoperational Choice 4. Concrete operational

1, 3, 4, 2

Question 8 Type: MCMA The nurse teaches parents how to care for their child who has tympanostomy tubes inserted. Which actions by the parents indicate appropriate understanding of the teaching session? Standard Text: Select all that apply. Encouraging the child to drink generous amounts of fluids Administering a decongestant for one to two weeks following surgery Restricting the child to quiet activities after surgery Limiting diet to soft, bland foods Avoiding getting water in ears during bath time

1, 3, 5

spacer medication system

1.Shake-attach spacer 2.Tilt head back breath in for 5 seconds 3.Hold 10 seconds 4.Breath out 5 seconds Teach 5-10-5 rule Without a spacer=only 20% of medication delivered to large airways

nursing considerations

1.Teach use of antibiotic therapy 2.Pain relief 3.Follow up medical care 4.Prevention-second hand smoke 5.Holding infants to feed 6.Limit use of pacifier

CHAPTER 19 Question 1 Type: MCSA A nurse is assessing infants for visually related developmental milestones. Which infant is showing a delay in meeting an expected milestone? 4-month-old who has a social smile 8-month-old who has just begun to inspect her own hand 12-month-old who stacks blocks 7-month-old who picks up a raisin by raking

Question 3 Type: MCSA A school-age client tells you that "Grandpa, Mommy, Daddy, and my brother live at my house." Which type of family will the nurse identify in the medical record based on this description? Binuclear family Extended family Gay or lesbian family Traditional nuclear family

Question 5 Type: MCSA A nurse caring for a school-age client notices some swelling in the child's ankles. The nurse presses against the ankle bone for five seconds, then releases the pressure and notices a markedly slow disappearance of the indentation. Which priority nursing assessment is appropriate? Skin integrity, especially in the lower extremities Urine output Level of consciousness Range of motion and ankle mobility

Question 6 Type: MCSA A nurse is caring for a visually impaired school-age child. Which nursing intervention is the highest priority for this child during the admission process? Explaining playroom policies Orienting the child to where furniture is placed in the room Letting the child touch equipment that will be used during the hospitalization Taking the child on a tour of the unit

Question 7 Type: MCSA An infant is diagnosed with acute otitis media. Which intervention is most appropriate for the nurse to teach the infant's parents? Keep the baby in a flat lying position during sleep. Administer acetaminophen (Tylenol) to relieve discomfort. Administer a decongestant. Place baby to sleep with a pacifier.

Question 7 Type: MCSA The nurse is working on parenting skills with a group of mothers. Which mother would need the fewest discipline-related suggestions? Authoritarian one Authoritative one Indifferent one Permissive one

CHAPTER 2 Question 1 Type: MCMA The nurse is planning care for an adolescent client who will be hospitalized for several weeks following a traumatic brain injury. Which interventions will enhance family-centered care for this client and family? Standard Text: Select all that apply. Making all ADL decisions for the adolescent and family Asking the adolescent what foods to include during meal time Allowing the family time to pray each day with the adolescent Encouraging the adolescent's friends to visit during visiting hours Leaving all questions for the healthcare provider

2. Asking the adolescent what foods to include during meal time3. Allowing the family time to pray each day with the adolescent4. Encouraging the adolescents friends to visit during visiting hours

Question 10 Type: MCSA During an examination, a nurse asks a 5-year-old child to repeat his address. What is the nurse evaluating with this action? Recent memory Language development Remote memory Social-skill development

Question 4 Type: MCSA The nurse is caring for four clients. Which client has the highest risk of developing retinopathy of prematurity? 30-week-gestation infant who was in an Oxy-Hood for 12 hours and weighed 1800 grams. 32-week-gestation infant who needed no oxygen and weighed 1850 grams. 28-week-gestation infant who has been on long-term oxygen and weighed 1400 grams. 28-week-gestation infant who was on short-term oxygen and weighed 1420 grams.

Question 6 Type: MCSA A new mother is worried about a "soft spot" on the top of her newborn infant's head. The nurse informs her that this is a normal physical finding called the anterior fontanel. At what age will the nurse educate the mother that the soft spot will close? 2 to 3 months of age 6 to 9 months of age 12 to 18 months of age Approximately 2 years of age

Question 6 Type: MCSA The community-health nurse is assessing several families for various strengths and needs in regard to after-school and backup child-care arrangements. Which family type will benefit the most from this assessment and subsequent interventions? The binuclear family The extended family The single-parent family The traditional nuclear family

Question 8 Type: MCSA The nurse in the pediatric clinic observes a parental lack of warmth and interest toward the child. Which family style will the nurse most likely document in this situation? Authoritarian Authoritative Indifferent Permissive

Question 9 Type: MCSA The nurse is caring for a newly-admitted infant diagnosed with "failure to thrive." The nurse begins to implement the healthcare provider prescribed orders by taking blood pressures in all four extremities. Which congenital cardiac defect does the nurse anticipate based on the prescribed order? Tetralogy of Fallot Pulmonary atresia Coarctation of the aorta Ventricular septal defect

Question 9 Type: MCSA The nurse is working on parenting skills with a mother of three children. The nurse demonstrates a strategy that uses reward to increase positive behavior. Which strategy will the nurse document in the medical record based on this description? Time out Reasoning Behavior modification Experiencing consequences of misbehavior

CHAPTER 9 Question 1 Type: MCSA An adolescent female presents at a nurse practitioner's office and requests a signature for working papers. The nurse reviews her chart and notes that the last physical examination was two years ago. In addition to providing the signature for the working papers, what else should the nurse use this visit? An opportunity to discuss birth-control measures A time to discuss exercise and sports participation A health-supervision opportunity A chance to discuss the importance of pursuing post secondary education

3 Rationale 1: All visits should be used as health-promotion and health-supervision visits. While discussing birth control, exercise, and future plans is important, these can be included in the overall health-supervision protocols.

Question 2 Type: MCSA A neonate has been diagnosed with a herpes simplex viral infection of the eye. Which medication will the nurse prepare to administer? Fluoroquinolone eye drops or ointment Intravenous penicillin Oral erythromycin Parenteral acyclovir (Zovirax) and vidarabine (VIRA-A) ophthalmic ointment

Question 4 Type: MCSA The nurse is performing an assessment of a child's biologic family history. Which situation would necessitate the nurse's asking the mother for information should use the term "child's father" instead of "your husband"? Traditional nuclear family Traditional extended family Two-income nuclear family Cohabitating informal stepfamily

Question 9 Type: MCSA Which action by the nurse can assist a child who has a mild hearing loss and reads lips to adapt to hospitalization? Speaking directly to the parents for communication Speaking in a loud voice while facing the child Using a picture board as the main means of communication Touching the child lightly before speaking

Question 3 Type: SEQ Place the nursing assessments of a toddler in the best order. Standard Text: Click and drag the options below to move them up or down. Choice 1. Examination of eyes, ears, and throat Choice 2. Auscultation of chest Choice 3. Palpation of abdomen Choice 4. Developmental assessment

4, 2 , 3, 1

Question 2 Type: MCSA A new pediatric hospital will open soon. While planning nursing care, the hospital administration is considering two models of providing health care: family-focused care and family-centered care. Which action best implements family-centered care? Telling the family what must be done for the family's health Assuming the role of an expert professional to direct the health care Intervening for the child and family as a unit Conferring with the family in deciding which healthcare option will be chosen

4. Conferring with the family in deciding which healthcare option will be chosen

6 cardinal gaze

6 Cardinal Fields of Gaze •Test extraocular movements • Have the child sit at your eye level. •Hold a toy or penlight about 12 in. from the child's eyes and move it in all six directions indicated. •Both eyes should move together,tracking the object.

Question 4 Type: MCSA While assessing the development of a 9-month-old infant, the nurse asks the mother if the child actively looks for toys when they are placed out of sight. Which developmental task is the nurse assessing this infant for? Object permanence Centration Transductive reasoning Conservation

Question 5 Type: MCSA The nurse is counseling the parents of a 6-1/2-month-old infant. Which age-appropriate toy is most appropriate for the nurse to suggest to these parents? Soft, fluid-filled ring that can be chilled in the refrigerator Colorful rattle Jack-in-the-box toy Push-and-pull toy

Question 6 Type: MCSA A mother of a 2-year-old child becomes very anxious when the child has a temper tantrum in the medical office. Which response by the nurse is the most appropriate? "What do you usually do or say during a temper tantrum?" "Let's ignore this behavior; it will stop sooner or later." "Pick up and cuddle your child now, please." "This is definitely a temper tantrum; I know exactly what you are feeling right now."

Question 8 Type: MCSA A parent says to a nurse, "How do you know when my child needs these screening tests the doctor just mentioned?" Which response by the nurse is the most appropriate? "Screening tests are administered at the ages when a child is most likely to develop a condition." "Screening tests are done in the newborn nursery and from these results, additional screening tests are ordered throughout the first two years of life." "Screening tests are most often done when the doctor suspects something is wrong with the child." "Screening tests are done at each office visit."

Fantasy

A creation of the mind to help deal with unacceptable fear A hospitalized child who is weak pretends to be Superman.

Question 9 Type: MCMA Which nursing assessment activities should be included for the child and family at each health-supervision visit? Standard Text: Select all that apply. Interview to obtain an updated health history. Performing an age-appropriate development assessment. Monitoring parents' ability to pay for services. Performing age-appropriate screening examinations. Physical assessment for genetic abnormalities.

A, B, D

Question 2 Type: MCSA A mother of a school-age client who recently had surgery for the removal of tonsils and adenoids complains that the child has begun sucking his thumb again. Which coping mechanisms is the child using to cope with the surgery and hospitalization? Repression Rationalization Regression Fantasy

A. regression

adolescent style of play

Adolescent ◦Increased maturity leads to new activities and ways to "play" ◦Adolescents can now drive, ride buses, or bike independently and are less dependent on parents ◦Peer group (as the focus of activities) plays an important role in establishing the adolescent's identity ◦Same sex friend groups still dominate though romantic relationships are now more common ◦Participate in and learn from social interactions fundamental to adult relationships

adolescents dev. response to illness

Adolescents ◦Understands complex nature of illness and often fear results of it ◦Fear of missing out with friends and peers ◦Encourage participation in play room, school ◦Concerned with effects of illness on appearance/body image ◦Respect need for privacy and independence ◦Careful listening by nurse ◦Partner with family and adolescent in care ◦Encourage family to include patient in decision making and empower the patient with choices

VII facial

All ages: Observe facial expressions when crying, smiling, frowning, etc. Facial features stay symmetric bilaterally.

Rationalization

An attempt to make unacceptable feelings acceptable A child explains hitting another because "he took my toy."

A nurse is working with pediatric clients in a research facility. The nurse recognizes that federal guidelines are in place that delineate which pediatrics clients must give assent for participation in research trials. Based upon the clients age, the nurse would seek assent from which children? Select all that apply. 1. The precocious 4-year-old starting as a cystic fibrosis research-study participant. 2. The 7-year-old leukemia client electing to receive a newly developed medication, now being researched. 3. The 10-year-old starting in an investigative study for clients with precocious puberty. 4. The 13-year-old client beginning participation in a research program for ADHD treatments. Correct

Answer: 2,3,4 Rationale 1: Federal guidelines mandate that research participants 7 years old and older must receive developmentally appropriate information about healthcare procedures and treatments and give assent.

Lenght vs height

Anthropometric Measurements Birth to 24 months Measuring board Height ◦After age 2 years ◦Stadiometer (standing)

What does all this mean for my pediatric patients??? How??

As nurses we need to use the data collected during developmental assessments to implement activities that promote development of children and adolescents even when they are hospitalized. •Encourage appropriate growth and development while hospitalized •Encourage play while hospitalized •Ensure that schoolwork continues while hospitalized •Include anticipatory guidance during and after hospitalization

Question 9 Type: MCSA The nurse, talking with the parents of a toddler who is struggling with toilet training, reassures them that their child is demonstrating a typical developmental stage. According to Erikson, which developmental stage will the nurse document in the medical record for this toddler? Trust versus mistrust Autonomy versus shame and doubt Initiative versus guilt Industry versus inferiority

babinski

Babinski Reflex •The Babinski response is normal in children under 2 years of age. Plantar flexion of the toes is the normal response in older children. •A Babinski response in children over 2 years of age can indicate neurologic disease.

authoritative

Behavior of parent Accepts and encourages growing autonomy of the child •Open communication with the child •Flexible rules Behavior of child •Tends to be best adjusted, self-reliant, self-controlled, and socially competent •Higher self-esteem •Better school performance

Authoritarian

Behavior of parent Highly controlling, issues commands and expects them to be obeyed •Little communication with child •Inflexible rules •Permits very little independence Behavior of child May be fearful, withdrawn, and unassertive •Girls are often passive and dependent during adolescent •Boys often aggressive and rebellious

Question 6 Type: MCSA A nurse is assessing language development in all the infants presenting at the doctor's office for well-child visits. At which age range would the nurse expect a child to verbalize the words "dada" and "mama"? 3 and 5 months 6 and 8 months 9 and 12 months 13 and 18 months

Question 7 Type: MCSA The parents of an 8-year-old state that their son seems very interested in trying new activities. When the parents ask for suggested activities for this age child, the nurse recommends scouts as an activity that will foster growth and development. In which stage of Erikson's "psychosocial stages of development" is this child? Trust versus mistrust Initiative versus guilt Industry versus inferiority Identity versus role confusion

Question 8 Type: MCSA Two 3-year-olds are playing in a hospital playroom together. One is working on a puzzle while the other is stacking blocks. Which type of play are these children exhibiting? Cooperative play Associative play Parallel play Solitary play

chest

Chest •Inspect the chest for any irregularities in shape. •A chest is considered rounded when the anteroposterior diameter is approximately equal to the lateral diameter; which is common with chronic obstructive lung condition such as asthma or cystic fibrosis. •If the sternum protrudes, increasing the anteroposterior diameter, pigeon chest (pectus carinatum) may be present.* •If the lower portion of the sternum is depressed, decreasing the anteroposterior diameter, funnel chest (pectus excavatum) may be present.* •Scoliosis, curvature of the spine, causes a lateral deviation of the chest

If not, how can we improve it?

Child's Behavior Parents' Adaptations Extremely active Plan periods of active play several times a day. Have restful periods before bedtime to foster sleep. Shy Allow time to adapt at own pace to new people and situations. Easily stimulated Have quiet room for sleeping for an infant. Have quiet room for homework for a school-age child. Short attention span Provide projects that can be completed in a short period. Gradually encourage longer periods at activities.

rhonchi

Coarse, low-pitched sound like a snore, heard during inspiration or expiration; may clear with coughing Air passing through thick secretions that partially obstruct the larger bronchi and trachea

Which legal or ethical offense would be committed if a nurse tells family members the condition of a newborn baby without first consulting the parents? 1. A breach of privacy 2. Negligence 3. Malpractice 4. A breach of ethics

Correct Answer: 1 Rationale 1: A breach of privacy would have been committed in this situation, because it violates the right to privacy of this family. The right to privacy is the right of a person to keep his or her person and property free from public scrutiny, including other family members. Negligence and malpractice are punishable legal offenses and are more serious. A breach of ethics would not apply to this situation

A supervisor is reviewing the documentation of the nurses in the unit. Which client documentation is the most accurate and contains all the required part for a narrative entry? 1. 2/2/05 1630 Catheterized using an 8 French catheter, 45 mL clear yellow urine obtained, specimen sent to lab, squirmed and cried softly during insertion of catheter. Quiet in mothers arms following catheter removal. M. May RN 2. 1/9/05 2 pm NG tube placement confirmed and irrigated with 30 ml sterile water. Suction set at low, intermittent. Oxygen via nasal canal at 2 L/min. Nares patent, pink, and nonirritated. K. Earnst RN 3. 4:00 Trach dressing removed with dime-size stain of dry serous exudate. Site cleansed with normal saline. Dried with sterile gauze. New sterile trach sponge and trach ties applied. Respirations regular and even throughout the procedure. F. Luck RN 4. Feb. 05 Port-A-Cath assessed with Huber needle. Blood return present. Flushed with NaCl sol., IV gamma globins hung and infusing at 30cc/hr. Child smiling and playful throughout the procedure. P. Potter, RN

Correct Answer: 1 Rationale 1: The client record should include the date and time of entry, nursing care provided, assessments, an objective report of the clients physiologic response, exact quotes, and the nurses signature and title.

Question 6 Type: MCSA The telephone triage nurse at a pediatric clinic knows each call is important. Which call would require extra attentiveness from the registered nurse because of an increased risk of mortality? 1. A 3-week-old infant born at 35 weeks gestation with gastroenteritis 2. A term 2-week-old infant of American Indian descent with an upper respiratory infection 3. A post term 4-week-old infant non-Hispanic black descent with moderate emesis after feeding 4. A 1-week-old infant born at 40 weeks gestation with symptoms of colic

Correct Answer: 1 Rationale 1: The leading causes of death in the neonatal period (birth to 28 days of age) are short gestation, low birth weight, and congenital malformations. The preterm infant experiencing gastroenteritis at 3 weeks of age is at the greatest risk for mortality; therefore, would require extra attentiveness from the registered nurse.

The nurse in a pediatric acute-care unit is assigned the following tasks. Which task is not appropriate for the registered to nurse complete? 1. Diagnose an 8-year-old with acute otitis media and prescribe an antibiotic. 2. Listen to the concerns of an adolescent about being out of school for a lengthy surgical recovery. 3. Provide information to a mother of a newly diagnosed 4-year-old diabetic about local support-group options. 4. Diagnose a 6-year-old with Diversional Activity Deficit related to placement in isolation.

Correct Answer: 1 Rationale 1: The role of the pediatric nurse includes providing nursing assessment, directing nursing care interventions, and educating client and family at developmentally appropriate levels; client advocacy, case management, minimization of distress, and enhancement of coping. Advanced practice nurse practitioners perform assessment, diagnosis, and management of health conditions.

Question 3 Type: MCMA The nurse in the newborn nursery is admitting a neonate. To determine the health and development of the newborn, what will the nurse include in the assessment? Standard Text: Select all that apply. Head circumference Body length Weight Length of pregnancy Hearing screens

Correct Answer: 1,2,3,4Rationale 1: The nurse should assess almost all of these parameters to determine the health of the newborn. However, hearing screens are typically done after the first 12 hours after birth and are not part of newborn assessment.

Question 3 Type: MCMA The school nurse performs screenings on all students in the middle school. In addition, the nurse will perform selected screenings on individual school-age children. When planning the screenings for the year, which screenings will the nurse include for all school-age children? Standard Text: Select all that apply. Hearing Height and weight Blood-pressure measurement Hepatitis B profile serology Chest x-ray

Correct Answer: 1,2,3Rationale 1: Routine screening for school-age children include hearing, checking for height and weight, and blood-pressure measurements. The hepatitis B profile is only needed once, prior to administration of hepatitis B vaccine; however, this is not a required screening for all school-age children. A chest x-ray is not a routine screening test for school-age children.

CHAPTER 7 Question 1 Type: MCMA A nursery nurse is planning care for the newborns currently in the newborn nursery. Which activities does the nurse plan for the first 48 hours of life? Standard Text: Select all that apply. Monitor feeding behaviors. Perform a hearing screening. Perform a heel stick to obtain blood for the newborn screen. Monitor the mother as she performs the first newborn bath to remove blood and amniotic fluids. Administer folic-acid injection to the infant to prevent bleeding.

Correct Answer: 1,2,3Rationale 1: The nurse should assess feeding behaviors of the infant whether the infant is breast-fed or bottle-fed. A hearing screening is performed on all newborn infants prior to discharge. The newborn screen is performed prior to infant discharge from the newborn unit. The nurse, not the mother, performs the first bath to remove blood and amniotic fluids. Vitamin K is administered, not folic acid.

Question 2 Type: MCMA An adolescent is accompanied by the mother for an annual physical examination. The nurse is aware of privacy issues related to the adolescent. While the mother is in the room, the nurse should avoid which questions? Standard Text: Select all that apply. Sexual activity Cigarette smoking School performance Use of alcohol Car seatbelt use

Correct Answer: 1,2,4Rationale 1: The nurse must maintain the nurseclient relationship, which is between the nurse and the adolescent, and the nurse must maintain confidentiality. Therefore, the nurse cannot ask any personal questions while the mother is in the room, such as those related to sexual activity, drug and alcohol use, and smoking cigarettes. The nurse can ask general questions about seatbelt use and academic performance without breaching confidentiality.

Question 9 Type: MCMA The nurse working with a family has observed that the older children have a large number of dental caries and plans to provide the mother with information to prevent the development of dental caries in her new infant. Which interventions will prevent the development of dental caries in the infant? Standard Text: Select all that apply. Avoiding nursing or giving the infant a bottle at bedtime Giving foods high in sugar only at breakfast time Using a soft moist gauze for cleaning Using a topical anesthetic daily beginning as soon as the first tooth begins to erupt

Correct Answer: 1,3Rationale 1: The only interventions that will assist in the prevention of dental caries listed in this question are wiping the gums with a soft, moist gauze and avoiding putting the infant to bed with a bottle. Foods high in sugar should be avoided in the infant period. Topical anesthetic should not be applied daily.

Question 6 Type: MCSA Which nursing diagnosis is most appropriate for an infant with acute bronchiolitis due to respiratory syncytial virus (RSV)? Activity Intolerance Decreased Cardiac Output Pain, Acute Tissue Perfusion, Ineffective (peripheral)

Correct Answer: 1Rationale 1: Activity intolerance is a problem because of the imbalance between oxygen supply and demand. Cardiac output is not compromised during an acute phase of bronchiolitis. Pain is not usually associated with acute bronchiolitis. Tissue perfusion (peripheral) is not affected by this respiratory-disease process.

Question 6 Type: MCSA The nurse is working with a school-age child who is hospitalized. Which action by the nurse will promote a sense of industry in this child? Allow the child to assist with her care. Encourage parents to participate in the child's care. Give the child a detailed scientific explanation of the illness. Speak to the child in a high-pitched voice.

Correct Answer: 1Rationale 1: Allowing the child to participate in her care will decrease the sense of loss of control and increase a sense of industry. While parents can certainly participate in their child's care, it does not increase the child's sense of control. School-age children in general will not understand detailed scientific explanations. Change in voice tone is appropriate when talking to very young children.

Question 9 Type: MCSA Following parental teaching, the nurse is evaluating the parents' understanding of environmental control for their child's asthma management. Which statement by the parents' indicates appropriate understanding of the teaching? "We will replace the carpet in our child's bedroom with tile." "We're glad the dog can continue to sleep in our child's room." "We'll be sure to use the fireplace often to keep the house warm in the winter." "We'll keep the plants in our child's room dusted."

Correct Answer: 1Rationale 1: Control of dust in the child's bedroom is an important aspect of environmental control for asthma management. When possible, pets and plants should not be kept in the home. Smoke from fireplaces should be eliminated.

Question 8 Type: MCSA The nurse working in the clinic includes an adolescent history in every client intake interview. Which issue should the nurse address when the parents are not present? Possible domestic violence Teen job responsibilities Activities that are done as a family The adolescent's role in the family

Correct Answer: 1Rationale 1: If domestic violence is suspected, it would only be appropriate to ask these questions when the teenager is alone with the nurse or healthcare provider.

Question 3 Type: MCSA A child is admitted to the hospital with the diagnosis of laryngotracheobronchitis (LTB). Which nursing intervention is the priority for this child? Administer nebulized epinephrine and oral or IM dexamethasone. Administer antibiotics and assist with possible intubation. Swab the throat for a throat culture. Obtain a sputum specimen.

Correct Answer: 1Rationale 1: Nebulized epinephrine and dexamethasone are given for LTB. Antibiotic administration and possible intubation are associated with epiglottitis. Throat cultures are not obtained for LTB because it is viral and swabbing the throat could cause complete obstruction to occur. Sputum specimens will not assist in the diagnosis of LTB.

Question 5 Type: MCSA The nurse is teaching a new mother developmental expectations. Which activity should the nurse expect a newborn to do within the first month of life? Bring hands to eyes and mouth. Push up with hands, moving chest up. Keep hands in a relaxed position. Roll over from back to abdomen.

Correct Answer: 1Rationale 1: Newborns at one month of age can bring hands to their eyes and mouths, move their heads from side to side when lying on their abdomens, and attempt to lift their heads only when prone. Newborn hands are kept in tight fist position, and the newborn cannot roll over until 4 months of age.

Question 8 Type: MCSA Which of these measures used by a nurse will help relieve parental anxiety related to the changing appetite in the toddler who is gaining weight along the 50th percentile? Discussing the growth of the toddler as compared to the growth chart Suggesting ways to have the toddler eat higher calorie foods Instructing the mother to feed the toddler alone without any distractions such as TV or music Teaching the mother to avoid disciplining the toddler within one-half hour of eating

Correct Answer: 1Rationale 1: Showing the parents the growth pattern of the child as compared to the normal growth chart will help relieve parental anxiety related to eating less food during the toddler years. Toddlers who are at the 50th percentile do not need additional high-calorie foods. Toddlers eat to their personal needs and there is no reason to restrict watching TV or other environmental stimuli during meals. There is no reason to relate timing of discipline and eating.

Question 7 Type: MCSA An adolescent reports the following: "I get up at 6 am, I attend early-morning band classes three times each week, I play sports for two hours each day after school, and homework takes me three hours each night. I always feel tired." Which question by the nurse is most appropriate based on this information? "How many hours of sleep do you get each night?" "Do you consume foods high in iron?" "Do you think you are doing too much?" "Have you considered talking with your teachers about decreasing your homework, since you have so many extracurricular activities?"

Correct Answer: 1Rationale 1: The data in this scenario reveals very little time for sleep; therefore, the history should focus on sleep patterns.

Question 10 Type: MCSA A nurse is assessing an 11-month-old infant and notes that the infant's height and weight are at the 5th percentile on the growth chart. Family history reveals that the infant's two siblings are at the 50th percentile for height and at the 75th percentile for weight. Psychosocial history reveals that the parents are separated and are planning to divorce. Which of these nursing diagnoses takes priority? Alteration in Growth Pattern Related to Parental Anxiety Alteration in Growth Pattern Secondary to Familial Short Stature Nutritional Intake: Excessive Secondary to Maternal Feeding Patterns At Risk for Constitutional Growth Delay Related to Decreased Appetite

Correct Answer: 1Rationale 1: The scenario reveals parental anxiety due to marital problems. The most appropriate nursing diagnosis is alteration in growth patterns related to parental anxiety. There is no data that indicates familial short stature. Since height and weight are at the 5th percentile, there is no indication of increased nutritional intake. This infant is not at risk for constitutional growth delay.

Question 10 Type: MCSA A parent questions how her toddler plays with other toddlers. Which response by the nurse displays the best description of the differences in play between the toddler and the preschooler? Toddlers play side by side, while preschoolers play cooperatively. Toddlers play house and imitate adult roles, while preschoolers become the Mom or Dad while playing house. Toddlers play cooperatively, while preschoolers play interactive games. There are no differences between toddlers and preschoolers since both groups play cooperatively.

Correct Answer: 1Rationale 1: Toddlers will play side by side with another child, but they do not interact with the child during play. Preschoolers play cooperatively with other children.

CHAPTER 20 Question 1 Type: MCSA A child is showing signs of acute respiratory distress. Which position will the nurse place this child? Upright Side-lying Flat In semi-Fowler's

Correct Answer: 1Rationale 1: Upright is correct because it allows for optimal chest expansion. Side-lying, flat, and semi-Fowler's (head up slightly) do not allow for as optimal chest expansion as the upright position

Pediatric nurses have foundational knowledge obtained in nursing school and add specific competencies related to the pediatric client. Which would be considered an additional specific expected competency of the pediatric nurse? 1. Physical assessment 2. Anatomical and developmental differences 3. Nursing process 4. Management of healthcare conditions

Correct Answer: 2 Rationale 1: Assessing anatomical and developmental differences would be a specific expected competency for the pediatric nurse that would not be learned in nursing school. Physical assessment, nursing process, and management of health conditions are all foundational knowledge learned in nursing school.

A 7-year-old child is admitted for acute appendicitis. The parents are questioning the nurse about expectations during the childs recovery. Which information tool would be most useful in answering a parents questions about the timing of key events? 1. Healthy People 2020 2. Clinical pathways 3. Child mortality statistics 4. National clinical practice guidelines

Correct Answer: 2 Rationale 1: Clinical pathways are interdisciplinary documents provided by a hospital to suggest ideal sequencing and timing of events and interventions for specific diseases to improve efficiency of care and enhance recovery. This pathway serves as a model outlining the typical hospital stay for individuals with specified conditions. Healthy People 2020 contains objectives set by the U.S. government to improve the health and reduce the incidence of death in the twenty-first century. Child mortality statistics can be compared with those from other decades for the evaluation of achievement toward health-care goals. National clinical practice guidelines promote uniformity in care for specific disease conditions by suggesting expected outcomes from specific interventions.

A 12-year-old pediatric client is in need of surgery. Which member of the health care team is legally responsible for obtaining informed consent for an invasive procedure? 1. Nurse 2. Physician 3. Unit secretary 4. Social worker

Correct Answer: 2 Rationale 1: Informed consent is legal preauthorization for an invasive procedure. It is the physicians legal responsibility to obtain this, because it consists of an explanation about the medical condition, a detailed description of treatment plans, the expected benefits and risks related to the proposed treatment plan, alternative treatment options, the clients questions, and the guardians right to refuse treatment.

What is the pediatric nurses best defense against an accusation of malpractice or negligence? 1. Following the physicians written orders 2. Meeting the scope and standards of practice for pediatric nursing 3. Being a nurse practitioner or clinical nurse specialist 4. Acting on the advice of the nurse manager

Correct Answer: 2 Rationale 1: Meeting the scope and standards of practice for pediatric nursing would cover the pediatric nurse against an accusation of malpractice or negligence because the standards are rigorous and cover all bases of excellent nursing practice. Following the physicians written orders or acting on the advice of the nurse manager are not enough to defend the nurse from accusations because the orders and/or advice may be wrong or unethical. Being a clinical nurse specialist or nurse practitioner does not defend the nurse against these accusations if he or she does not follow the Society of Pediatric Nurses standards of practice.

The nurse recognizes that the pediatric client is from a cultural background different from that of the hospital staff. Which goal is most appropriate for this client when planning nursing care? 1. Overlook or minimize the differences that exist. 2. Facilitate the familys ability to comply with the care needed. 3. Avoid inadvertently offending the family by imposing the nurses perspective. 4. Encourage complementary beneficial cultural practices as primary therapies.

Correct Answer: 2 Rationale 1: The incorporation of the familys cultural perspective into the care plan is most likely to result in the familys ability to accept medical care and comply with the regimen prescribed. Since culture develops from social learning, attempts to ignore or minimize cultural consideration will result in mistrust, suspicion, or offenses that can have negative effects upon the health of children by reducing the resources available to promote health and prevent illness.

Question 5 Type: MCMA Which of these developmental milestones should the nurse expect to find in children who are between 2 and 3 years old? Standard Text: Select all that apply. Always feeds self Scribbles and draws on paper Kicks a ball Throws ball overhand Goes up and down stairs

Correct Answer: 2,3,5Rationale 1: Children between the ages of 2 and 3 years can scribble and draw on paper, kick a ball, and go up and down the stairs. Children who are between the ages of 3 and 4 years can feed themselves. Children between the ages of 4 and 5 years can throw a ball overhand.

Question 7 Type: MCSA A nurse assesses the height and weight measurements on an infant and documents these measurements at the 75th percentile. The nurse notes that the previous measurements two months ago were at the 25th percentile. Which interpretation by the nurse is the most accurate? The infant is not gaining enough weight. The infant has gained a significant amount of weight. The previous measurements were most likely inaccurate. These measurements are most likely inaccurate.

Correct Answer: 2Rationale 1: A comparison of these two sets of measurements shows that the infant has crossed two percentiles going from the 25th to the 75th percentile and therefore has gained a significant amount of weight. There is neither indication that the previous measurements are inaccurate nor that the current measurement is inaccurate.

Question 4 Type: MCSA An infant weighs 9 pounds, 3 ounces at birth. The nurse plans to make a home visit to the mother and infant when the infant is 7 days old. What is the lowest acceptable weight the infant should be at this age? 7 pounds, 12 ounces 8 pounds, 2 ounces 8 pounds, 12 ounces 9 pounds

Correct Answer: 2Rationale 1: In the first week of life, most infants lose about one-tenth of their birth weight; therefore, this infant's weight should be 8 pounds, 2 ounces at 7 days of age. A weight loss to 7 pounds, 12 ounces would be too much for this infant. A decline to 8 pounds, 12 ounces is less than the expected one-tenth weight loss after birth, and an infant would not be expected to lose only 3 ounces during the first week of life.

Question 6 Type: MCSA An adolescent reports participating in an exercise program at school each Wednesday throughout the school year. Further history reveals that the adolescent does not participate in any other physical activities. Which outcome is most appropriate for this adolescent? The adolescent is reporting information consistent with what 60 percent of adolescents report as participation in physical activities. The adolescent is not meeting the recommendations of the Healthy People 2020initiative. The adolescent should be encouraged to continue this program of exercise, since something is better than nothing. The adolescent should be encouraged to vigorously exercise for at least five minutes each day.

Correct Answer: 2Rationale 1: In this scenario, the adolescent is not receiving the recommended amount of exercise to support good health habits. Encouraging the adolescent to continue as is or to exercise vigorously for five minutes each day also is not consistent with current recommendations. Suggesting that something is better than nothing is not good practice.

Question 4 Type: MCSA A nurse is preparing to perform a physical assessment on a toddler. Which action is most appropriate for the nurse to take? Perform the assessment from head to toe. Leave intrusive procedures such as ear and eye examinations until the end. Explain each part of the examination to the child before performing it. Ask the mother to tell the child not to be afraid.

Correct Answer: 2Rationale 1: Intrusive procedures such as examination of the ears, throat, eye, and genital areas should be done last to decrease the anxiety of the child during the initial phases of the examination, which includes the heart and lungs.

CHAPTER 11 Question 1 Type: MCSA The parents of a critically injured child wish to stay in the room while the child is receiving emergency care. Which action by the nurse is the most appropriate? Escort the parents to the waiting room and assure them that they can see their child soon. Allow the parents to stay with the child. Ask the physician if the parents can stay with the child. Tell the parents that they do not need to stay with the child.

Correct Answer: 2Rationale 1: Parents should be allowed to stay with their child if they wish to do so. This position is supported by the Emergency Nurses Association and is a key aspect of family-centered care.

Question 7 Type: MCSA A child is admitted to the hospital with pneumonia. The child's oximetry reading is 88 percent upon admission to the pediatric floor. Which is the priority nursing intervention for this child? Obtain a blood sample to send to the lab for electrolyte analysis. Begin oxygen per nasal cannula. Medicate for pain. Begin administration of intravenous fluids.

Correct Answer: 2Rationale 1: Pulse oximetry reading should be 92 or greater. Oxygen by nasal cannula should be started initially. Medicating for pain, administering IV fluids, and sending lab specimens can be done once the child's oxygenation status has been addressed

Question 9 Type: MCSA Parents of a preschool child report that they find it necessary to spank the child at least once a day. Which response should the nurse make to the parents? "Spanking is one form of discipline; however, you want to be certain that you do not leave any marks on the child." "Let's talk about other forms of discipline that have a more positive effect on the child." "Can you try only spanking the child every other day for one week and see how that affects the child's behavior?" "I think you are not parenting your child properly, so let's talk about ways to improve your parenting skills."

Correct Answer: 2Rationale 1: The behavior reported by the parent was excessive. The only response that is appropriate is to find a more positive way of influencing behavior in this age child. The nurse's response needs to reflect these feelings. To suggest spanking as an appropriate form of discipline is inappropriate, especially when the parent is describing daily spanking of the child.

Question 7 Type: MCSA A nurse who is the manager of an ambulatory pediatric healthcare center is planning protocols for the routine healthcare visits of the children. Children at this care center have a high incidence of obesity. At which age should the nurses at this clinic calculate the body mass index (BMI) for all pediatric clients? 12 months 24 months 36 months 4 years

Correct Answer: 2Rationale 1: The body mass index is first calculated at 2 years of age and gives information about the relationship between the height and weight of the child. With this information, the nurse would be able to develop strategies that may reduce the incidence of obesity.

Question 2 Type: MCSA The nurse is planning care for clients seen in a newborn clinic. Which is the priority for a newborn client during the first clinic visit? Providing pamphlets to reinforce information provided at the visit Assessing the newborn-and-family interactions Modeling infant-nurturing behaviors Informing the parents of the infant's gains in height and weight

Correct Answer: 2Rationale 1: The first step in the nursing process is assessment; therefore, the nurse should assess the interactions of the parents with the newborn. Providing pamphlets to help educate the parents should be done at each appropriate office visit; however, the pamphlets would be distributed after assessment of parent needs. While the nurse should be a role model for nurturing behaviors during the office visit, this would not be the first thing the nurse performs at the office visit. While parents are informed of the infant's gains in height and weight, this activity does not take priority.

Question 5 Type: MCSA An school-age client who recently moved to a new school in a different town presents to an ambulatory care center and describes the following: "I have no friends in my new school, and I no longer want to go to play soccer. I know I will be lonely there, too." Which of these takes priority when speaking with the school-age client? Helping the school-age client realize the value of soccer Promoting healthy mental-health outcomes Acknowledging the fact that it takes several months to make new friends at a new school Stressing the importance of remaining in a close parent-child relationship during these stressful times

Correct Answer: 2Rationale 1: The school-age client is obviously lonely with the move to the new school. The nurse should focus on appropriate coping skills, which will enhance good mental-health outcomes for the child. It would not be appropriate to discuss the importance of soccer at this time, since the school-age client must deal with the loss of friends and developing new friendships first. The parentchild relationship should not be used as a substitute for the development of new peer relationships.

Question 2 Type: MCSA The charge nurse on a hospital unit is developing plans of care related to separation anxiety. The charge nurse recognizes that which hospitalized child at highest risk to experience separation anxiety when parents cannot stay? 6-month-old 18-month-old 3-year-old 4-year-old

Correct Answer: 2Rationale 1: While all of these children can experience separation anxiety, the young toddler is at highest risk. Toddlers are the group most at risk for a stressful experience when hospitalized. Separation from parents increases this risk greatly.

A 12-year-old child is admitted to the unit for a surgical procedure. The child is accompanied by two parents and a younger sibling. What is the level of involvement in treatment decision making for this child? 1. That of an emancipated minor. 2. That of a mature minor. 3. That of assent. 4. None.

Correct Answer: 3 Rationale 1: Assent requires the ability to generally understand what procedure and treatments are planned, to understand what participation is required, and to make a statement of agreement or disagreement with the plan. Usually, in Piagets stage of formal operations, 11- to 13-year-olds should be able to problem solve using abstract concepts and are able to give valid assent when parents sign the informed consent. An emancipated minor is a self-supporting adolescent who is not subject to the control of a parent or guardian. A mature minor is a 14- or 15- year-old whom the state law designates as being able to understand medical risks and who is thus permitted to give informed consent for treatment.

Despite the availability of Childrens Health Insurance Programs (CHIP), many eligible children are not enrolled. Which nursing intervention would be the most appropriate to help children become enrolled in CHIP? 1. Assessment of the details of the familys income and expenditures 2. Case management to limit costly, unnecessary duplication of services 3. To advocate for the child by encouraging the family to investigate its SCHIP eligibility 4. To educate the family about the need for keeping regular well-childvisit appointments

Correct Answer: 3 Rationale 1: In the role of an advocate, a nurse will advance the interests of another; by suggesting the family investigate its SCHIP eligibility, the nurse is directing their action toward the childs best interest. Financial assessment is more commonly the function of a social worker. The case-management activity mentioned will not provide a source of funding nor will the educational effort

Which nursing intervention is most appropriate when providing education to the pediatric client and family? 1. Giving primary care for high-risk children who are in hospital settings 2. Giving primary care for healthy children 3. Working toward the goal of informed choices with the family 4. Obtaining a physician consultation for any technical procedures at delivery

Correct Answer: 3 Rationale 1: The educator works with the family toward the goal of making informed choices through education and explanation.

Question 7 Type: MCSA The nurse is caring for a client in the pediatric intensive-care unit (PICU). The parents have expressed anger over the nursing care their child is receiving. Which nursing intervention is most appropriate based on the situation? Ask the physician to talk with the family. Explain to the parents that their anger is affecting their child so they will not be allowed to visit the child until they calm down. Acknowledge the parents' concerns and collaborate with them regarding the care of their child. Call the chaplain to sit with the family.

Correct Answer: 3Rationale 1: Hospitalization of the child in a pediatric intensive-care unit is a great stressor for parents. If the parents feel that they are not informed or involved in the care of their child, they may become angry and upset. Calling the physician or chaplain may be appropriate at some point, but the nurse must assume the role of supporter in this situation to promote a sense of trust. Telling the parents that they cannot visit their child will only increase their anger.

Question 8 Type: MCSA A nurse asks the mother of a 4-month-old infant to undress the infant. The nurse observes the mother taking off several layers of clothing and knows that the outdoor temperature is 70 degrees Fahrenheit. Which statement by the nurse is most appropriate in this situation? "My, you are dressing your infant warmly today." "Did you think it was cold when you left your home this morning?" "I see that you have many layers of clothing on your baby. This may cause your baby's temperature to rise. " "When you leave the office, only put one layer of clothing on your baby."

Correct Answer: 3Rationale 1: In this scenario, the mother has overdressed the infant. The nurse needs to gently inform the mother of this problem and to provide information to the mother on why it is a problem. Just making a statement on how warmly the child is dressed will not accomplish this goal or just telling the mother to only put one layer of clothing on the child does not provide a rationale for the mother to make a better decision the next time, so this statement also is not helpful to the mother.

Question 10 Type: MCSA A newborn is suspected of having cystic fibrosis. As the child is being prepared for transfer to a pediatric hospital, the mother asks the nurse which symptoms made the practitioner suspect cystic fibrosis. Which response by the nurse is the most appropriate? Steatorrheic stools Constipation Meconium ileus Rectal prolapse

Correct Answer: 3Rationale 1: Newborns with cystic fibrosis may present in the first 48 hours with meconium ileus. Steatorrhea, constipation, and rectal prolapse may be signs of cystic fibrosis seen in an older infant or child

Question 4 Type: MCSA A preschool-age client is seen in the clinic for a sore throat. In this child's mind, what is the most likely causative agent for the sore throat? Was exposed to someone else with a sore throat. Did not eat the right foods. Yelled at his brother. Did not take his vitamins.

Correct Answer: 3Rationale 1: Preschoolers understand some concepts of being sick but not the cause of illness. They are likely to think that they are sick as a result of something that they have done. They will frequently view illness as punishment. A child of this age does not yet understand that he can become sick from exposure to someone else who is sick. The other two answers, while not causes of sore throat, can be factors in some illnesses but are beyond the thinking of a 4-year-old.

Question 6 Type: MCSA A nurse observes the parent/child interaction during the 4-year-old well-child checkup and notes that the parent speaks harshly to the child and uses negative remarks when speaking with the nurse. Which statement by the nurse would be most beneficial? "Perhaps you should leave the room so that I can speak with your child privately." "I am going to refer you for counseling since your interactions with your child seem so negative." "Let's talk privately. Let's discuss the way you speak with your child and possible ways to be more positive." Addressing the child, the nurse says, "Are you unhappy when Mommy talks to you like this?"

Correct Answer: 3Rationale 1: The best approach to this encounter would be for the nurse to discuss concerns with the parent privately, since the nurse wants to help the parent develop a good relationship with the child. The child should not be a part of this conversation. Since the child is only 6 years old, it would be difficult to ask the parent to leave the room. If the nurse also wants to speak alone with the child, the nurse perhaps would escort the child to another area and speak briefly with the child. Referring to counseling without a discussion with the parent is not appropriate. The nurse should not ask the child if she is "unhappy" with the parent.

Question 10 Type: MCSA An obese adolescent who adamantly denies sexual activity has a positive pregnancy test, which was performed in the adolescent clinic. Which statement by the nurse is the most appropriate in this situation? "Tell me how you feel about your body image." "When was your last menstrual period (LMP)?" "Let's discuss some activities that you have done within the past few months that could possibly lead to pregnancy." "Were you involved in a date rape and are you hesitant to speak about it?"

Correct Answer: 3Rationale 1: The nurse must help the adolescent realize that previous behaviors have led to a positive pregnancy test. The only response by the nurse that will accomplish this goal is for the nurse to ask a direct question in which the nurse and client search for an answer.

Question 3 Type: MCSA At a routine healthcare visit, a nurse measures a toddler and plots the height and weight on the growth charts. The nurse documents that the toddler is above the 95th percentile for weight and is at the 5th percentile for height. How should the nurse interpret these data? The toddler is proportionate for the age. The toddler needs to eat more at each feeding. The height and weight are disproportionate, and the toddler needs further evaluation. The family is most likely short.

Correct Answer: 3Rationale 1: Usually height and weight are at approximately the same percentile. When the weight of a child is found to be at the 95th percentile, the child's height is also greater than the 50th percentile. The height and weight for the child described in this question are a concern, and the child may need further endocrine testing.

Question 8 Type: MCSA A toddler recently diagnosed with a seizure disorder will be discharged home on an anticonvulsant. Which action by the mother best demonstrates understanding of how to give the medication? Verbalizing how to give the medication Acknowledging understanding of written instructions Drawing up the medication correctly in an oral syringe and administering it to the child Observing the nurse draw up the medication and administering it to the child.

Correct Answer: 3Rationale 1: Verbalization of how to give the medication and acknowledging understanding of written instructions are methods that might be used, but they do not actually demonstrate understanding. Observing the nurse draw up and administer the medication may be used in the teaching process. The best way for the mother to demonstrate understanding is to actually draw up and give the medication.

A child is being prepared for an invasive procedure. The mother of the child has legal custody but is not present. After details of the procedure are explained, who can provide legal consent on behalf of a minor child for treatment? 1. The divorced parent without custody 2. A cohabitating unmarried boyfriend of the childs mother 3. A grandparent who lives in the home with the child 4. A babysitter with written proxy consent

Correct Answer: 4 Rationale 1: A parent may grant proxy consent in writing to another adult so that children are not denied necessary health care. In the case of divorced parents, the parent with custody may be the only parent allowed by some states to give informed consent. Residence in the same household with a child does not authorize an adult to sign consent for treatment.

Which nursing role is not directly involved when providing family-centered approach to the pediatric population? 1. Advocacy 2. Case management 3. Patient education 4. Researcher

Correct Answer: 4 Rationale 1: A researcher is not involved in the family-centered approach to patient care of children and their families. Advocacy, case management, and patient education are all roles directly involved in the care of children and their families.

Question 3 Type: MCSA A group of children on one hospital unit are all suffering separation anxiety. Which child is experiencing the "despair" stage of separation anxiety? Does not cry if parents return and leave again Screams and cries when parents leave Appears to be happy and content with staff Lies quietly in bed

Correct Answer: 4Rationale 1: Children in the "despair" stage appear sad, depressed, or withdrawn. A child who is lying in bed might be exhibiting any of these. Screaming and crying are components of the "protest" stage. The young child who appears to be happy and content with everyone is in the "denial" stage, as is the child who does not cry if parents return and leave again.

Question 5 Type: MCSA A nurse is assessing a neonate. Which assessment finding indicates that the neonate's respiratory status is worsening? Acrocyanosis Arterial CO2of 40 Periorbital edema Grunting respirations with nasal flaring

Correct Answer: 4Rationale 1: Grunting respirations with nasal flaring indicates respiratory status is becoming worse. Acrocyanosis (cyanosis of the extremities) is a normal finding in a neonate. CO2 of 40 is within a normal range. Periorbital edema does not necessarily mean deterioration in respiratory status.

Question 10 Type: MCSA A young school-age client is in the playroom when the respiratory therapist arrives on the pediatric unit to give the child a scheduled breathing treatment. Which action by the nurse is the most appropriate? Reschedule the treatment for a later time. Show the respiratory therapist to the playroom so the treatment may be performed. Escort the child to his room and ask the child-life specialist to bring toys to the bedside. Assist the child back to his room for the treatment but reassure the child that he may return when the procedure is completed.

Correct Answer: 4Rationale 1: Procedures should not be performed in the playroom. Scheduled respiratory treatments should be performed on time; however, the child should be allowed to return to the playroom as soon as the procedure is completed.

Question 8 Type: MCSA The practitioner changes the medications for the child with asthma to salmeterol (Serevent). The mother asks the nurse what this drug will do. The nurse explains that salmeterol (Serevent) is used to treat asthma because the drug produces which characteristic? Decreases inflammation Decreases mucous production Controls allergic rhinitis Dilates the bronchioles

Correct Answer: 4Rationale 1: Salmeterol (Serevent) is a long-acting beta2-agonist that acts by bronchodilating. Steroids are anti-inflammatory, anticholinergics decrease mucous production, and antihistamines control allergic rhinitis.

Question 6 Type: MCSA The nurse is providing anticipatory guidance instructions to the parents of a newborn. Which instruction should the nurse give as a strategy for illness/disease prevention? Don't allow visitors for the first month. Smoke outside only. Take the newborn to weekly child-stimulation classes. SIDS risk-reduction measures

Correct Answer: 4Rationale 1: Several disease-prevention strategies are used during anticipatory guidance for the parents of newborns. Not allowing visitors is unreasonable but screening for illness is appropriate. Smoking outside will not prevent disease. Attending weekly stimulation classes is not a disease prevention strategy. SIDS risk-reduction measures can reduce the risk of sudden infant death syndrome.

Question 2 Type: MCSA A nurse delegates the task of neonatal vital-sign assessment to a nurse technician. Which instruction will the nurse give to the technician prior to assign care? Report any neonate using abdominal muscles to breathe. Report any neonate with apnea for 10 seconds. Count respirations for 15 seconds and multiply by 4 to get the rate for 1 minute. Report any neonate with a breathing pause that lasts 20 seconds or longer.

Correct Answer: 4Rationale 1: The abnormal assessment finding for vital signs that the nurse should instruct a nurse technician to report is any breathing pause by a neonate lasting longer than 20 seconds. This can indicate apnea and could lead to an apparent life-threatening event (ALTE). A breathing pause of 10 seconds or less is called periodic breathing and is a normal pattern for a neonate. Respirations should be counted for 1 minute, not 15 seconds. It is normal for neonates to use abdominal muscles for breathing.

Question 9 Type: MCSA The nurse is reviewing the immunization record of an adolescent who will be seen later in the day. Which item in the client's history makes heptatis B status a priority? Chronic acne Overuse injuries from playing varsity sports Chronic asthma Plans to get a tattoo

Correct Answer: 4Rationale 1: The adolescent who is most at-risk in the scenario presented is the teen who is planning on getting a tattoo. Adolescents with chronic acne or asthma do not have an increased risk for hepatitis B, since transmission has nothing to do with a diagnosis of acne. Overuse of muscles while playing sports is not related to development of hepatitis B

Question 4 Type: MCSA A school nurse is performing annual height and weight screening. The nurse notes that three females who are close friends each lost 15 pounds over the past year. What is the priority nursing action in this situation? Call the respective parents to discuss the eating patterns of each adolescent. Speak with the girls in a group to discuss the problems associated with anorexia nervosa. Refer these adolescents to the school psychologist. Obtain a nutritional history for each of these adolescents.

Correct Answer: 4Rationale 1: The school nurse must evaluate why these three friends have all lost 15 pounds in one year. The best way to begin this assessment is to obtain a nutritional history for each client. Speaking with the parents would not be appropriate at this time. Discussing anorexia nervosa is too extreme, as is referring the adolescents to a school psychologist without performing a complete nursing assessment.

Question 5 Type: MCSA The charge nurse is concerned with reducing the stressors of hospitalization. Which nursing intervention is most helpful in decreasing the stressors for the toddler-age client? Assign the same nurse to the toddler as much as possible. Let the child listen to an audiotape of the mother's voice. Place a picture of the family at the bedside. Encourage a parent to stay with the child.

Correct Answer: 4Rationale 1: While all of the interventions are appropriate for the hospitalized toddler, presence of a parent is most important. Separation from parents is the major stressor for the hospitalized toddler.

Question 9 Type: MCSA The nurse must perform a procedure on a toddler. Which technique is the most appropriate when performing the procedure? Ask the mother to restrain the child during the procedure. Ask the child if it is okay to start the procedure. Perform the procedure in the child's hospital bed. Allow the child to cry or scream.

Correct Answer: 4Rationale 1: While the toddler will need to be restrained, the parent should not be the one to do this. The nurse should avoid giving the child a choice if there is no choice. The treatment room should be utilized for the procedure so that the hospital bed remains a safe place. The child should be allowed to cry or scream during the procedure.

Question 10 Type: MCSA The nurse of an outpatient clinic is sitting with the parents while their adolescent goes for a test. The parents are complaining about their child's behavior. Which statement by the nurse fosters family-centered communication? "I agree with you, discipline is an important part of parenting." "I know just how you feel. I had the same experience with my children." "You are so right. Adolescents function in the me-first mode all the time." "Tell me what concerns you about your child's behavior."

Question 3 Type: MCSA While being comforted in the emergency department, a young school-age sibling of a pediatric trauma victim blurts out to the nurse, "It's all my fault! When we were fighting yesterday, I told him I wished he was dead!" Which response is most appropriate by the nurse? Asking the child if she would like to sit down and drink some water Sitting the child down in an empty room with markers and paper so that she can draw a picture Calmly discussing the catheters, tubes, and equipment that the patient requires and explaining to the sibling why the patient needs them Reassuring the child that it is normal to get angry and say things that we do not mean but that we have no control over whether or not an accident happens

Question 7 Type: MCSA A nurse says to the mother of a 6-month-old infant, "Does the baby sit without assistance, and is the baby crawling?" Which process is the nurse using in this interaction? Health promotion Health maintenance Disease surveillance Developmental surveillance

Head and chest circumference

Done until age 3 years Wrap around head at supraorbital prominence, above ears & around occipital prominence Measure 2x Chest Circumference Done until 1 year of age Measure across nipple line Useful to compare to head circumference The head is approximately 2 cm larger than chest circumference at birth. Over time the values tend to equilibrate until 2 years of age when the chest circumference surpasses head circumference.**

ear

Ear •Examine the external ear structures looking for overall symmetry, shape of tragus, position and alignment, and the external ear canal. •Inspect for any drainage, sinus or pit, or swelling to surrounding tissues •Examine the tympanic membrane •Normal tympanic membrane is usually pearly gray and translucent. It reflects light, and the bones (ossicles) in the middle ear are normally visible. It should move when an pneumatic bulb is used. To restrain an uncooperative child, place the child on the parent's lap with the child's head and chest held firmly against the parent's chest. Keep your hands free to hold the otoscope and position the external ear •During an otoscopic examination, for children 3 and younger you should pull pinna down and back. For children over 3 years old you should pull the pinna up and back.

How do we embrace these roles

Education ◦Goals in helping child and parents/guardians: ◦Make informed choices. ◦Adapt to healthcare settings. ◦Prepare for procedures ◦Case Management ◦Many children with chronic problems require discharge planning and post-acute care, nurses often have the most contact with family and best understand their wishes ◦Research ◦Children are not small adults! They require their own research and evidenced based care ◦Advocacy ◦Working to enable the child and the family to adjust to changes in the child's health in their own way

Estimated "normal" SBP for children >1 years old = 90mmHg + (2 x age in yrs) Pediatric Hypotension (5th percentile) Estimates Age Systolic BP Term Neonates <60mmHg Infants 1 mo-12mo <70mmHg Children 1-10 years <70mmHg + 2 x age in years Child >10 years <90 mmHg •Use of the correct cuff is of the utmost importance. •Too large = low BP •Too small = high BP •Cuff should be 50-75% length of extremity •Cuff bladder should be 40% of circumference of extremity •Four limp BPs are useful if patient has known cardiac issues and occasionally done to screen for CHD in neonates •Remember that BP should be done last in young children as it can be upsetting.

eyes

Eyes •Inspect external eye structures, including the eyeballs, eyelids, and eye muscles. •The eyes should be the same size but not unusually large or small. •Observe for eye bulging, which can be identified by retracted eyelids or a sunken appearance. •Bulging may be associated with a tumor, and a sunken appearance may reflect dehydration. •Inspect the conjunctivae lining the eyelids by pulling down the lower lid and then everting the upper lid. The conjunctivae should be pink and glossy.* •The lacrimal punctum, the opening for the lacrimal gland on each lid, is located near the medial canthus. No redness or excess tearing should be present.*

eyes cont.

Eyes •When the eyes are open, inspect the level at which the upper and lower lids cross the eye. Sunset sign, in which the sclera is seen between the upper lid and the iris, may indicate retracted eyelids or hydrocephalus.** •Inspect the iris for color, typically the iris is blue or light colored at birth and becomes pigmented within 6 months •Inspect the pupils for size and shape. Normally the pupils are round, clear, and equal in size. •Asses for red reflex. Shine the ophthalmoscope light at the child's eye from a distance of 12 in. The first image seen is the red reflex. When the red reflex is seen, the ophthalmoscope is being used correctly and the child's lens is clear. If a white reflex is seen it is referred to as leukocoria and a retinoblastoma may be present.**

male and female genital assess

Female Genital Assessment •Inspect the external genitalia of girls for color, size, and symmetry of the mons pubis, labia, urethra, and vaginal opening. •Simultaneously look for any abnormal findings such as swelling, inflammation, masses, lacerations, or discharge. •At this time, determine the stage of pubertal maturation using Tanner staging Male Genital Assessment •Inspect the male genitalia for the structural and pubertal development of the penis, scrotum, and testicles •The penis is normally straight. A downward bowing of the penis may be caused by a chordee, a fibrous band of tissue associated with hypospadias. •To inspect the glans penis of an uncircumcised boy, ask the child or parent to pull the foreskin back. •Palpate the scrotum for the presence of the testicles. •Touch the inner thigh of each leg to stimulate the cremasteric reflex. The testicle and scrotum normally rise on the stroked side. This response indicates intact function of the spinal cord at the T12, L1, and L2 levels. An absent cremasteric reflex can be a sign of testicular torsion and is a surgical emergency. •At this time, determine the stage of pubertal maturation using Tanner staging

What does a safe environment for a baby sleep in look like?

Firm mattress in a crib, tucked in sheet, no stuffed toys or animals or anything else in the crib, have baby wear a onesie to stay warm, and place baby on his/her back to sleep, have crib in parents room next to them to sleep A - ALONE B - BACK C - CRIB

Freud stages of development

Freud emphasized the importance of meeting the needs of each stage of development in order to move onto the next. When a child is ill, it can interfere with normal development and add challenges for the nurse who is trying to meet the child's needs. Freud identified the following stages of development: Oral (Birth to 1 year) ◦Infant gets pleasure from the mouth primarily through sucking and eating (pacifiers, bottles, etc.) Anal (1 to 3 years) ◦The young child seeks pleasure through control of body secretions (toilet training!) Phallic (3 to 6 years) ◦Sexual energy is focus on the genitalia areas (boys seek out their father and girls seek out their mother) Latency (6 to 12 years) ◦Sexuality is at rest (no major changes) During this stage, the child compares his/her self-worth to others Genital (12 years to adulthood) ◦Mature sexuality occurs as physical growth is completed and relationships with others grow and develop

freud 3 stages

Freud viewed the personality as having three parts: ◦Id ◦Present at birth, drives an individuals need to seek pleasure ◦"I want it now" ◦Ego ◦Realistic part of the person which develops later in infancy & toddlerhood ◦"We need to wait to have it" ◦Superego ◦The moral/ethical system that helps with values and conscience ◦"You can't have it, it isn't right"

6-12 Physical Growth Fine Motor Ability Gross Motor Ability Sensory Ability

Gains 1.4-2.2 k g (3-5 l b) /year •Grows 4-6 c m/year •Enjoys craft projects •Plays card and board games •Rides two-wheeler** •Jumps rope** •Roller skates or ice skates** •Can read** •Able to concentrate for longer periods on activities by filtering out surrounding sounds

2-3 yrs Physical Growth Fine Motor Ability Gross Motor Ability Sensory Ability

Gains 1.4-2.3 k g (3-5 l b)/year •Grows 5-6.5 c m (2-2.5 i n.)/year •Draws a circle and other rudimentary forms** •Learns to pour** •Learning to dress self •Jumps** •Kicks ball •Throws ball overhand

4-6 months Physical Growth Fine Motor Ability Gross Motor Ability Sensory Ability

Gains 140-200 g (5-7 o z)/week •Doubles birth weight at 5-6 months** •Grows 1.5 c m/month •Head circumference increases 1.5 cm/month •Teeth may begin erupting by 6 months** •Ingests 100 m L/k g/24 h r •Grasps rattles and other objects at will; drops them to pick up another offered object •Mouths objects •Holds feet and pulls to mouth •Holds bottle** •Grasps with whole hand (palmar grasp)** •Manipulates objects •Head held steady when sitting •No head lag when pulled to sitting** •Turns from abdomen to back by 4 months and then back to abdomen by 6 months** •When held standing supports much of own weight** •Examines complex visual images •Watches the course of a falling object

Physical Growth Fine Motor Ability Gross Motor Ability Sensory Ability

Gains 140-200 g (5-7 o z)/week** •Grows 1.5 c m/month •Head circumference increases 1.5 cm/month •Posterior fontanelle closes** •Ingests 120 m L/k g/24 h r (2 oz/l b/24 h r) •Holds rattle and other objects when placed in hand** •Looks at and plays with own fingers •Brings hands to midline** •Moro reflex fading in strength •Can turn from side to back and then return** •Decrease in head lag when pulled to sitting position; sits with head held in midline with some bobbing •When prone, holds head and supports weight on forearms** •Follows objects 180 degrees •Turns head to look for voices and sounds

Physical Growth Fine Motor Ability Gross Motor Ability Sensory Ability

Gains 140-200 g (5-7 oz)/week •Grows 1.5 cm in first month** •Head circumference increases 1.5 cm month • •Holds hand in fist** •Draws arms and legs to body when crying • Inborn reflexes such as startle and rooting are predominant activity •May lift head briefly if prone •Alerts to high-pitched voices** •Comforts with touch** • Prefers to look at faces and black-and-white geometric designs •Follows objects in line of vision**

10-12 months Physical Growth Fine Motor Ability Gross Motor Ability Sensory Ability

Gains 85-140 g (3-5 o z)/week •Grows 1 c m/month •Head circumference equals chest circumference •Triples birth weight by 1 year** •May hold crayon or pencil and make mark on paper** •Places objects into containers through holes •Stands alone** •Walks holding onto furniture •Sits down from standing •Plays peek-a-boo and patty cake

General assessment

General Assessment Examination of the child begins from the first contact. You should be observing the behavior of the child and parent by using visual cues to make a proper assessment. What is the child's overall appearance? Are they comfortable? Are they in any distress? Does the child appear well nourished? Does the child appear secure with the parent? What is your gut instinct? IPAP (inspect....)

hair

Hair •Inspect the scalp hair for color, distribution, and cleanliness. •Children are frequently exposed to head lice. •Inspect the individual hair shafts for small nits (lice eggs) that adhere to the hair •Normally, hair is distributed evenly over the scalp. •Investigate areas of hair loss •Hair loss in a child may result from tight braids or skin lesions such as ringworm •Endocrine conditions such as hypothyroidism may result in coarse, brittle hair

head

Head & Face •During early childhood the skull's sutures permit expansion for brain growth. Infants and young children normally have a rounded skull with a prominent occipital area. •Inspect & palpate the skull in infants and young children to assess the sutures and fontanelles and to detect soft bones. •Use your fingerpads to palpate each suture line. At the intersection of the sutures, palpate the anterior and posterior fontanelles. The fontanelle should feel flat and flush/soft.* •A tense fontanelle, bulging above the margin of the skull, is an indication of increased intracranial pressure.* •A sunken fontanelle below the margin of the skull is associated with dehydration.*

fine crackles

High-pitched, discrete, noncontinuous sound heard at end of inspiration; does not clear with coughing (Rub pieces of hair together beside your ear to duplicate the sound.) Air passing through watery secretions in the smaller airways (alveoli and bronchioles)

stridor

High-pitched, piercing sound most often heard during inspiration without a stethoscope Whistling sound as air passes through a narrowed trachea and larynx, associated with croup

sibilant wheezing

Higher pitched, musical, squeaking, or hissing noise usually heard continuously during inspiration or expiration, but generally louder on expiration; does not clear with coughing Air passing through mucus or fluids in a narrowed lower airway (bronchioles) as with asthma

hearing loss indications

Indications of Hearing Loss Infant: •No startle reaction to loud noises •Does not turn to sound by 4 months old •Babbles as young infant but does not keep babbling or does not develop speech sounds after 6 months Young Child: •No speech by 2 years of age •Speech sounds are not distinct at appropriate ages or regress

Infant style of play?

Infant ◦Engages primarily in solitary play ◦Solitary play is playing alone without others ◦Learns and matures through feel and sound of activities and objects ◦Physical growth occurs as the infant moves toward and plays with objects of interest ◦Playing with blocks enhances cognitive development as the manipulation of blocks produces new and different sounds that are of interest to the infant. ◦As the infant begins to crawl and walk, the sphere of play enlarges and the effect of play on growth and development increases.

infant developmental response to illness

Infant ◦Unaware of illness and its effects only see a deviation from their normal life ◦Encourage normal wake/sleep cycles, feeding times, and typical daily activities ◦Sense stress and anxiety in loved ones ◦Provide family centered care and encourage participation from family to reduce anxiety ◦Awareness of self as separate from parents by 6-8 months leading to separation anxiety and stranger anxiety which is exacerbating if the parent is not staying with the child. ◦Encourage participation when able. Allow parents to touch the infant, remain within view and talk to the infant to calm them when possible.

Infant (2 months-12months)

Infant (2 months-12 months) ◦Plan assessments based on: ◦Appropriate serial weight and height measurements and growth ◦Presence of tooth eruptions ◦Ability to walk and talk ◦Progression into toddlerhood

weight

Infant scale Measure in Kg, grams Remove clothing Zero scale to account for diaper & sheet Standing scale when older Weight doubles by 5-6 months** Weight triples by 1 year old**

XI Spinal accessory

Infant: Not tested. Child: Ask child to raise the shoulders and turn the head side to side against resistance. Good strength in neck and shoulders.

olfactory 1 nerve

Infant: Not tested. Child: Not routinely tested. Give familiar odors to child to sniff, one naris at a time. Identifies odors such as orange, peanut butter, and chocolate.

XII Hypoglossal

Infant: Observe feeding. Sucking and swallowing are coordinated. Child: Tell the child to stick out the tongue. Listen to speech. Tongue is midline with no tremors. Words are clearly articulated.

(IX Glossopharyngeal) (X Vagus)

Infant: Observe swallowing during feeding. Good swallowing pattern. All ages: Elicit gag reflex. Gags with stimulation.

VIII Acoustic

Infant: Produce a loud sound near the head. Blinks in response to sound, moves head toward sound or freezes position. Child: Whisper words and ask for them to be repeated. Repeats words correctly.

optic 2 nerve

Infant: Shine a bright light in eyes. A quick blink reflex and dorsal head flexion indicate light perception. Child: Test vision and visual fields if cooperative. Visual acuity appropriate for age.

III Oculomotor) (IV Trochlear) (VI Abducens)

Infant: Shine a penlight at the eyes and move it side to side. Focuses on and tracks the light to each side. Child: Move an object through the six cardinal points of gaze. Tracks object through all fields of gaze. All ages: Inspect eyelids for drooping. Inspect pupillary response to light. Eyelids do not droop and pupils are equal size and briskly respond to light.

V Trigeminal

Infant: Stimulate the rooting and sucking reflex. Turns head toward stimulation at side of mouth and sucking has good strength and pattern. Child: Observe the child chewing a cracker. Touch forehead and cheeks with cotton ball when eyes are closed. Bilateral jaw strength is good. Child points to location touched by cotton ball.

abdomen assess

Inspection Shape Umbilicus Observe the newborn's umbilical stump for color, bleeding, odor, and drainage Abdominal movements Inguinal area Auscultation •To evaluate bowel sounds, auscultate the abdomen with the diaphragm of the stethoscope. •Bowel sounds normally occur every 10 to 30 seconds •Before determining that bowel sounds are absent, auscultate at least 5 minutes in each quadrant Percussion •Dullness is found over the liver, spleen, and full bladder. •Tympany is found over the stomach or the intestines when an obstruction is present. Palpation •Light palpation evaluates the tenseness of the abdomen (how soft or hard it is), the liver, the presence of any tenderness or masses, and any defects in the abdominal wall. •Deep palpation detects masses, defines their shape and consistency, and identifies tenderness in the abdomen. If an enlarged kidney or mass is detected, do not continue to palpate the kidney. Pressure on the mass may release cancerous cells.**

cardiac assessment

Inspection Shape and symmetry Should be while the child is both sitting and lying down Palpation Apical impulse = the point of maximum intensity, is located where the left ventricle taps the chest wall during contraction Thrills = murmur you can "feel" Pulse Location & Quality Auscultation Rate and rhythm Normal heart sounds (S1/S2) Murmurs

course crackles

Loud, lower pitched, more moist or bubbly sound heard during inspiration; does not clear by coughing Air passing through thicker secretions in the airway

Nurses role in Peds patient safety

Medications are based on weight and environmental factors are the main concerns o Patient safety is a major concern in all healthcare but there are particular concerns that are unique to pediatrics: oPediatric medications are based on the patient's weight - dosage errors are a major concern as there are multiple steps in calculating safe medication doses oPediatric patients also have immature physiology which affects their ability to metabolize and excrete medications oEnvironmental hazards pose additional risks to pediatric patients: crib rails, cords, sleep habitats oParents play a very important role in the care of children. It is important to work WITH them to help provide the safest environment for patients.

Musculoskeletal assessment

Musculoskeletal Assessment •Inspection •Inspect and compare the arms and then the legs for differences in alignment, contour, skin folds, length, and deformities. •The extremities normally have equal length, circumference, and numbers of skin folds bilaterally •Inspect and compare the joints bilaterally for size, discoloration, and ease of voluntary movement •Redness, swelling, and pain with movement may indicate injury or infection. •Palpation •Palpate the bones and muscles in each extremity for muscle tone, masses, or tenderness. •Palpate each joint and surrounding muscles to detect any swelling, masses, heat, or tenderness. •Range of motion •Observe the child during typical play activities, such as reaching for objects, climbing, and walking, to assess range of motion of all major joints. •Children spontaneously move their joints through the full normal range of motion with play activities when no pain is present •Muscle strength •Posture •Inspect the child's posture when standing from a front, side, and back view. •The shoulders and hips are normally level. •Spine Alignment •Assess the school-age child and adolescent for scoliosis, a lateral spine curvature. •Stand behind the child, observing the height of the shoulders and hips and ask the child to bend forward slowly at the waist, with arms extended toward the floor. No lateral curve should be present in either position •Hips •Assess the hips of newborns and young infants for dislocation or subluxation. •First inspect the skin folds on the upper legs. The same number of skin folds should be present on each leg. •Uneven skin folds may indicate a hip dislocation or difference in leg length (Allis' sign). •Then check for a difference in knee height symmetry •The Ortolani-Barlow maneuver is used to assess an infant's hips for dislocation or subluxation

neck and lymph nodes

Neck & Lymph Nodes ◦Inspection ◦Swelling ◦Deviations ◦Palpation ◦Nodes ◦Trachea ◦Thyroid gland ◦Range of motion ◦Torticollis ◦Meningismus

neuro assessment

Neurological Assessment •Overall behavior •Level of Consciousness •Cranial Nerve Function •Common Newborn Reflexes •Reflexes

nose

Nose •Inspection •Inspect the external nose for size, shape, symmetry, and midline placement on the face. •Look for any signs of nasal obstruction or deviation. •Nasal flaring, an effort the child makes to widen the airway, is a sign of respiratory distress and should not be present. •Inspect the internal nose for color of the mucous membranes and the presence of any discharge, swelling, lesions, or other abnormalities •Patency •To test for nasal patency, occlude one nostril and observe the child's effort to breathe through the open nostril with the mouth closed. •Infants under 6 months of age will not automatically open their mouths to breathe when their nose is occluded, such as by mucus. It is of the utmost importance to clear nasal passages in infants particularly during feeding times. •Smell •The olfactory nerve (cranial nerve I) can be tested in school-age children and adolescents by asking them to smell common scents with their eyes closed.

preschooler and style of play

Preschooler ◦Interacts with others in associative play ◦Instead of playing side by side with friends (like toddlers do), children this age now interact with their playmates. For example: one child will cut out a shape while the other glues the shape to a piece of paper ◦Enjoys large motor activities ◦Swinging, riding a tricycle, throwing a ball ◦Demonstrates increased manual dexterity in greater complexity of play activities ◦Better able to manipulate blocks and building, better ability to color, draw, craft ◦Enhances growth and development through fantasy play ◦Fantasy play is very powerful at this age and kids readily engage in dramatic play. Dramatic play is the act of living out the drama of human life. This includes the use of dolls, play furniture, and clothing.

Question 2 Type: MCSA A 27-month-old toddler who is in the pediatric office for a well-child visit begins to cry the moment he is placed on the examination table. The parent attempts to comfort the toddler; however, nothing is effective. Which of these actions by the nurse takes priority? Instruct the father to hold the toddler down tightly to complete the examination. Allow the toddler to sit on the parent's lap and begin the assessment. Allow the toddler to stand on the floor until he stops crying. Ask another nurse in the office to hold the toddler, since the parent is not able to control the toddler's behavior.

Rationale 1: Toddlers are most comfortable when sitting with the parents. Much of the examination can be completed in this way. Allowing the toddler to stand on the floor is inappropriate. A nurse can assist if the parent is unable to hold the child during the examination of the throat and ears to prevent injury from movement.

tympanic membrane Characteristic Tympanic Membrane Unexpected Findings Associated Conditions

Redness Slight redness Amber Deep red or blue Absent Distorted, loss of triangular shape Extra prominent No movement Excessive movement Infection in middle ear Prolonged crying Serous fluid in middle ear Blood in middle ear Bulging tympanic membrane, infection in middle ear Retracted tympanic membrane, serous fluid in middle ear Retracted tympanic membrane, serous fluid in middle ear Infection or fluid in middle ear Healed perforation

Regression

Return to an earlier behavior A child who has been previously toilet trained becomes incontinent when a new infant is born into the family.

Peds Nursing roles

Role of nurse ◦Interact effectively with children and family ◦Modify physical assessment techniques to age ◦Identify strategies to reduce pain and stress ◦Calculate accurate medication dosages ◦Provide safety for child's developmental status ◦Adapt procedures to child's age and development

Strategies to Promote Coping and Normal Development

Rooming In ◦24/7 parental visitation ◦Parental involvement with care Child Life Specialist https://www.youtube.com/watch?v=G1Pp3yespPQ ◦Planned play ◦Collaborate with child life therapists Therapeutic play ◦Dramatic play ◦Medical play Therapy •Animal-assisted therapy •Art Therapy •Music Therapy https://www.youtube.com/watch?v=KNuT3x4KJsY

school age style of play

School-Age ◦Play is an extremely important method of learning and living for the school-age child. ◦Increased physical abilities allow greater range and complexity of activities ◦Able to participate in team sports due to overall increase in physical ability but also cognitive abilities that allow them to follow the rules ◦Engages in cooperative play, which increases social and cognitive skills ◦Cooperative play includes the cooperation of others and also the ability to play a part of a unified whole (i.e. team sports)

school age dev. response to illness

School-age ◦Beginning understanding of body functions ◦Foster sense of industry. ◦Encourage participation in care, continued schoolwork, and arts/crafts ◦Stressful procedures can lead to regression or behavior changes.

School-age (6 - 12 years old) ◦Plan assessments based on:

School-age (6 - 12 years old) ◦Plan assessments based on: ◦Growing interest in peer group and extracurricular activities ◦Growth spurt occurring earlier in girls than boys ◦Ability to think about solutions and determine the best among several alternatives ◦Understanding of the concept of conservation

skin and hair

Skin & Hair •Examination of the skin requires good lighting to detect variations in skin color and to identify lesions •Rather than inspecting the entire skin surface of the child at one time, examine the skin simultaneously with other body systems as each region of the body is exposed. •Use gloves to inspect the child's skin for color and the presence of imperfections, elevations, or other lesions. •Use standard precautions when palpating mucous membranes, open wounds, or lesions. •The palms of the hands and soles of the feet are often lighter than the rest of the skin surface in darker-skinned children and can be a good location to assess for color.

CHAPTER 4 Question 1 Type: MCMA While in the pediatrician's office for their child's 12-month well-child exam, the parents ask the nurse for advice on age-appropriate toys for their child. Based on the child's developmental level, which types of toys would the nurse suggest? Standard Text: Select all that apply. Soft toys that can be manipulated Small toys that can pop apart and go back together Jack-in-the-box toys Toys with black and white patterns Push-and-pull toys

Soft toys that can be manipulated. Jack-in-the-box toys. Push-and-pull toys.

stepping

Stepping reflex ◦When held upright with one foot touching a flat surface, the newborn puts one foot in front of the other and "walks" (stepping reflex). ◦This reflex is more pronounced at birth and is lost in 4-8 weeks.

sucking

Sucking reflex ◦Elicited when an object is placed in the newborn's mouth or anything touches the lips. ◦Newborns suck even while sleeping. ◦This is called nonnutritive sucking. ◦Can have a quieting effect on the baby. ◦Disappears by 12 months

temp texture and moisture

Temperature •Excessively warm skin may indicate the presence of fever or inflammation, whereas abnormally cool skin may be a sign of shock or cold exposure. Texture •Children have soft, smooth skin over the entire body. Abnormalities in texture are associated with endocrine disorders, chronic irritation, and inflammation. Moisture •The child's skin is normally dry to the touch. Excessive sweating without exertion can be associated with a fever or with an uncorrected CHD.

leading cause of death in infants

The leading cause of infant mortality in the post-neonatal period is sudden infant death syndrome (SIDS), congenital malformations, and unintentional injuries.

difference between viral and bacterial conjunctivitis

The major difference between bacterial and viral conjunctivitis is that bacterial conjunctivitis has a purulent discharge that may result in crusting, whereas the discharge from viral conjunctivitis is serous (watery). Allergic conjunctivitis produces watery to thick drainage and is characterized by itching and usually bilateral in nature.

Therapeutic recreation and strategies to meet education needs

Therapeutic recreation Social interactions Modified physical activity Strategies to meet educational needs Comfortable work environment Interactions with classmates Child and family teaching Teaching plans Teaching for children with special needs

Review of systems

This is not the PE General Skin and lymph Hair and nails Head Eyes Ears Nose and sinuses Mouth and throat Cardiac and hematologic Chest and respiratory Gastrointestinal Urinary

toddler and style of play

Toddler ◦Increased motor skills enable the toddler to engage in new ways of playing ◦Play becomes more social, and often includes parallel play with other toddlers ◦Parallel play is when two toddlers or children play with similar objects side by side ◦Engages in imitative behavior, which teaches new actions and skills ◦Have peaked interest in things they see at home: toy vacuum cleaner, hammers or tools, baking in the play kitchen, etc. ◦Increased cognitive abilities enable toddler to manipulate objects and learn about their qualities ◦Learning to stack blocks, place rings, and build towers are all examples of expanded cognitive abilities that help teach spatial relationships and provide a foundation for future learning.

toddler 1-3 yrs

Toddler (1-3 year old) ◦Plan assessments based on: ◦Increasing verbal ability and skill at walking ◦Ability to control elimination ◦Tooth eruption ◦Increasing independence

toddlers/preschoolers dev response to illness

Toddlers/Preschoolers ◦Separation from parents and disruption of routine are major stressors and fears ◦Encourage participation and maintenance of home routines ◦May see illness as punishment ◦Has incorrect cause-and-effect perceptions ◦Calmly explain source of illness and no fault to child

tonsil size

Tonsil Size •Tonsil size can be graded from 1 to 4 in relation to how much of the airway is obstructed. •Tonsil size of 1 and 2 is normal. •Tonsil size of 3 is common with infections such as strep throat. •Tonsils that "kiss" or nearly touch each other (4) significantly reduce the size of the airway.

turgor

Turgor •The child's skin is taut, elastic, and mobile because of the balanced distribution of intracellular and extracellular fluids. •To evaluate skin turgor, pinch a small amount of skin on the abdomen between the thumb and forefinger, release the skin, and watch the speed of recoil. •Poor skin turgor is commonly associated with dehydration. •If edema, an accumulation of excess fluid in the interstitial spaces, is present, the skin feels doughy or boggy. •To test for the degree of edema present, press for 5 seconds against a bone beneath the area of puffy skin, release the pressure, and observe how rapidly the indentation disappears.

leading cause of death by age group (1 yr, 1-4, 5-9, 10-14, 15-19)

Under 1 year Suffocation Homicide, unspecified cause 1 to 4 years Drowning Motor vehicle 5 to 9 years Motor vehicle Drowning 10 to 14 years Motor vehicle Suicide, suffocation 15 to 19 years Motor vehicle Homicide, firearms

Respiratory System Anatomy and Physiology: Pediatric vs. Adult

Upper airway differences •Airway diameter •An infant's airway diameter is approximately 4 mm (0.16 in.). •In contrast to the adult's 20-mm (0.8-in.) airway diameter. •Any inflammatory process in the airway causes swelling. •Narrows the airway •Airway resistance increases •Note that swelling of 1 mm (0.04 in.) reduces the infant's airway diameter to 2 mm (0.08 in.), but the adult's airway diameter is only narrowed to 18 mm (0.7 in.).

visual acuity

Visual Acuity •Infants assessed based on ability to track an object. •Snellen picture cards for children 3-6 years old •Snellen E chart is appropriate depending on if the child knows the alphabet (usually school age) and how well they can follow direction •Visual acuity depends on age (p. 112).

Question 4 Type: MCSA Which of these strategies would be most effective for a "teachable moment" during a routine office visit for the parents of a 6-year-old child? Select one topic and present a brief amount of information on the topic. Review all 6-year-old anticipatory guidelines with the parents. Review 7-year-old anticipatory guidelines with the parents. Discuss signs of malnutrition with the parents.

nuclear family

a couple and their dependent children, regarded as a basic social unit.

Binuclear family

a type of family consisting of divorced parents living in two separate households but remaining one family in spirit for the sake of the children

Question 5 Type: MCMA The clinic administrator has asked each nurse to classify the nursing activities as a beginning step of clinic reorganization. Which of these strategies can be identified as health promotion and health maintenance? Standard Text: Select all that apply. Administration of the flu vaccine for infants from 6 months to 23 months old. Daily feeding schedules for infants. Instruction to adolescents on how to use dental floss. Treatment for a child with a diagnosis of acute otitis media.

a, b, c

chronic airway conditions

asthma cystic fibrosis

CHAPTER 6 Question 1 Type: MCSA A nurse is helping the parents of 2-year-old twins cope with the daily demands of life in an active household. Which strategy is most appropriate for the nurse to use? Health maintenance Health promotion Health protection Health supervision

Question 2 Type: MCSA When assessing the cognitive development, which technique would be appropriate to test the remote memory of a 5-year-old? Say the name of an object and after 5 minutes ask the child to tell you what you said the object was. Ask the child to repeat his address. Ask the child to say a poem and listen to the child's speech articulation. Have the child point to various parts of the body as you name them.

Question 3 Type: MCSA A mother brings a child to the pediatric office for a sick visit. Which action by the nurse is the most appropriate? Focus exclusively on the reported illness. Review health-promotion and health-maintenance activities. Ask the mother to leave the room after obtaining the history. Obtain a comprehensive history, including sociodemographic data.

permissive

behavior of parent Few or no restraints •Unconditional love •Communication flows from child to parent •Much freedom and little guidance behavior of parent •May be rebellious, aggressive, socially inept, self-indulgent, or impulsive •May be creative, active, and outgoing

CHAPTER 5 Question 1 Type: MCSA The nurse is taking a health history from a family of a 3-year-old child. Which statement by the nurse would most likely establish rapport and elicit an accurate response from the family? "Does any member of your family have a history of asthma, heart disease, or diabetes?" "Hello, I would like to talk with you and get some information on you and your child." "Tell me about the concerns that brought you to the clinic today." "You will need to fill out these forms; make sure that the information is as complete as possible."

Question 2 Type: MCSA A nurse in the outpatient pediatric clinic is reviewing the records of a preschool-age child and notes that because the parents often miss routine healthcare visits the child has not received the second measles, mumps, and rubella (MMR) vaccine. Which action by the nurse is most appropriate in this situation? Speak firmly with the parents about the importance of being compliant. Notify the physician that the child's immunizations are no longer up to date. Call the parents and encourage them to bring the child for recommended care. Plan to discuss the principles of health supervision at the next scheduled visit.

Question 4 Type: MCSA While assessing a 10-month-old African American infant, the nurse notices that the sclerae have a yellowish tint. Which organ system should the nurse further evaluate to determine an ongoing disease process? Cardiac Respiratory Gastrointestinal Genitourinary

•Skills develop according to two processes: from the head downward and from the center of the body outward.

cephalocaudal proximodistal

Blended family

consists of a biological parent, a stepparent, and the children of one or both parents

Question 4 Type: MCSA The nurse is teaching a group of mothers of infants about the benefits of immunization. Which immunization will the nurse teach to the mothers that can assist in preventing the life-threatening disease epiglottitis? Measles, mumps, and rubella (MMR) Haemophilus influenzae type B (HIB) Hepatitis B Polio

correct Answer: 2Rationale 1: The Haemophilus influenzae type B (HIB) immunization can assist in prevention of epiglottitis. Hepatitis B, measles, mumps, rubella, and the polio virus are not causative agents for epiglottitis

upper airway conditions

croup epiglottis

extended family

household made up of several generations of family members

Repression

involuntary forgetting of uncomfortable situations An abused child cannot consciously recall episodes of abuse.

Periorbital cellulitis cause tx management

is a bacterial infection of the eyelid and surrounding tissues. uTypical causitive agent is staphylococcus or streptococcus uS/S: swollen, tender, red or purple eyelids with restricted, painful movement of the area around the eye, and fever uTreatment is required promptly. Failure to provide treatment can cause the infection to spread, including progression to bacterial meningitis. uManagement: IV antibiotics, IV fluids, warm packs uUsually see improvement in 48-72 hours

morbidity and mortality in peds what is morbidity and top 5 leading causes of hospitalization in 1-17 yr old

is an illness or injury that limits activity, requires medical attention or hospitalization, or results in a chronic condition. •Diseases of the respiratory system account for the greatest number of hospitalizations when pneumonia and asthma hospitalizations are combined .

Chapter 5 pediatric assessment

look at ppts

stressors for hospitalized children

oSeparation from parents, primary caretaker, or peers oLoss of self-control, autonomy, and privacy oPainful and/or invasive procedures oFear of bodily injury and disfigurement

cystic fibrosis diagnosis

picture hopefully on study guide

•Proximodistal

refers to development that occurs from the center of the body outward. Examples of this is that infants are able to control their trunk much before they master fine motor movements of they hands.

•Cephalocaudal

refers to growth that occurs from the head downward though the body and toward the feet. Examples of this is infants learn head control before learning to sit and they learn to sit before they learn to stand.

•Common defense mechanisms of children:

repression, regression, rationalization fantasy

child free family •Single-parent family •Single-mother-by-choice family •Heterosexual cohabiting family •Gay or lesbian family

self-explanatory

Mature minors:

these are adolescents who may give independent consent to receive or refuse treatment fro a limited number of conditions. These conditions often include: testing and treating sexually transmitted infections (STIs), contraception cervices, substance abuse, and mental health care.

•Emancipated minors

these patients typically are self-supporting adolescents (under age 18) or those who may be married, pregnant, or incarcerated and are not subject to parental control. Additionally, minor parents may make medical decisions for their own child.

conjunctivitis 4 causes

uConjunctivitis is an inflammation of the conjunctiva (the clear membrane that lines the inside of the lid and sclera) uFour main causes of conjunctivitis: uChemical -Splash injuries -Foreign Body uBacterial uViral -URI uAllergic

epistaxis tx

uEpistaxis or nosebleed is common in school-age children especially boys uThe most common cause is from nose picking, foreign bodies, or dry air. Though it may also occur from allergies, infections, or forceful coughing. uNursing care of these children include examining the nose for any bleeding, determining the flow of the blood (anterior vs posterior), and helping to stop the bleed. uChildren with nosebleeds may often swallow the blood and thus develop abdominal upset, this is especially common after T/A procedures. uBlunt trauma to the head with nose bleeding is worrisome and the child should be assessed for a posterior nose bleed. uTreatment: uHave the child sit upright, tilt the head forward, squeeze the nares just below the nasal bone and hold for 10-15 minutes. uIf bleeding does not resolve a cotton ball may be inserted either plainly or soaked in epinephrine, thrombin or lidocaine. Consider evaluating a CBC, coags, bleeding studies if repeated or prolonged

eyes injuries

uEye injuries are very common in the U.S. especially among school-age and adolescent boys. uCommon causes include: BB guns, fireworks, sharp objects, chemical burns, and sports injury. uTreatment depends on the offending agent uBurns: irrigate the eye for 15-30 minutes and transport to ER immediately uPenetrating injuries: never remove the object as only should be done my an opthamalogist uCorneal abrasions: flourisein strip to see the abrasion, erythromycin eye drops prophylactically uFB on conjunctiva: Avoid rubbing. Irrigate. If cannot be removed, head to ER u"Black eye": Ice the eye then after 2 days, apply warm compresses

conjunctivits cont.

uIn newborns (or infants under 30 days) conjunctivitis is referred to as opthalmia neonatorum*. In this patient population, these infections are usually acquired from the mother during vaginal birth and contact with infected vaginal secretions. uCommon organisms that cause eye infections in newborns include: chlamydia, gonorrhea, or herpes simplex virus* uThese infections (especially herpes simplex) required prompt treatment to prevent injury or blindness* uIn older infants with frequent eyelid discharge especially upon waking, a plugged tear duct may be suspected

otitis media

uOtitis media is an inflammation of the middle ear. When a child has acute ear pain, bulding of the tympanic membrane, and middle ear effusion, this is referred to as acute otitis media (AOM). uMore common among boys, children in daycare, children with allergies, and during the winter months. uBreastfeeding has been shown to be effective in preventing OM. uA specific cause is unknown but appears to be related to disfunction of the eustachian tubes. uIn very many cases, an OM is preceeded by a viral URI that causes the infection to block air from reaching in the inner ear and the eustachian tubes become inflammed and the virus lingers. uThe tympanic membrane and fluid behind it become infected.

Tonsillectomy Nursing Care

uProvide adequate cool fluids to help prevent dehydration uIce cream uAn ice collar may help with discomfort and swelling uProvide adequate pain relief uTylenol uNarcotics uObserve for bleeding uLook for frequent swallowing, avoid dislodging clots uObserve for infection Normal for the back of the throat to have slight smell and white exudate for 7 days after surgery. Low grade fever may also be present. Fever >38.8C is concerning though infection is rare.

uRecurrent otitis media or effusion uOtitis externa

uRecurrent otitis media or effusion uE N T referral for possible tympanostomy tube placement uOtitis externa uInflammation of the skin and soft tissue of the ear canal uOccasionally called "Swimmer's Ear" uCan also be caused by placing things into the ear uAntibiotic ear drops uSteroid + Antibiotic Drops

tonsilitis/pharyngitis s/s

uTonsillitis is an infection or inflammation of the palatine tonsils. uPharyngitis is an infection of the pharynx uMay be caused by a virus (80%) or bacteria uBacteria: often group-A beta hemolytic strep (GABHS) uDiagnosed by throat culture uSymptoms: uDifficulty swallowing uEnlargement of cervical nodes uBreathing difficulties uAssess for redness, swelling, exudates

conjunct tx and nursing consideration

uTreatment uBacterial: crusty yellow purulent discharge uAntibiotics (atleast 48 hours) uIsolation uSupportive care uViral: white discharge (starts in one eye and eventually goes to other from rubbing it) uSupportive Care uAntivirals uNo antivirals unless herpes virus I think uAllergic (both eyes and itchy) uAntihistamines uDecongestants uLubricants uNursing Considerations uDocumentation: what eye, drainage, matting of eye, sweeliing,

tonsilitis tx tonsillectomy

uTreatment: uViral pharyngitis or tonsillitis is treated with supportive care uTonsillitis from streptococcal bacteria is treated with oral PCN for 10 days uAcute symptoms should resolve within 24 hours of therapy, at which time the child is no longer contagious When is a Tonsillectomy warranted? uTonsillectomy can be considered when there are at least 7 episodes of tonsillitis in the previous year, at least 5 episodes per year for 2 years, or three episodes per year for three years. uSleep disordered breathing from tonsillar hypertrophy is also an appropriate reason Amey - Tonsillectomy - Post Op Care

•Health maintenance

•Activities that preserve a person's present state of health •Prevents occurrence of disease or injury •Examples include: •Developmental screening •Immunizations •Preventing injury (safety hazards

acute respiratory failure

•Acute Respiratory Failure (ARF) is a common medical emergency in children •It is defined as the inability to provide O2 and remove CO2 at a rate that meets metabolic demands and occurs when the body can no longer maintain effective gas exchange** •Physiologically, it is defined by a PaO2 of < 60 mm and/or by an acute increase in pCO2 of 10-15 mm Hg, particularly if associated with a decrease in pH to 7.32 or less •Not all patients with ARF require intubation and mechanical ventilation**

Opthalmic drops

•Adequate immobilization is needed to avoid injury •Stabilize hand by resting wrist on head •Have medications at room temperature

otic drops

•Adequate immobilization is needed to avoid injury •Stabilize hand by resting wrist on head •Pull pinna up from children >3yr or down for kids under <3yr

table 2 key elements to family centered care ¡How do we provide family centered care in pediatrics? ¡What challenges might we have when trying to provide family centered care?

•Allow the family to participate in the care of the child; encourage family participation in medical decision making, participation in procedures, & maintaining normal feeding and bath routines when possible •Each party respects what other brings to interactions because collaboration brings optimal outcome. • By incorporating the family's cultural background and beliefs into care at every encounter •Encouraging the child to participate in care with the help of the family •Provide age appropriate education, keeping in mind the understanding of the family •Value the input of the family including their past experiences and perception of the patient and the illness as the parents' perspective can be critical to quality care.

anticipatory guidance sexuality

•Anticipatory Guidance •Sexuality •School-age children •Have many misconceptions about the bodies of men and women, sexual intercourse, and reproduction •May begin to ask questions •Questions should be answered truthfully and fully •Children typically learn about sex through the media •Adolescents •Ask directly if they have had any sexual activity •Focus on birth control, prevention of sexually transmitted infections (STIs)

anticapatory guidance sleep toileting

•Anticipatory Guidance •Sleep Patterns •Should sleep 9 to 11 hours a night and may nap once per day •A regular sleep schedule is important to maintain positive behaviors •Nightmares & night terrors are common among this age group •What is the difference? •Toilet Training •Assessing Readiness for Toilet Training •Able to stay dry for 2 hours •Fine motor skills to remove clothing •Willingness to please parents •Curiosity about adult's or sibling's toilet habits •Impatient with wet or soiled diapers

age 3-6 yrs play & toys communication

•Associative play is facilitated by simple games, puzzles, nursery rhymes, songs** •Dramatic play is fostered by dolls and doll clothes, play houses and hospitals, dress-up clothes, puppets** •Stress is relieved by pens, paper, glue, scissors •Cognitive growth is fostered by educational television shows, music, stories, and books •All parts of speech are developed and used, occasionally incorrectly •Communicates with a widening array of people •Play with other children is a favorite activity** •Health professionals can:** -Verbalize and explain procedures to children -Use drawings and stories to explain care -Use accurate names for body functions -Allow the child to talk, ask questions, and make choices

asthma

•Asthma is a common chronic disorder in children that is characterized by bronchial constriction, hyper responsive airways, and airway inflammation. •An estimated 10.5 million children in the United States have asthma and there is high percentage of children with asthma in Michigan and Genesee county •Barriers to asthma care include inability to access primary care, asthma specialist care, or asthma medication due to cost.

VS: HR

•Auscultate apical pulse a full minute using a stethoscope •Heart rate will normally increase with fever, stress, and anxiety •Be sure to document what state the child is in when measurement was obtained Neonate 100-180 awake 80-160 asleep Infant 100-160 75-160 Toddler 80-110 60-90 Preschool 70-110 60-90 School Age 65-110 60-90 Adolescent 60-90 50-90

•Mental & Spiritual Health

•Begin to have self-regulation to soothe and comfort self •Adequate sleep and rest are needed to be successful •Positive discipline •Self-esteem build as the child masters age appropriate skills •Examples: brush teeth independently, toilet training •Growing sense of independence and differentiation of self from parent/caregiver and from significant others •Preschools develop a growing awareness of gender and sexuality issues •Common to ask questions about body parts, kissing, or relationships •Important to be honest and use accurate body part description

tanner staging

•Breast budding, the first stage of pubertal development in girls, normally occurs between 9 and 14 years of age. Breast development before age 7 warrants evaluation. •The presence of pubic hair before 8-9 years of age is uncommon, and delayed onset of testicular enlargement after 14 years of age needs evaluation. •The sexual maturity rating (SMR) is an average of the breast and pubic hair Tanner stages in females and of the genital and pubic hair Tanner stages in males. The rating is a number between 2 and 5, as stage 1 is prepubertal.

lower airway conditions

•Bronchiolitis •Pneumonia

bronchiolitis patho s/s

•Bronchiolitis is a lower respiratory tract infection that occurs when viral or bacterial organisms cause inflammation and obstruction of the bronchioles •Very common condition. Bronchiolitis is the lead cause of hospitalization of children in the first year of life and nearly all children will have been infected with RSV by 2 years of age. •Pathophysiology: •Respiratory syncytial virus (RSV) is the typical culprit (more common Oct-March) and is transmitted through contact with respiratory secretions or infected surfaces. •Other viruses such as adenovirus, enterovirus, or rhinovirus can also cause inflammation and obstruction of the bronchioles •These viruses invade the mucosal cells of the bronchioles and fuse with healthy cells to create "syncytia" or large masses. These masses then clog and irritate the airway. The airway then swells and causes air trapping and hyperinflation. Symptoms include cough, runny nose, congestion, fever, wheezing, tachypnea, retractions, and subsequent poor PO intake and dehydration

iv start

•Careful maintenance of sites is needed •Common sites include: hand, feet, antecubital fossa, and sometimes scalp •It is essential to do hourly IV checks as children's IV can infiltrate VERY easily. usually D5 for kids bc risk for hypoglyc .45 also used often

Next steps

•Chief Complaint - what brought you here?** •History of Present Illness or Injury (HPI)** •Patient's Medical History:** •Birth Hx •GA, Drug use, PNC, GBS status, delivery complications •Communicable disease and illness •Travel and school exposures •Hospitalizations & Surgeries •When? PICU admissions? •Injuries Trends in injury? •Current health status** ◦Health maintenance pattern ◦Last visit? •Medications (prescribed and OTC) •Allergies •Immunization status •Use of safety equipment? •Guns, smoke detectors, car seats

school age prep

•Clear, thorough explanations are helpful. Use drawings, pictures, books, and contact with equipment. •Teach stress-reduction techniques such as deep breathing and visualization. •Offer a choice of reward after procedure is completed. during •Be ready to immobilize the child if needed. Allow child to remain in position by self if child is able to be still. •Explain throughout procedure what is happening. •Facilitate use of stress-control techniques. •Praise cooperative efforts.

color

•Color •The color of the child's skin usually has an even distribution. •Check for color variations—such as increased or decreased pigmentation, pallor, mottling, bruises, erythema, cyanosis, or jaundice

sibling responses to hospitalization

•Confusion - siblings may not understand what is happening and why. •Guilt - siblings may have been in an argument with their brother or sister and think that they caused the hospitalization. They may also feel guilty because they are not sick, but their sibling is. •Anger - siblings may be angry at their brother or sister for getting sick. They may be angry that their parents did not prevent their brother or sister from becoming ill. •Jealousy - siblings can feel jealous of all the attention the patient is receiving. The patient may receive gifts and relatives may travel to visit them. Siblings who do not know what is happening at the hospital often think that their brother or sister is there having nothing but fun. •Rejection - siblings may feel left out. If they are unsure about what is happening at the hospital, they feel that they are not included and not important. The sibling may also worry that the parent cares about the patient more because the parent may need to spend a great deal of time with the patient.

Croup/ Laryngotracheobronchitis (LTB)

•Croup refers to a broad class of upper airway illnesses that result from inflammation and swelling of the epiglottis and larynx. The swelling can extend into the trachea and bronchi too. •Laryngotracheobronchitis (LTB) refers to a viral infection that causes the swelling •Most common among children 3 months to 3 years •Starts as a URI then progresses to early fever, barky/seal like croupy cough, inspiratory stridor, retractions, and potential airway obstruction over 24-48 hours

cystic fibrosis

•Cystic fibrosis is an inherited disorder that causes severe damage to the lungs, digestive system and other organs in the body. It is an autosomal recessive disorder that is unaffected by gender. •Roughly 30,000 children and adults in the U.S. have CF and approximately 50% of those living with CF are over 18 years of age. •Roughly 10 million people in the U.S. are carriers for CF •The current lifespan for those with CF in the U.S. is mid-40's •More common among non-Hispanic whites and Hispanics than non-Hispanic blacks or Asian Americans

Assent

•Despite limitations in informed consent, children and adolescents should have an opportunity to participate in treatment decisions. Assent is the voluntary agreement to accept treatment or participate in research. To give assent, a child must have a basic understanding of what will be done and what is required for participation. Parents make the final decision on treatment for a child, but allow children the opportunity to assent or dissent helps keep them engaged in their own healthcare.

Development ASQ

•Development •Begin using developmental screening tools based on the child's age •Ages & Stages Questionnaire (ASQ) is parent-completed questionnaire that pinpoints developmental progress in children between the ages of one month to 5 ½ years •Developmental Milestones •Draws a circle and other rudimentary forms, learning to dress self, able to jump •Hearing, smell, taste, and touch development increase •Learning to have voluntary control of elimination •Increase in overall understanding and comprehension Know more than 300 words in vocabulary by age 2

Parental Responses to Stressors of Hospitalization

•Disbelief, anger, guilt ◦Especially if sudden illness •Fear, anxiety ◦Related to child's pain, seriousness of illness •Frustration ◦Especially related to need for information •Depression •Family processes disrupted •Parental roles may be altered •Burdens of missed work, additional expenses, caring for siblings

discipline media use

•Discipline •Provide guidance on how the parent deals with difficult behavior •Positive discipline is essential to help the child develop a sense of right and wrong (p. 172) •Encourage parents to role model acceptable behavior •Media Use •Avoid TV or computers in children's room because media use can interfere with sleep. •Limit screen time to a maximum of 2 hours per day

The "difficult" child

•Displays irregular schedules for eating, sleeping, and elimination •Adapts slowly to new situations and persons •Displays a predominantly negative mood •Intense reactions to the environment common

the rules of two

•Do you use your quick-relief inhaler more than 2 times per week? •Do you awaken at night due to asthma more than 2 times per month? •Do you refill a quick-relief inhaler Rx more than 2 times per year? Out of Control! •If you can answer "YES" to ANY of these questions, your asthma is probably not under good control.

epiglottis s/s

•Epiglottitis is a bacterial infection, most often caused by Haemophilus influenzae, that causes inflammation and swelling of the epiglottis and larynx. •While epiglottitis used to be common, the introduction of the HiB vaccine has reduced rates dramatically. However, group A streptococcus and staphylococcus can still cause the disease, though rare. •This is a life threatening condition that progresses very rapidly and can cause complete airway obstruction •Symptoms include high fever (typically >39C), intense sore throat, drooling, dysphagia, tachycardia, tachypnea, and may be in the tripod position. There is no barky cough with epiglottitis.

Erik Erikson

•Erik Erikson studied Freud's theory of psychoanalysis and established his own developmental theory, which he classifies into 8 different stages, 5 of which apply to children:

discharge considerations

•Family ability to provide care •Equipment, training •Financial burdens •Educational needs •Parent teaching •follow up, signs and symptoms, ongoing care needs •Return to schoolwork •Prepare the family •Procedures •Medications •Emergencies •Prepare parents to act as case managers

why do we care about developmental theories

•Freud's theory helps us to understand why a child may have defense mechanisms, why they may regress to earlier stages, and how illness can affect a child's behavior. As nurses, who are providing care to children, it is of the utmost importance that we understand the impact hospitalization has on our patients. •Erikson's theory is directly applicable to the nursing care of children. Health promotion is at the center of what we do as nursing and health maintenance in the community allows us nurses to meet the needs of the community. Understanding these crucial points in the child's life and what normal progression looks like is tantamount in providing care. •Piaget's theory helps use to understand the child's thought process in order to design age appropriate activities and distraction techniques. •As nurses we need to be able to synthesize information from several theoretical approaches and use them to plan assessments of the child's physical growth and developmental milestones.****

3-6 preschooler physical growth fine motor ability Gross motor sensory ability

•Gains 1.5-2.5 k g (3-5 l b)/year •Grows 4-6 cm/year •Uses scissors •Draws circle, square, cross •Draws at least a six-part person •Enjoys art projects such as pasting, stringing beads, using clay •Learns to tie shoes at end of preschool years (C) •Buttons clothes •Brushes teeth** •Uses spoon, fork, knife** •Eats three meals with snacks** •Throws a ball overhand •Climbs well •Rides bicycle** •Visual acuity continues to improve •Can focus on and learn letters and numbers

1-2 yrs Physical Growth Fine Motor Ability Gross Motor Ability Sensory Ability

•Gains 227 g (8 o z) or more per month •Grows 9-12 c m (3.5-5 i n.) during this year •Anterior fontanelle closes** •By end of second year, builds a tower of four blocks** •Scribbles on paper •Can undress self •Throws a ball •Runs •Shows growing ability to walk and finally walks with ease** •Walks up and down stairs a few months after learning to walk with ease •Likes push-and-pull toys •Visual acuity 20/50

8-10 months Physical Growth Fine Motor Ability Gross Motor Ability Sensory Ability

•Gains 85-140 g (3-5 o z)/week •Grows 1 c m/month •Picks up small objects •Uses pincer grasp well •Crawls or pulls whole body along floor by arms** •Creeps by using hands and knees to keep trunk off floor •Pulls self to standing and sitting by 10 months** •Recovers balance when sitting •Understands words such as "no" and "cracker" •May say one word in addition to "mama" and "dada"**

6-8 months Physical Growth Fine Motor Ability Gross Motor Ability Sensory Ability

•Gains 85-140 g (3-5 oz)/week •Grows 1 c m /month •Growth rate slower than first 6 months** •Bangs objects held in hands •Transfers objects from one hand to the other •Beginning pincer grasp at times** •Inborn reflexes extinguished** •Sits alone steadily without support by 8 months** •Likes to bounce on legs when held in standing position Responds readily to sounds •Recognizes own name and responds by looking and smiling** •Enjoys small and complex objects at play

general obs

•General Observation •How is the parent interacting with the child? What type of tone do they use when speaking with the child? •Is the parent praising the child and partnering with them? Or do they criticize the child frequently? •During adolescence parents and children should start to form a partnership •Be alert for any mention of divorces or separations, remarriages, ill siblings or grandparents, or parent job changes - these can cause stress to the child and family. •Nurse should encourage adolescent to answer questions as well as parent •Adolescent has increasing independence for managing disease and illness

health promotion general observations of an infant and newborn

•General Observation: •Do infant and parent have close physical contact, eye contact, and vocalization during visit? •Does baby respond to eye contact, movement, and vocalizations by the nurse? •Do parents appear relaxed or stressed? •Does infant behave as expected for age and situation? •Is parent able to effectively handle infant being seen as well as any other siblings present? •In newborns, be sure to thoroughly assess the mother. Are there any concerns for post-partum depression?

The "easy" child

•Generally moderate in activity •Shows regularity in patterns of eating, sleeping, and elimination •Usually positive in mood •Adapts to new situations when subjected to new stimuli •Able to accept rules •Works well with others

adolescents prep

•Give clear explanations orally and in writing. •Teach stress-reduction techniques. •Explore fear of certain procedures, such as staple removal or venipuncture. during •Assist adolescent in self-control. Assist with use of stress-control techniques. •Explain expected outcome and tell when results of test will be completed.

toddler prep

•Give explanation just before procedure, since toddler's concept of time is limited. Explain that child did nothing wrong; the procedure is simply necessary. during •Perform in treatment room. •Nursing staff should immobilize the child securely. •Give short explanations and directions in a positive manner. •Avoid giving choices when none is available. For example, •"We are going to do this now" is better than "Is it okay to do this now?" •Allow child to cry or scream. •Comfort child after procedure. Give child a choice of favorite drink, if allowed, or special sticker.

preschool prep

•Give simple explanations of procedure. Basic drawings may be useful. •While providing supervision, allow the child to touch and play with equipment to be used, if possible. Since any entry into the body is viewed as a threat, state that the child's body will remain the same, and use adhesive bandages to reassure the child that the body is intact and parts will not "fall out." during •Perform in treatment room. Nursing staff should immobilize the child securely. •Give short explanations and directions in a positive manner. Encourage control by having the child count to 10 or spell name. •Allow child to cry. Give positive feedback for cooperation and getting through procedure. •Encourage the child to draw afterward to explore the experience.

6-12 yr activities and communication

•Gross motor development is fostered by ball sports, skating, dance lessons, water and snow skiing/boarding, biking •A sense of industry is fostered by playing a musical instrument, gathering collections, starting hobbies, playing board and video games** •Cognitive growth is facilitated by reading, crafts, word puzzles, schoolwork •Mature use of language •Ability to converse and discuss topics for increasing lengths of time •Spends many hours at school and with friends in sports or other activities •Health professionals can:** -Assess child's knowledge before teaching -Allow the child to select rewards following procedures -Teach techniques such as counting or visualization to manage difficult situations -Include both parent and child in healthcare decisions

growth and development

•Growth & Development •Physical Growth •School age is the last period which girls and boys are close in size and body proportions •Weight gain remains1.4-2.3 k g (3-5 lb) per year •Height increases by 4-6cm (1.5-2.5 inches) per year •Measurements •Weight •Height •BMI •Screenings •Vision •Hearing •Hgb/Hct •Lead •Lipid screening (10 years old) •STI (13 years old/sexually active) •Scoliosis

Lower airway differences

•Growth of alveoli •By 36 weeks of age alveoli begin to differentiate •Increase in number for 5-8 years then by size and complexity Diaphragm use for respirations •Pediatric patients use the diaphragm to breath until roughly age 6 years because their intercostal muscles are immature Immaturity of respiratory system •Children consume more oxygen then adults because they have high metabolic rates •Ribs are made of cartilage and are very flexible, in respiratory distress the negative movement from the diaphragm causes the chest wall to be drawn in resulting in retractions.

growth vs development

•Growth refers to a quantitative increase in physical size or measurement whereas development refers to a qualitative increase in capability or function. •Pediatric nurses rely on their knowledge and understanding of growth and developed in order to properly assess their patients. •Since growth and development is both predictable and sequential, deviations from normal help nurses to analyze a patient's current state. •A skilled pediatric nurse will integrate knowledge of physical growth and development into each child's health care encounter •The qualitative and quantitative changes in body organ functioning, ability to communicate, and performance of motor skills develop over time and are crucial components in the planning of pediatric health care.

high flow NC

•HFNC oxygen therapy provides oxygen but also provides "flow". •The "flow" is a form of continuous positive airway pressure (CPAP) to children and young infants •The use of HFNC has dramatically reduced the need for full CPAP or intubation in recent years •Because flow is high and oxygen can be drying, humidification is needed •The use of HFNC works well in patients with bronchiolitis because it helps to improve alveoli volume recruitment

•Health promotion

•Health promotion refers to activities that increase well-being and enhance wellness or health. •Healthy Flint & Genesee County 2020: •Promote Improved Health Behaviors •Be Tobacco & Smoke Free •Commit to Fit! to Reduce & Prevent Obesity •Focus on Our Future: Promote Healthy Children & Adolescents •Promote Access to High Quality Health Care for All •Improve Diabetes Support, Identification, & Prevention •Promote Heart Health •Create Coordinated Children's Healthcare Access •Develop a Community System for Advance Care Planning •Create, Redesign, & Expand Health Promoting Environments •Develop a Skilled, Diverse Healthcare Workforce Collaboratively Monitor Health Data to Measure Our Progress

interventions

•Help parents create schedule for medication administration •Teach respiratory therapy techniques •Create schedule •Determine nutritional needs •Determine if financial assistance is needed •Plan for exercise

Nursing role in peds: Legal responsibilties

•Informed consent is a formal authorization by the child's parent or guardian allowing care or a procedure to be performed for their child. •Information must be provided to the parents regarding: the child's diagnosis, proposed treatment or procedure, possible outcomes, risks vs benefits, alternative treatment options, and answers to any questions. •Providers have the responsibility to understand complex family situations and identify who is authorized to sign for the child. Many children live with parents or adults that are not their legal guardian (step parents, grandparents, etc.) •Nurses are often asked to sign or witness the informed consent for patients. It is very important that you recognize what you are signing.

The "slow-to-warm-up" child

•Initial withdrawal, followed by gradual, quiet, slow interaction with the environment •Adapts slowly to new situations •Mild reactions to environment

mouth

•Inspect ◦Lips ◦Teeth ◦# of teeth appropriate for age, dental caries? ◦Gums and buccal mucosa ◦Tongue ◦Midline ◦Palate ◦Defects? ◦Throat and tonsils Exudate?

resp assessment

•Inspect for simultaneous chest expansion and abdominal rise. •Chest movement is normally symmetric bilaterally, rising with inspiration and falling with expiration •On inspiration the chest and abdomen should rise simultaneously. •Asymmetric chest rise is associated with a pneumothorax. •The diaphragm is the primary muscle used for ventilation by infants and young children and the thoracic muscles are used as accessory muscles until they are older (>6 years) when the thoracic muscles become the primary muscle group. •When a child has partial airway obstruction they use accessory muscles for inspiration and retractions are seen. •Retractions are visible depressions of the tissue between the ribs of the chest wall. This is an indication of increased work of breathing and respiratory distress. Retractions may be mild, moderate, or severe. •Young infants with respiratory distress may use other accessory muscles resulting in "headbobbing"* •Palpation Crepitus Crepitus, a crinkly sensation palpated on the chest surface, is caused by air escaping into the subcutaneous tissues Tactile fremitus Ask the child to repeat a series of words. The vibration or tingling sensation is normally palpated over the entire chest. Decreased sensations indicate that air is trapped in the lungs, as occurs with asthma. Increased sensations indicate lung consolidation, as occurs with pneumonia. •Auscultation •Auscultation of breath sounds is difficult when an infant is crying. First, try to quiet the infant with a pacifier, bottle, or toy. If the infant continues to cry, all is not lost. At the end of each cry the infant takes a deep breath, which you can use to assess breath sounds

Jean Piaget

•Jean Piaget was a Swiss scientist who formulated a theory of cognitive development. He believed that the child's view of the world was influenced largely by age and maturational ability. •The child incorporates new experiences via assimilation and changes to deal with these experiences by the process of accommodation. pg 70-71 look at

diagnostics tx nursing considerations

•Labs: Blood cultures, CBC, respiratory panel •Radiology: "Thumb" sign •Nursing Considerations: DO NOT touch this child or upset them in anyway. Doing so could cause death. Keep them calm do NOT put anything in their mouth. Prepare for intubation, provide oxygen, & after intubated obtain labs and IV access for antibiotic administration •Treatment: Antibiotics, IV dexamethasone, nebulized racemic epinephrine, fever reducer, oxygen

diagnostics tx nursing consideration

•Labs: None, Flu/RSV/Viral panel if admitting •Radiology: classic steeple's sign •Treatment: Oral dexamethasone, nebulized racemic epinephrine, fever reducer, oxygen •Nursing Considerations: Administer medications, maintain hydration, continuous respiratory assessment, quiet environment •Homeopathic: Cold air, humidification

mental health and relationships

•Mental & Spiritual Health •School-Age children continue to work on self-regulation and more readily solve problems •Development of new skills encourages positive self-esteem •Body image and sexuality are developed by adolescence •Develops spiritual "place in the world" and participates in faith-based activities •Children can begin to participate in planning and helping around the home •Family & Social Relationships •Family still important, but peers and school also important. Learning how to make and maintain friendships

Developmental Approach to Exam:

•Newborns/Infants <6 months: •Keep parent close by to aid in the exam •Allow normal activities that do not interfere with the exam (feeding, holding, pacifier) •Alter the sequence of the exam as necessary •Infants > 6 months •Because of stranger anxiety, examining the infant in the parents lap is often best •Examining feet & hands may be less anxiety producing then the trunk •Toddlers •Toddlers still possess stranger anxiety so continue to keep toddlers with family present •Demonstration of instruments (i.e. otoscope or stethoscope) may alleviate anxiety •Do NOT ask the child if you can do something rather explain what you are going to do. •Offer choices when possible Consider less invasive areas (hands & feet) first & more invasive procedures last (those that require equipment

indifferent parenting

•No limit setting •Lack affection for the child •Focused on stress of own life May show a high expression of destructive impulses and delinquent behavior

infant prep before during

•None for infant. Explain to parents the procedure, the reason for it, and their role. •Allow parents the option of being present for procedures. •Parents may be able to touch a foot, rub a cheek, and talk soothingly to the infant. •During Nursing staff should immobilize the infant securely and gently. Parents should not be asked to hold the child down. •Perform procedure quickly. Use touch, voice, pacifier, and bottle as distractions. •Ask parent to hold, rock, and sing to infant after procedure.

role of play and growth in kiddos

•Nurses should be able to understand the role of play in the growth and development of children.** •Functions of play include: •Contributes to physical, cognitive, emotional, and social development •Stress reliever for child/family •Pain relief/distracter •Barometer of illness •Encourage play while hospitalized ◦Play is important to encourage development. •Include social interaction when hospitalized ◦Roommates ◦Play room/recreation room activities

oral health

•Oral Health •Average age of first tooth loss: 6 years •Eruption of permanent teeth beings •Dental visits should be every 6 months •Brushing and flossing should be part of daily hygiene •Braces or orthodontic referrals as necessary •Education about reducing amount of sugary foods to prevent carries

oral health

•Oral Health •Child should begin seeing dentist regularly by 1 year of age •Exam consists of removal of plaque, use of fluoride, screen for caries •Early childhood caries is one or more cavities in a child 71 months or younger •Develop brushing, flossing skills, and habits •By 2-5 years old can use a pea size amount of fluoridated toothpaste •By 2 years of age, child has full set of 20 primary (deciduous) teeth •By ages 2-4 young children should have discontinued thumb sucking and pacifier use

oral health

•Oral Health •First teeth begin to develop half way through infancy and its not uncommon to have two teeth by 6 months old •Mother's nutritional intake contributes to oral health in infant especially when breastfeeding. •Encourage parents to wipe gums with soft moist gauze once or twice daily. •Educate parents not to bottle prop •Offer anticipatory guidance to parents about teething •American Academy of Pediatric Dentistry recommends first visit within 6 months of tooth eruption and no later than 12 months.

PE diagnostics tx nursing considerations

•PE: Wheezing and crackles on auscultation, increased WOB (retractions, nasal flaring, grunting), copious nasal secretions, dehydration s/s (dry lips, tachycardia, lethargy), distended abdomen due to hyperinflation of lung/air trapping •Labs: respiratory panel •Radiology: "reactive airway disease" •Nursing Considerations: Obtain nasal swabs, place in respiratory and contact isolation ("combined"), administer humidified oxygen (NC, HFNC), careful observation of respiratory status & oxygen saturations, aggressive nasal suctioning, and IV fluid administration •Treatment: Supportive nursing care. Antibiotics, nebulized albuterol, and CPT are not routinely recommended. •Prevention of RSV is important for children who are at high risk including those who were premature (less than 32 weeks), those that require supplemental oxygen at baseline, and those with heart failure, chronic lung disease, or pulmonary hypertension •Synagis: provides passive immunity to help support high-risk infants •A dose is given every 30 days for 5 months beginning in October or November

patho s/s PE diagnostics

•Pathophysiology •Bacteria or viruses enters the lungs and either colonizes the trachea and bronchi or invades the local cells. Inflammation then leads to edema and mucopurulent secretions. The mucus then causes airway obstruction. •CAP is most often preceded by a viral URI. •Bacterial pneumonia is more often associated with a higher fever, ANC, and % of bands •Symptoms: Cough, congestion, fever, chest pain, restlessness, abdominal pain, and poor appetite. •PE: Rhonchi and crackles on auscultation, increased WOB (retractions, nasal flaring, grunting), shortness of breath, lethargy. Diminished breath sounds may also be present. •Labs: May do Flu/RSV to determine viral vs bacterial. CBC to look at WBC, blood culture

patho

•Pathophysiology •Cystic fibrosis (CF) is a genetic disease caused by a mutation in a gene named the cystic fibrosis transmembrane conductance regulator (CFTR) •There are more than 1900 mutation of the CFTR but only 127 cause CF. Individuals who have CF must have at least two mutations of CFTR in order to have the disease. The more mutations an individual has the more severe the CF can be. •With a defective CFTR protein, chloride-ion transport across the exocrine and epithelial cells is impaired which causes reduced water movement across cell membranes. •This reduction in water movement leads to thickened secretions in various different parts of the body.

patho

•Pathophysiology •In asthma, there is persistent inflammation of the airway which then causes the normal protective mechanisms of the lungs to overreact to certain triggers. This hyper responsiveness causes excess mucous formation, mucosal swelling, and airway muscle contraction. •Triggers vary but often can include environmental sources, exercise, viral illness, or allergens •Certain persistent environmental exposures also create additional risk for reaction such as smoke exposure (active & passive), pet dander, cockroach feces, and air pollutions •Once a trigger occurs, the airway has an exaggerated inflammatory response causing vasodilation, increase capillary permeability, mucosal edema, airway narrowing, and hyperinflation. Hyperinflation of the alveoli then causes decreased perfusion of the capillaries and hypoxemia.

•Physical Exam (PE): •The sequence and approach to pediatric assessment varies by age and developmental stage. However, the technique for exam is the same for all ages. •As a general rule: •Young children ◦Foot-to-head & out-to-in sequence allows least distressing parts of the exam to be completed first ◦ Older children ◦A more traditional head-to-toe traditional approach is easily tolerated by older children

•Growth & Development

•Physical Growth •How much weight do we expect a new baby (0-1 month) to gain each week? •When should their weight double? Triple? •Length should increase 1 inch per month for first 6 months •Measurements •Weight •Length •Head & Chest circumference •Plot on growth chart

•Growth & Development toddler and preschool

•Physical Growth •Weight gain slows dramatically to 1.4-2.3 k g (3-5 lb)/year •Growth is more "step-like" rather than "linear" •Growth below 5th percentile and above 85th percentile warrants investigation •Most physiologic systems relatively mature by the end of toddlerhood •Kinesthesia is one's sense of body position and movement •Hand eye coordination develops during these years •Motor development is very important •CDC recommendation is to have 60 minutes of structure play, unstructured play, and sedentary behavior at any one time, exclusive of sleep •Measurements •Weight •Height •Obtain BMI starting at age 2 BP to screen for HTN age 3

pneumonia and types

•Pneumonia is an inflammation or infection of bronchioles and alveoli •Pneumonia can be community acquired (CAP) or hospital acquired •Types include: Viral, mycoplasmal, and bacterial •Viral pneumonia is more common in children under 5 years old •Bacterial pneumonia can occur in any age group •Mycoplasmal pneumonia is more common in children over 5 years old •Children with comorbidities such as CF or immunosuppression are more susceptible to fungal and parasitic infections •Aspiration of food, emesis, and reflux may also cause pneumonia •More common in children with dysphagia, weak cough & gag reflexes

Cont. Preschoolers School age Adolescents

•Preschoolers •Assess each child's willingness to be separated from the parents individually •Allow the child to examine the equipment prior to use •Allow choices when possible •Use distraction to gain cooperation and provide praise for cooperation •School-Age •Often school age children want to help with the exam and are interested in the process •By this age a head-to-to examination is appropriate •Children this age like to learn about their body during the exam and it is appropriate to teach them and allow participation •Adolescents •Modesty is of the utmost importance during this age •Exam should be conducted without others present unless the child asks otherwise •This is a great time to build rapport and allow the child to ask any "private" questions •Any time a breast, genitals or an anorectal exam or procedure is conducted a chaperone should be present

lesions

•Primary lesions (such as macules, papules, and vesicles) are often the skin's initial response to injury or infection. •Secondary lesions (such as scars, ulcers, and fissures) are the result of irritation, infection, and delayed healing of primary lesions.

tx nursing considerations

•Radiology: "focal consolidation" "airspace opacity" "lobar consolidation" •Nursing Considerations: Obtain nasal swabs if ordered, place in respiratory and contact isolation ("combined") if appropriate, administer humidified oxygen (NC, HFNC) if hypoxic, careful observation of respiratory status & oxygen saturations, IV fluid administration, antibiotic administration •Treatment: •Antibiotics for bacterial infections •Ampicillin for inpatient or high dose amoxicillin for outpatient HCAP •Azithromycin for mycoplasma or atypical pneumonia •Ceftriaxone for high risk or unvaccinated hospitalized children •Pain control •Fever control

1-3 yrs Play & toys Communication

•Refines fine motor skills by use of cloth books, large pencil and paper, wooden puzzles •Facilitates imitative behavior by playing kitchen, grocery shopping, toy telephone** •Learns gross motor activities by riding Big Wheel tricycle, playing with soft ball and bat, molding water and sand, tossing ball or bean bag** •Cognitive skills develop with exposure to educational television shows, music, stories, and books •Increasingly enjoys talking** •Exponential growth of vocabulary, especially when spoken and read to •Needs to release stress by pounding board, frequent gross motor activities, and occasional temper tantrums •Likes contact with other children and learns interpersonal skills**

risk prevention drowning motor accidents burns

•Risk Prevention •Drowning •Increasing mobility makes drowning a major risk and is the leading cause of death in children 1-4 years old. •Empty buckets, bathtubs, pools can all be sources for drowning •AAP now recommends swimming lessons for all children age 4 and older and ages 1-4 if the parent feels the child is ready and the class is tailored to the child's age. •Swimming classes do not protect from drowning •Motor Vehicle Accidents •As of August 2018, American Academy of Pediatrics now recommends keeping kids in car seats until they grow out of them. •Most car seats hold up to 65lbs, this may mean are remaining in car seats until they are 5 or 6 years old. •Verify that the child is secured properly and hasn't undid seatbelt or moved in the vehicle Burns

risk prevention

•Risk Prevention •More independence and activities lead to injury •Leading cause of death is still MVC and Auto vs. Pedestrian •The AAP recommends kids under 13 should always ride in the backseat and using belt-positioning booster seats until the child reaches 4 feet, 9 inches tall. •Protective gear such as helmets and pads coupled with education on crossing the street and being aware of surroundings •Second leading cause of death is drowning, suicide, & homicide (based on age) •Education on self-esteem, safe social media, & bullying •Gun safety education for parents, including lethal means restriction •Assault occurs more frequently in adolescents than other age groups •Education on not accepting rides from strangers, avoiding meeting people online, and saying no to drugs and alcohol

•Risk Prevention

•Safe Sleep/Suffocation •Back to Sleep - ABCs •Homicide/NAT •Shaken Baby Syndrome •Motor Vehicle Injury •Car Seats •AAP now suggests parents keep kids rear-facing until they outgrow their car seat's height and weight limits. •For a lot of kids, this means they'll be rear facing until they're 3 or 4 years old. •Ensure car seat is anchored to the seat correctly •No reuse of car seats!

•Mental & Spiritual Health •Stranger Anxiety & Separation Anxiety •When does it occur? What can parents expect? What information can we provide them? •What developmental stage is this according to Piaget? Erikson? Look in textbook PURPLE

•Self regulation is process of dealing with feelings, learning to soothe self, and focusing on activities for increasing periods of time •Help parents identify what the infant likes and how they self soothe •Examples: thumb sucking, pacifiers, swaddling •Period of PURPLE crying

Freud

•Sigmund Freud was a Austrian physician who believed that early childhood experiences form the unconscious motivations for actions later in life. •He extensively studied psychoanalysis, which explored the driving forces of the unconscious mind. •Freud also believed that there is a psychosexual focus on personality development and unresolved conflict and unmet needs at a certain stage lead to a fixation of development at that stage.

sleep

•Sleep •Go to bed & get up at same time each day •Follow bedtime routine to prepare for sleep •Recognize that we do not "make up" for "lost" sleep by sleeping late •Avoid caffeine for several hours before sleep •Gradually slow down activity 1-2 hours before sleep •Do not watch TV, play games, text, or do other activities in the sleep location •Avoid naps in the late afternoon and evening •Darken the room for sleep

Mixed

•Some of each personality type's characteristics apparent

adolescence activities and communication

•Sports—ball games, gymnastics, water and snow skiing/boarding, swimming, school sports •School activities—drama, yearbook, class office, club participation •Quiet activities—reading, schoolwork, television, computer, video games, music •Increasing communication and time with peer group—movies, dances, driving, eating out, attending sports events •Applying abstract thought and analysis in conversations at home and school

s/s PE Diagnostics Prevention

•Symptoms: Sudden onset of breathing difficulty including cough, wheezing, shortness of the breath. May also have tachypnea and intercostal retractions •PE: Inspiratory and expiratory wheeze, +/- productive cough, decrease air movement •Labs: none, diagnosis is made based on history, PE, and PFT •Radiology: none, possible "hyperinflation" •Daily Prevention: depends on the severity of asthma, age of the patient, and medications previously used

temperament

•Temperament: the matter of thinking, behavior, or reacting as a characteristic of an individual There are three major personality types, clustered by type of response: ◦Easy temperament ◦Difficult temperament ◦Slow-to-warm-up temperament

Temp

•Temperatures should be obtained orally in all children who are able as it is a "core" temperature and most reliable. Axillary temps can be obtained in children who cannot provide an oral temperature (usually, <4 years). •Rectal temps can be obtained, according to hospital policy & when warranted. •According to the American Academy of Pediatrics (AAP), hypothermia occurs when the newborn's axillary temperature drops below 36.5°C. The smaller or more premature the newborn is, the greater the risk of heat loss. •Temperature <36.5°C and ≥38°C should be reporter and treated. •Low temps, especially infants can be indicative of sepsis and warrants attention.

Id Ego Superego

•The ego divert impulses and protects itself from excess anxiety by the use of defense mechanisms including regression to an earlier stage and repression or forgetting of painful experiences (p. 68)

Peds assessment 1st step How do we accomplish this?

•The first step in pediatric assessment is to obtain a history. •In order to obtain an adequate and accurate history the patient and the family must feel that they can trust you with there very personal information. How do we accomplish this? •Start with an introduction including your position and role in caring for the child. Don't forget to ask the family members how they would like to be addressed. •Involve the child in the interview by asking age-appropriate questions and being honest when the child asks a question •Use open ended questions to obtain the parents' perception of illness •Example: What brought you to the ER today?** •Use closed ended questions to clarify information •Example: How high was the fever?**

im injection

•The gluteus maximus muscle is NOT recommended for children because of damage to sciatic nerve •The vastus lateralis is preferred for children •Amounts to give should be NO more than 1-2mL for vastus lateralis and NO more than 0.5mL for deltoid •Z-track method should be used to prevent seepage

goal of culturally competent family centered care

•The goal of culturally competent family-centered nursing management is to assess and help families recognize their strengths and resilience. •Nurses can embrace the family and their culture by: •Asking questions and learn the family's preferences •Incorporating cultural preferences into all care provided •Determine how the illness or condition is influencing the family functioning on a daily level •Show respect and a nonjudgmental attitude at all times, even if beliefs vary widely from one's own

genital assessment

•The inguinal area is inspected and palpated during the abdominal examination to detect enlarged lymph nodes or masses. •The femoral pulse, a part of the heart examination, may also be assessed. •Examination of the genitalia and perineal area can cause stress in children because they sense their privacy has been invaded. •To make young children feel more secure, position them on the parent's lap with their legs spread apart or in a position of comfort.** •In younger children the genital and perineal examination is performed immediately after assessment of the abdomen. The genitals and perineum may be examined last in older children and adolescents •Preschool-age children are often taught that strangers are not permitted to touch their "private parts." Ask the parent to tell the child you have permission to look at and touch these parts of the body. •Briefly explain what you need to examine and why. Then calmly and efficiently examine the child. •Always follow institutional guidelines have a same-sex chaperone present for genital or breast exams if the parent is not present.** •A rectal examination is not routinely performed on children but may be done for newborns or children with individual complaints.

How can we synthesize information and make assessments???

•The nurse must assess a child according to developmental age •Make comparisons between actual and expected age based on physical, cognitive, and psychosocial changes at each stage •Make referrals for disparity between actual and expected age

resp failure causes

•Three primary causes: •Malfunction of the respiratory stimulation center •Drug overdose •Brain injury •Muscles of ventilation are impaired or fatigued and therefore do not work effectively •Prolonged increased work of breathing such as in the case of asthma or bronchiolitis •V/Q Mismatch (Ventilation/Perfusion): The relationship between the ventilation and perfusion is impaired •Pneumonia •COPD •Pulmonary Edema

•Treatment •Treatment focuses on: •Controlling inflammation of the airways •SABA may be used for airway hyper responsiveness or bronchospasm •Treating any infection •Inhaled and IV antibiotics can be used for flares •CF patients are known to be susceptible to pseudomas organisms •Often treated with inhaled Tobramycin and IV Cefepime •Reducing mucous accumulation •Hypertonic Saline Nebulizer treatments hydrates the mucous in the airway making it easier to clear •Pulmozyme will loosen or liquefy pulmonary secretion to help clear •Improving nutrition •Pancreatic supplements to assist in digestion Vitamin ADEK to supplement what the body cannot get

tx nursing considerations

•Treatment for acute attacks: •Short-acting beta-2-agonists (SABA) •Relax smooth muscles in the airway causes swift bronchodilation and reverse bronchospasm •Example: •Corticosteroids •Decreases airway inflammation and works with SABA to help with bronchodilation •Example: •Anticholinergics •Inhibit bronchoconstriction and decrease mucous production •Example: •Adjuncts •Examples: •Nursing Considerations: administer breathing treatments if needed, administer humidified oxygen (NC, HFNC) if hypoxic, careful observation of respiratory status & oxygen saturations, IV fluid administration, adjunct therapy if needed. Provide teaching during hospitalization and at discharge.

Adolescence 12-18 yrs Physical Growth Fine Motor Ability Gross Motor Ability Sensory Ability

•Variation in age of growth spurt •During growth spurt, girls gain 7-25 k g and grow 2.5-20 c m; boys gain approximately 7-29.5 k g and grow 11-30 c m Four and a half to 12 inches. •Skills are well developed •New sports activities attempted and muscle development continues •Some lack of coordination common during growth spurt** •Fully developed

•Health supervision

•Well child visits - age based visits •Evaluate & Educate •Disease & Injury prevention •Growth & Development surveillance Health promotion

what is culture

•What is culture? •Culture has many different definitions. Currently it is described as as combination of a body of knowledge, belief, and behavior (p. 33) •Culture includes personal identification, language, thoughts, communications, actions, customs, beliefs, values and institutions that are often specific to ethnic, racial, religious, geographic, or social groups (US Department of Health, 2013) •Although culture is connected with groups, each individual has their own manifestation of his or her own cultural background. •It is of the utmost importance to understand what nursing interventions can be used to provide culturally sensitive and competent care to the child and family.

VS RR

•You'll want to observe the abdomen (rather than the chest) rise and fall in children < 6 years old. •You may watch the chest in children >6 years old to obtain a RR •If you are in doubt of what the respiratory rate is, you can listen with your stethoscope, though do so in a way that does not cause anxiety in the child •Count for one full minute as pediatric patients, particularly infants often breathe irregularly Infant 30-60 Toddler 24-40 Preschool 22-34 School Age 18-30 Adolescent 12-16

developmental response to illness

•young children have limited knowledge about the body and what causes illness. They do not understand what causes them to be ill and they respond to hospitalization and illness based on where they are at in their development. •Previous hospitalizations or experience with medical professionals will also guide how they ensure illness and future hospitalizations. •As children progress in age they are better to understand what causes illness and hospitalization but they still experience stress. •Stress comes from a variety of sources and the nursing care of children in the hospital focuses on minimizing stress as well as fear, anxiety, and disruption of the child's "normal life".

Adolescence ◦Plan assessments based on:

◦Child undergoing identity formation ◦Sexual maturity nearing completion ◦Formal operational thought processes becoming possible ◦Importance of peer relationships and seriousness of romantic or emotional relationships ◦Knowledge that privacy, confidentiality, and honesty are means to gain trust in adolescent patients

Palmar grasp reflex

◦Elicited by stimulating the newborn's palm with a finger or an object. ◦The newborn grasps and holds the object or finger firmly enough to be lifted momentarily from the crib.

Moro reflex

◦Elicited when the newborn is startled by a loud noise or lifted slightly above the crib and then suddenly lowered. ◦In response, the newborn straightens arms and hands outward while the knees flex. ◦Slowly the arms return to the chest, as in an embrace. ◦The fingers spread, forming a C, and the newborn may cry. ◦This reflex may persist until about 6 months of age.

Tonic neck reflex (fencer position)

◦Elicited when the newborn is supine and the head is turned to one side. ◦In response, the extremities on the same side straighten, whereas on the opposite side they flex. ◦This reflex may not be seen during the early newborn period, but once it appears it persists until about the third month.

Rooting reflex

◦Elicited when the side of the newborn's mouth or cheek is touched. ◦In response, the newborn turns toward that side and opens the lips to suck (if not fed recently).

Newborn (0 - 1 month)

◦Plan assessments based on: ◦Presence or absence of reflexes ◦Attachment behaviors ◦States of alertness

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Peds Exam 1

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