The nurse is caring for a child who has just returned from surgery for repair of a cleft lip. In which order, from first to last, should the nurse do the following?
Rationale:
Maintain a clear and adequate airway.
Ensuring a clear airway is paramount immediately post-surgery, especially in children. The risk of airway obstruction is heightened after anesthesia, making this the critical first step in recovery to ensure safety and proper oxygenation.
B: Maintain sufficient fluid and caloric intake. Prioritizing airway management takes precedence over fluid intake, as without a clear airway, the child cannot effectively consume fluids or nutrients.
C: Provide emotional comfort to the child. While emotional support is important, it cannot be prioritized before ensuring the child’s airway is secure and functional post-surgery.
D: Apply elbow restraints. Restraints can be effective, but they should not be the first action taken; airway management is more critical in the immediate postoperative phase.
E: Teach the parents proper feeding methods. Parental education is essential but should follow airway management and emotional comfort, as addressing immediate recovery needs takes priority over instructional guidance.
A child who was intubated after a craniotomy now shows signs of decreased level of consciousness. The physician orders manual hyperventilation to keep the PaCO2 between 25 and 29 mm Hg and the PaO2 between 80 and 100 mm Hg. The nurse interprets this order based on the understanding that this action will accomplish which of the following?
Rationale:
Decrease intracranial pressure. Manual hyperventilation leads to reduced carbon dioxide levels, causing vasoconstriction of cerebral blood vessels, which subsequently decreases intracranial pressure. This is crucial in managing patients post-craniotomy with altered consciousness.
B: Ensure a patent airway. While maintaining a patent airway is important, manual hyperventilation specifically targets intracranial pressure management rather than just ensuring the airway remains open.
C: Lower the arousal level. The objective is to stabilize intracranial pressure, not to deliberately lower the arousal level of the patient, which could be detrimental to recovery.
D: Produce hypoxia. The goal of hyperventilation is to maintain adequate oxygen levels, not to induce hypoxia, which would compromise the patient's overall respiratory status and brain function.
The parents of a child with a serious head injury ask the nurse if the child is going to be all right. Which of the following responses by the nurse would be most appropriate?
Rationale:
It's hard to tell this early, but we'll keep you informed of the progress.
This response is appropriate as it acknowledges the uncertainty of the child's condition while reassuring the parents that they will receive ongoing updates. It reflects empathy and professionalism, allowing the parents to feel supported during a distressing time without providing false hope or misleading information.
A: Children usually don't do very well after head injuries like this. This statement conveys a pessimistic outlook, potentially instilling fear and anxiety in the parents without providing helpful information.
B: Children usually recover rapidly from head injuries. This response may create unrealistic expectations, as recovery can vary significantly. It oversimplifies the situation, which could lead to misunderstanding and false reassurance.
D: That's something you'll have to talk to the doctor about. This reply shifts responsibility away from the nurse, failing to provide immediate support or information, which may leave the parents feeling neglected and anxious.
The nurse observes as a child with Duchenne's muscular dystrophy attempts to use from a sitting position on the floor. After attaining a kneeling position, the child 'walks' his hands up his legs to stand. The nurse documents this as which of the following?
Rationale:
D: Gower's sign. This observation describes Gower's sign, a characteristic maneuver in children with Duchenne's muscular dystrophy where they use their hands to push against their legs to achieve standing from a seated position.
A: Galeazzi's sign. Galeazzi's sign indicates hip dislocation or discrepancy in leg length, which is unrelated to the muscle weakness exhibited in Duchenne's muscular dystrophy.
B: Goodell's sign. Goodell's sign refers to cervical changes during pregnancy, having no connection to muscle function or the standing maneuver observed in this child.
C: Goodenough's sign. Goodenough's sign does not pertain to muscular dystrophy and is not recognized in clinical settings for indicating any specific condition related to muscle strength or mobility.
An adolescent sustains a T3 spinal cord injury. After insertion of an intravenous line, a nasogastric tube, and an indwelling urinary (Foley) catheter, the adolescent is admitted to the intensive care unit. What should the nurse do next when assessment reveals that the adolescent's feet and legs are cool to the touch?
Rationale:
Cover the adolescent's legs with blankets.
This action is appropriate as it helps retain body heat, promoting warmth in the extremities. In spinal cord injuries, compromised circulation can lead to coolness in the limbs, necessitating warmth for comfort and prevention of further complications.
B: Report this finding to the physician immediately. This step is premature; while cool limbs warrant attention, immediate reporting may not address the urgent need for warmth first.
C: Reposition the adolescent's legs. While repositioning might have benefits, it doesn't directly address the immediate issue of coolness and warmth, which is crucial for the patient's comfort.
D: Lay the adolescent flat to aid circulation. This approach could potentially worsen circulation issues in a spinal cord injury, as it doesn't focus on addressing the temperature of the limbs effectively.
After teaching the parents of an infant diagnosed with Hirschsprung's disease, the nurse determines that the parents understand the diagnosis when the father states which of the following?
Rationale:
C: The nerves at the end of the large colon are missing. This statement accurately reflects the essential characteristic of Hirschsprung's disease, which involves the absence of nerve cells (ganglia) in the colon, leading to obstructive symptoms due to lack of peristalsis.
A: There is no rectal opening for stool to pass. This describes a severe condition but does not specifically relate to Hirschsprung's disease, which involves nerve absence rather than anatomical obstruction.
B: There is a tube between the trachea and esophagus. This statement pertains to the tracheoesophageal anatomy and is unrelated to Hirschsprung's disease, which specifically affects the colon's nerve supply.
D: The muscle below the stomach is too tight. This description does not accurately represent Hirschsprung's disease, which is primarily characterized by the absence of nerves rather than muscular tightness or spasm.
The nurse is monitoring an infant receiving IV fluids for gastroenteritis. Which finding suggests the infant is responding well to treatment?
Rationale:
Urine output of 1 mL/kg/hour suggests the infant is responding well to treatment. Adequate urine output indicates proper hydration and kidney function, essential for recovery from gastroenteritis. This finding reflects improved fluid balance and effective intravenous therapy, demonstrating that the body is processing fluids appropriately, which is vital in managing dehydration from gastroenteritis.
A: Dry mucous membranes indicate dehydration, suggesting the infant is not adequately hydrated, which contradicts the goal of treatment for gastroenteritis. This finding raises concerns about the effectiveness of fluid administration.
B: Weight gain of 50 grams daily does not directly reflect hydration status or treatment response. Weight fluctuations can occur for various reasons and may not solely indicate improvement in the context of gastroenteritis.
D: Heart rate of 180 bpm signals possible distress or dehydration rather than a positive response to treatment. Elevated heart rates can indicate compensatory mechanisms due to inadequate fluid resuscitation, which is concerning in this scenario.
A child with nephrosis is taking prednisone. The nurse should teach the caregivers to report which of the following adverse effects? Select all that apply.
Rationale:
Hematemesis, respiratory infection, bleeding gums, and vision problems should be reported by caregivers of a child taking prednisone for nephrosis due to their association with serious side effects of corticosteroid therapy.
B: Hematemesis This indicates potential gastrointestinal bleeding, a serious side effect that necessitates immediate medical attention, as it could arise from prednisone's effects on the gastric lining.
C: Respiratory infection Corticosteroids like prednisone can suppress the immune system, increasing susceptibility to infections, particularly respiratory ones, which require prompt reporting for appropriate intervention.
D: Bleeding gums This symptom can signal a bleeding disorder or the impact of prednisone on blood clotting, making it crucial for caregivers to communicate this to healthcare providers.
E: Vision problems Vision issues can stem from prolonged corticosteroid use, leading to conditions like cataracts or glaucoma, thus requiring caregivers to report any changes in visual acuity or clarity.
The health care team has noticed an increase in I.V. infiltrations on the pediatric floor. As part of a Plan, Do, Study, Act quality improvement plan the team should do the following in which order?
Your Selected Order (Tap items to remove)
Available Options (Tap to select in order)
A
Analyze the data.
B
Decide to monitor I.V. gauges.
C
Perform chart audits.
D
Write a new I.V. insertion policy.
Rationale:
B: Decide to monitor I.V. gauges. This step is essential as it establishes immediate oversight on I.V. placements, allowing for proactive identification of infiltration issues before analyzing data or implementing policies.
C: Perform chart audits. Conducting audits comes after monitoring, as it reviews existing practices but does not directly address the immediate need for enhanced vigilance regarding I.V. placements.
A: Analyze the data. While analyzing data is critical, it follows monitoring and auditing; without the previous steps, data analysis may not accurately reflect the current issues affecting I.V. infiltrations.
D: Write a new I.V. insertion policy. Creating a new policy is a later stage in the quality improvement process, requiring prior data and monitoring insights to ensure relevance and effectiveness.
A charge nurse is making assignments for a group of children on a pediatric unit. The nurse should avoid assigning the same nurse to care for a 2-year-old with respiratory syncytial virus (RSV) and:
Rationale:
A 1-year-old with a heart defect. Assigning the same nurse to care for a child with RSV and a child with a heart defect poses a significant risk of cross-infection and complications, as the heart defect may compromise the child's immunity and overall health status.
A: An 18-month-old with RSV. Caring for two children with RSV does not mitigate infection risk, but it ensures focused management of similar conditions, which is typically acceptable in a pediatric setting.
B: A 9-year-old 8 hours post-appendectomy. This choice involves a post-operative patient who requires careful monitoring and specific post-surgical care, unrelated to the infectious disease context of RSV.
D: A 6-year-old with sickle cell crisis. While this scenario involves a chronic condition, it does not directly relate to infectious disease concerns associated with RSV, making it a less critical pairing for nursing assignments.
A 10-year-old with leukemia is taking immunosuppressive drugs. To maintain health the nurse should instruct the child and parents to:
Rationale:
Not receive any live attenuated vaccines. Children on immunosuppressive therapy have weakened immune systems, making them highly susceptible to infections from live vaccines, which could lead to serious health complications.
A: Continue with immunizations. Immunizations that involve live viruses pose significant risks for immunocompromised children, potentially causing illness rather than providing protection against diseases.
C: Receive vitamin and mineral supplements. While beneficial for general health, supplements do not address the specific risks associated with live vaccines in immunosuppressed children.
D: Stay away from peers. Social interaction is important for emotional well-being; instead, precautions like avoiding sick individuals are more relevant for maintaining health during immunosuppressive therapy.
When developing a teaching plan for the parents of a child with Down syndrome, the nurse focuses on activities to increase which of the following for the parents?
Rationale:
D: Confidence in their ability to care for their child.
Fostering confidence empowers parents to effectively manage their child's needs, promoting a positive caregiving experience. This assurance enhances their capacity to nurture and support their child's development.
A: Affection for their child.
While affection is essential, the primary focus of the teaching plan emphasizes parental confidence, which directly impacts their ability to engage and care for their child effectively.
B: Responsibility for their child's welfare.
Although responsibility is vital, the teaching plan prioritizes enhancing parental confidence, as a secure sense of self-assurance allows parents to fulfill their responsibilities more effectively.
C: Understanding of their child's disability.
Understanding is important, yet the teaching plan aims to build parental confidence first, as this foundational element is crucial for effectively applying their understanding in everyday situations.
Which complication is the nurse most concerned about in an obese child?
Rationale:
Type 2 diabetes. This complication is particularly concerning in obese children due to the increased risk associated with excess weight, which affects insulin sensitivity and can lead to serious long-term health issues.
A: Asthma. While obesity can contribute to asthma, it is not as directly correlated or prevalent as type 2 diabetes in this population, making it a lesser concern.
C: Seasonal allergies. Seasonal allergies are not directly linked to obesity and typically do not escalate in severity due to excess weight, rendering them a minor issue compared to diabetes.
D: Iron deficiency. Iron deficiency is unrelated to obesity; instead, it often stems from dietary insufficiencies. Thus, it does not represent a prominent complication for obese children.
The nurse identifies a nursing diagnosis of Risk for perioperative-positioning injury related to the surgical procedure for a school-age child scheduled for a tonsillectomy. Which of the following is an expected outcome for this nursing diagnosis?
Rationale:
The child remains on nothing-by-mouth (NPO) status for the designated preoperative period. Maintaining NPO status is crucial for minimizing the risk of aspiration during anesthesia, thereby directly addressing the risk for positioning injury associated with the surgical procedure.
A: The child is able to tell about the surgery and recovery. This outcome focuses on the child's understanding rather than addressing the specific risk of positioning injuries during surgery.
C: The child and family demonstrate an understanding of the procedure. While understanding is important, it does not specifically mitigate the risk of perioperative positioning injuries that are a priority in this context.
D: The child knows the parents will not leave. This outcome relates to emotional support but does not influence the physical risk posed by the surgical positioning during the procedure.
Which of the following would be the best activity for the nurse to include in the plan of care for an infant experiencing severe diarrhea?
Rationale:
B: Weighing the infant each day is crucial for assessing fluid loss and determining hydration status in an infant suffering from severe diarrhea, guiding timely interventions and care adjustments.
A: Monitoring the total 8-hour formula intake does not directly address the immediate concern of fluid loss due to diarrhea and may not reflect the infant's hydration status accurately.
C: Checking the anterior fontanel every shift provides limited information regarding hydration status and may not be as effective as daily weight measurements in managing severe diarrhea.
D: Monitoring abdominal skin turgor every shift offers some insights into hydration but is less comprehensive than daily weight checks, which provide a clearer picture of fluid balance.
A nurse is teaching the parents of a preschooler about the possibility of post-operative hemorrhage after a tonsillectomy and adenoidectomy. The nurse should explain that the risk is greatest at which of the following times?
Rationale:
The risk of post-operative hemorrhage after a tonsillectomy and adenoidectomy is greatest 7 to 10 days after surgery. This period corresponds with the time when scabs formed during healing can detach, increasing the likelihood of bleeding.
A: 1 to 3 days after surgery. This timeframe is generally characterized by initial recovery, where the risk of hemorrhage is lower as the surgical site begins to heal.
B: 4 to 6 days after surgery. During this period, while some healing is occurring, it is still too early for significant risk of hemorrhage linked to scab detachment.
D: 11 to 14 days after surgery. By this time, most healing processes are well underway, and the risk of significant post-operative hemorrhage typically decreases as the tissues stabilize.
Which of the following should the nurse include in the postoperative care plan for a child after an appendectomy to promote recovery?
Rationale:
Encouraging early ambulation promotes circulation, reduces the risk of deep vein thrombosis, and aids in the return of bowel function, which is crucial for recovery after an appendectomy.
B: Administer laxatives daily. Administering laxatives immediately after surgery can disrupt the natural healing process and may lead to complications such as bowel obstruction or irritation.
C: Keep the child NPO for 48 hours. Prolonged fasting can hinder recovery; instead, a gradual reintroduction of diet supports healing and maintains nutritional status.
D: Apply a heating pad to the abdomen. Applying heat could exacerbate inflammation or pain at the surgical site, potentially delaying the healing process and causing discomfort.
The nurse teaches the parents of an infant with developmental dysplasia of the hip how to handle their child in a Pavlik harness. Which of the following is most appropriate?
Rationale:
Fitting the diaper under the straps. This method ensures the infant's comfort and hygiene while maintaining the effectiveness of the Pavlik harness, preventing any potential skin irritation or complications during treatment.
B: Leaving the harness off while the infant sleeps. This practice undermines the purpose of the harness, as continuous wear is essential for proper hip positioning and to achieve desired treatment outcomes.
C: Checking for skin redness under straps every other day. Regular assessments should occur daily to promptly identify and address any skin issues, minimizing the risk of further complications related to the harness.
D: Putting powder on the skin under the straps every day. Applying powder can lead to moisture retention, increasing the risk of skin irritation or infection, which contradicts the care guidelines for the harness.
A 9-year-old child with Guillain-Barré syndrome requires mechanical ventilation. Which action should the nurse take?
Rationale:
D: Turn the child slowly and gently from side to side to prevent respiratory complications. This action promotes lung expansion and secretion clearance, essential for patients requiring mechanical ventilation, especially those with respiratory muscle weakness from Guillain-Barré syndrome.
A: Maintain the child in a supine position to prevent unnecessary nerve stimulation. This position does not address respiratory needs and may lead to complications associated with immobility in ventilated patients.
B: Transfer the child to a bedside chair three times a day to prevent postural hypotension. While mobility is important, it is inappropriate for a child on mechanical ventilation who requires stabilization and monitoring.
C: Engage the child in vigorous passive range-of-motion exercises to prevent loss of muscle function. Vigorous exercises are unsuitable for a child with respiratory compromise, risking further injury and fatigue.
Which of the following breathing rates should the nurse use when performing rescue breathing during cardiopulmonary resuscitation for a 5-year-old?
Rationale:
12 breaths/minute. This rate is appropriate for a 5-year-old child during rescue breathing, aligning with pediatric guidelines that recommend a slower rate to ensure adequate oxygenation without causing hyperventilation.
A: 10 breaths/minute. This rate is insufficient for a child, potentially leading to inadequate oxygen delivery during critical moments of cardiopulmonary resuscitation.
C: 15 breaths/minute. While closer to the correct rate, this option may still be slightly fast for optimal ventilation, risking ineffective breathing during resuscitation efforts.
D: 20 breaths/minute. This rate exceeds the recommended threshold, increasing the risk of hyperventilation and compromising the quality of rescue breathing in a pediatric patient.
The nurse is assessing a child with suspected appendicitis. Which physical finding supports this diagnosis?
Rationale:
Rebound tenderness in the right lower quadrant. This finding indicates irritation of the peritoneum, which is a hallmark symptom of appendicitis, suggesting inflammation and possible perforation in the appendix area.
B: Soft, non-tender abdomen. This symptom suggests a lack of significant abdominal distress, which contradicts the typical findings associated with appendicitis and does not indicate any inflammation or serious condition.
C: Frequent bowel movements. This symptom typically indicates gastrointestinal issues unrelated to appendicitis, as appendicitis often presents with constipation or a lack of bowel activity due to inflammation in the abdomen.
D: Generalized abdominal bloating. This symptom can result from various gastrointestinal problems and does not specifically point to appendicitis, where localized symptoms are more indicative of the condition's presence and severity.
While assessing a 3-year-old child who has had an injury to the leg, has pain, and refuses to walk, the nurse notes that the child's left thigh is swollen. What should the nurse do next?
Rationale:
Notify the physician immediately.
The child's symptoms of leg injury, pain, refusal to walk, and thigh swelling indicate a potentially serious condition requiring urgent medical attention. Prompt notification of the physician ensures timely diagnosis and intervention, preventing complications and addressing any underlying issues effectively.
A: Assess the neurologic status of the toes. This assessment, while important, does not prioritize immediate intervention for the child's evident distress and possible serious injury.
B: Determine the circulatory status of the upper thigh. Focusing on circulatory status is vital, yet it does not directly address the need for urgent medical intervention indicated by the child's condition.
C: Obtain the child's vital signs. Although vital signs provide essential information, they do not take precedence over the necessity of notifying the physician about the child's alarming symptoms.
The mother of a child with chronic renal failure who is receiving peritoneal dialysis at home asks the nurse what she can do if both inflow and drain times are increased. Which of the following instructions would be most appropriate for the nurse to include when responding to the mother?
Rationale:
Assess the child for constipation.
Increased inflow and drain times may indicate that the child is experiencing constipation, which can impede the effectiveness of peritoneal dialysis. Addressing this issue promptly can enhance the overall dialysis process and prevent further complications related to bowel function, ensuring the child's health remains stable during treatment.
B: Decrease the amount of dialysate infused for each dwell. Reducing the dialysate volume may not address the underlying issue of prolonged inflow and drain times, potentially leading to inadequate dialysis.
C: Incorporate the increased inflow and drain times into the dialysis schedule. Adjusting the schedule without investigating the cause of the delays does not resolve the potential complications affecting the child's health and treatment efficacy.
D: Monitor the child for shoulder pain during inflow and drain times. While shoulder pain could occur, it does not directly relate to the increased inflow and drain times, which suggests a different underlying issue.
When teaching the family of an older infant who has had a hip spica cast applied for developmental dysplasia of the hip, which information should the nurse include when describing the abduction stabilizer bar?
Rationale:
The abduction stabilizer bar adds strength to the cast. This component is essential for maintaining the correct positioning of the hips in infants with developmental dysplasia, ensuring stable alignment during healing.
A: It can be adjusted to a position of comfort. The abduction stabilizer bar is designed for stability rather than comfort adjustments, ensuring the cast remains effective and aligned.
B: It is used to lift the child. The abduction stabilizer bar does not function for lifting purposes; its primary role is to stabilize and support the hip during recovery.
D: It is necessary to turn the child. Turning the child is not a function of the abduction stabilizer bar; it is primarily focused on maintaining proper hip positioning and support.
A 12-year-old client with asthma is receiving I.V. hydrocortisone, ampicillin, and theophylline. The client vomits after breakfast and lunch, is very irritable, and has a heart rate of 120 beats/minute. The nurse should:
Rationale:
C: Add the missed dose of theophylline and inform the primary health care provider of the vomiting. The child's symptoms, including vomiting and irritability, suggest possible inadequate theophylline levels, necessitating dose adjustment and provider notification for further assessment.
A: Offer small amounts of clear liquids. While hydration is important, this does not address the underlying issue of potential theophylline deficiency contributing to the client’s current symptoms.
B: Inform the primary health care provider that the child is having an allergic reaction to the ampicillin. Symptoms presented do not indicate a typical allergic reaction but rather suggest side effects or an exacerbation of the asthma condition.
D: Administer oxygen to decrease the heart rate. Administering oxygen is not an appropriate response to a high heart rate; the focus should be on evaluating and managing the underlying causes.
When assessing a 2-year-old child brought by his mother to the clinic for a routine checkup, which of the following should the nurse expect the child to be able to do?
Rationale:
A: Ride a tricycle. A 2-year-old typically lacks the coordination and balance necessary to ride a tricycle, as this skill generally develops around age 3 or 4.
B: Tie his shoelaces. Mastering the ability to tie shoelaces usually occurs much later in childhood, typically around ages 5 to 6, requiring fine motor skills not yet developed at age 2.
D: Use blunt scissors. While children may begin to explore cutting with supervision, the fine motor control needed for effective scissor use is usually not present until they are 3 or older.
A 5-year-old child brought to the clinic with several superficial sores on the front of the left leg is diagnosed with impetigo. Which of the following instructions should the nurse give the parent?
Rationale:
Children with impetigo can return to school 24 hours after starting appropriate antibiotic treatment, reducing the risk of spreading the infection to classmates. This guideline promotes a safe environment for both the child and peers.
A: Wash the child's legs gently three times per day with a mild soap. While hygiene is important, frequent washing may irritate the sores and delay healing.
B: Cover the sores with loose gauze. Covering sores isn't necessary if the child is under treatment, as exposure aids in healing and minimizes moisture buildup.
D: Have the child return to the clinic the next week for a follow-up examination. A follow-up is valuable but not required within a week if the child shows improvement.
A child with a lead level of 20 mcg/dL is prescribed oral chelation therapy. The nurse should monitor for which side effect?
Rationale:
B: Renal toxicity. Oral chelation therapy can lead to renal toxicity as it mobilizes lead from tissues, increasing the burden on kidneys. Monitoring for signs of renal impairment is essential during treatment.
A: Hypertension. Chelation therapy does not typically cause hypertension; instead, it primarily affects the kidneys and electrolytes, making hypertension an unlikely side effect in this context.
C: Hypoglycemia. Hypoglycemia is unrelated to chelation therapy and is not a common side effect, as the therapy's primary focus is on heavy metal removal rather than affecting glucose metabolism.
D: Seizures. While seizures can occur in various medical conditions, they are not a direct consequence of oral chelation therapy, which primarily targets lead elimination without affecting seizure activity.
An 18-year-old high school senior wishes to obtain birth control through her parents' insurance but doesn't want this information disclosed. The nurse tells the client that under the Health Information Portability and Accountability Act (HIPAA) parents:
Rationale:
C: May not view the medical record, but may learn of the visit through the insurance bill. Under HIPAA, while parents generally have access to their child's medical records, they may still see billing details indicating services rendered, which could disclose information about the visit, such as birth control consultations, depending on the insurance plan's statements.
A: Have the right to review a minor's medical records until high school graduation. This statement misrepresents HIPAA guidelines; access depends on the specific circumstances and the patient's age, not solely on graduation status.
B: Have the right to review a minor's medical record if they are responsible for the payment. While payment responsibility may grant some access, it does not guarantee unrestricted viewing of sensitive medical information under HIPAA regulations.
D: May not view the minor's medical record or the insurance bill. This option contradicts HIPAA provisions; parents can often access medical records, yet they might only see insurance billing details related to the visit.
Which of the following would alert the nurse to suspect that a child with severe gastroenteritis who has been receiving intravenous therapy for the past several hours may be developing circulatory overload?
Rationale:
Auscultation of moist crackles. This finding indicates fluid accumulation in the lungs, a sign of circulatory overload, particularly concerning for a child with severe gastroenteritis receiving intravenous fluids.
A: A drop in blood pressure. This symptom typically suggests hypovolemia or dehydration rather than fluid overload, making it an unlikely indicator of circulatory issues in this context.
B: An increase in temperature. Elevated temperature often signifies infection or an inflammatory response, neither of which directly points to circulatory overload in a child receiving IV therapy.
D: Marked increase in urine output. Increased urine output generally signifies effective renal function and fluid balance, contradicting the notion of fluid overload, thus not indicative of this condition.
When preparing the teaching plan for the mother of a child with asthma, which of the following should the nurse include as signs to alert the mother that her child is having an asthma attack?
Rationale:
Wheezing on expiration. This sign indicates narrowed airways during an asthma attack, making it difficult for the child to breathe. Recognizing wheezing is crucial for timely intervention and management of the condition.
A: Secretion of thin, copious mucus. While mucus production may occur, it is not a definitive sign of an asthma attack and can relate to other respiratory conditions.
B: Tight, productive cough. Although coughing can indicate an attack, a productive cough suggests different respiratory issues, typically associated with infections rather than the characteristic wheezing of asthma.
D: Temperature of 99.4°F (37.4°C). This temperature is within a normal range and does not specifically indicate an asthma attack, as asthma symptoms are not directly related to fever.
The charge nurse finds the mother of a child with a chronic bladder condition requiring clean intermittent catheterization (CIC) visibly upset. The mother states, "That other nurse said parents are not allowed to perform CIC in the hospital because of increased infection risk." The charge nurse should tell the parent:
Rationale:
You can use CIC on your child. I will talk with your nurse to clarify the policy.
This response addresses the mother's concern while also ensuring that hospital policies are respected. It reassures her that her child's needs will be met and opens the door for further clarification, promoting communication between the mother and nursing staff.
A: Your child is exposed to additional bacteria in the hospital that makes CIC unsafe. This statement does not acknowledge the mother's right to perform CIC, nor does it clarify actual hospital policies.
B: You can catheterize your child as long as you use sterile technique. While this offers some reassurance, it fails to address the mother's specific concern about hospital policy and the other nurse's statement.
D: I can tell you are having a conflict with this nurse. I will switch assignments. This option dismisses the mother's valid concerns without providing any support or clarification regarding the actual policy on CIC.
The parent of a 9-month-old infant is concerned that the infant's front soft spot is still open. The nurse should tell the parent:
Rationale:
It is normal because this soft spot usually closes between 12 and 18 months. Parents should be reassured that the open fontanelle is typical for infants at this age and generally indicates healthy growth and development. Monitoring continues until the soft spot closes, usually not an indicator of any immediate concern regarding the child's health.
A: I will measure your baby's head to see if it is a normal size. Measuring head size does not address the commonality of the open fontanelle, potentially causing unnecessary worry.
B: Your infant will need to be referred for more testing. Referral for testing is unwarranted, as the open soft spot is a standard aspect of infant development and not indicative of a problem.
C: You should contact your physician immediately. Immediate contact with a physician is not necessary, as the open fontanelle is within the normal range for a 9-month-old infant and requires no urgent action.
In planning the discharge for a newborn diagnosed with torticollis (wry neck), the nurse should:
Rationale:
B: Coordinate outpatient physical therapy. Outpatient physical therapy is essential for managing torticollis in newborns, as it provides targeted interventions to improve neck mobility and alignment, promoting better developmental outcomes and minimizing potential complications.
A: Teach the parent the side effects of botulinum toxin (BOTOX). While educating about botulinum toxin might be relevant for some conditions, torticollis management primarily relies on physical therapy rather than this intervention.
C: Verify the date for corrective surgery. Corrective surgery is not typically the first-line approach for newborns with torticollis, making this option less relevant in discharge planning for this diagnosis.
D: Demonstrate the use of positioning wedges for sleep. Although positioning may assist with comfort, it doesn't address the underlying issue of neck muscle tightness, which requires more comprehensive treatment through physical therapy.
A hospitalized preschooler with meningitis who is to be discharged becomes angry when the discharge is delayed. Which of the following play activities would be most appropriate at this time?
Rationale:
C: Pounding on a pegboard. This activity allows the child to release pent-up anger and frustration through physical engagement, providing an outlet for emotional expression while maintaining focus and fine motor skill enhancement.
A: Reading the child a story. While storytelling can be calming, it lacks the physical engagement needed to address the child's immediate anger and emotional turmoil effectively.
B: Painting with watercolors. This creative activity may not sufficiently channel the child's intense emotions or provide the immediate physical release they require at this moment of frustration.
D: Stacking a tower of blocks. Although this promotes fine motor skills, it does not offer the same level of active engagement and emotional release that pounding on a pegboard provides.
Which of the following would indicate that an infant with a tracheoesophageal fistula (TEF) needs suctioning?
Rationale:
Substernal retractions indicate that an infant with a tracheoesophageal fistula (TEF) needs suctioning. This sign suggests that the infant is experiencing respiratory distress due to obstruction or fluid accumulation, necessitating immediate suctioning to clear the airway and facilitate breathing.
A: Brassy cough. While a brassy cough may indicate airway issues, it does not specifically signal an urgent need for suctioning like substernal retractions do.
C: Decreased activity level. A decrease in activity level can suggest various health concerns but does not directly indicate that suctioning is necessary for airway clearance in TEF cases.
D: Increased respiratory rate. An increased respiratory rate may point to respiratory distress; however, it does not specifically denote the need for suctioning compared to the more critical sign of substernal retractions.
A nurse is assessing the growth and development of a 14-year-old boy. He reports that his 13-year-old sister is 2 inches taller than he is. The nurse should advise the boy that the growth spurt in adolescent boys, compared with the growth spurt of adolescent girls:
Rationale:
Adolescent boys experience their growth spurt 2 years later than girls. This delay means that while girls tend to grow taller earlier, boys typically achieve their maximum height after a longer period of development.
A: Occurs at the same time. The growth spurts in boys and girls do not align; girls generally grow earlier than boys, leading to height differences during adolescence.
B: Occurs 2 years earlier. This option misrepresents the timing of growth spurts, as adolescent girls typically begin their growth phase before boys, not earlier by two years.
D: Occurs 1 year earlier. This statement inaccurately suggests that boys grow sooner than girls, whereas research shows that boys actually start their growth spurts later than their female counterparts.
When interviewing the parents of a 2-year-old child, a history of which of the following illnesses should lead the nurse to suspect pneumococcal meningitis?
Rationale:
Middle ear infection. A history of middle ear infections, or otitis media, is significant as it can lead to the spread of bacteria to the central nervous system, increasing the risk of pneumococcal meningitis in young children.
A: Bladder infection. While bladder infections can occur in young children, they do not have a direct connection to the development of pneumococcal meningitis or its risk factors.
C: Fractured clavicle. A fractured clavicle does not relate to infections or conditions that would predispose a child to pneumococcal meningitis, making it irrelevant in this context.
D: Septic arthritis. Although septic arthritis indicates a severe infection, it does not specifically suggest a higher risk for pneumococcal meningitis compared to a history of middle ear infections.
A nurse is planning care for a 12-year-old with rheumatic fever. The nurse should teach the parents to:
Rationale:
C: Provide for adequate periods of rest between activities.
Adequate rest is crucial for a child with rheumatic fever, as it helps prevent fatigue and allows the body to recover, reducing the risk of complications and promoting overall well-being.
A: Observe the child closely. Monitoring is important, but it does not directly address the need for rest and recovery, which is vital in managing rheumatic fever effectively.
B: Allow the child to participate in activities that will not tire him. While participation in low-energy activities may seem beneficial, it does not prioritize the essential need for sufficient rest to aid recovery.
D: Encourage someone in the family to be with the child 24 hours a day. Continuous presence may provide emotional support, but it does not contribute to the necessary recovery process through rest and reduced activity.
A mother brings her 18-month-old to the clinic because the child 'eats ashes, crayons, and paper.' Which of the following information about the toddler should the nurse assess first?
Rationale:
C: Any changes in the home environment. Assessing changes in the home environment is crucial as they can contribute to the child's unusual eating behaviors, potentially indicating underlying issues such as stress or neglect.
A: Evidence of eruption of large teeth. While significant in child development, tooth eruption does not directly relate to the child's unusual consumption of non-food items like ashes and crayons.
B: Amount of attention from the mother. The mother's attention level is important for overall wellbeing, yet it does not specifically address the immediate concern regarding the child's peculiar eating habits.
D: Intake of a soft, low-roughage diet. This dietary consideration does not pertain to the child's behavior of eating non-edible items, making it less relevant to the urgent assessment needed.
The nurse is conducting a quality improvement audit on the pediatric unit. Which finding indicates a need for further staff education on IV catheter care?
Rationale:
C: Infiltration rates above 10%. High infiltration rates suggest that staff may not be adequately trained in IV catheter care practices, indicating a significant need for targeted education to improve patient outcomes.
A: IV sites checked every 2 hours. Regular monitoring of IV sites every two hours demonstrates adherence to standard care protocols, indicating that staff are attentive to potential complications.
B: Use of transparent dressings. Utilizing transparent dressings is a best practice that allows for visibility of the IV site, suggesting that staff are following guidelines for maintaining site integrity.
D: Documentation of insertion dates. Accurate documentation of insertion dates reflects proper record-keeping practices, indicating that staff are mindful of tracking IV catheter usage and potential replacement needs.
The nurse is planning care with the parents of a child who requires continuous peritoneal dialysis. Which finding should be discussed with the physician?
Rationale:
The child reports having a previous surgery for a ruptured appendix. This surgical history may indicate potential complications or altered anatomy, which should be evaluated and discussed with the physician to ensure safe and effective dialysis management.
A: The family lives a long distance from the medical facility. While location poses challenges, it does not directly impact the child's immediate medical needs or dialysis management.
B: The child attends a large public school. School attendance does not significantly influence the child’s medical condition or the immediate planning needed for dialysis care.
D: The family feels the child cannot self-regulate to wake at night and change bags. While this concern is valid, it does not require immediate physician intervention compared to surgical history.
The nurse is transferring a child who has had open heart surgery from the pediatric intensive care unit to the pediatric unit. The child's blood pressure has been fluctuating but has been stable during the last 2 hours. The nurse from the pediatric intensive care unit should include which of the following information in the report to the nurse on the pediatric unit?
Rationale:
The child’s care requires information on medications being used to ensure continuity and safety in treatment during the transfer from pediatric intensive care to the pediatric unit.
The nurse must communicate ongoing medication regimens to maintain effectiveness and avoid complications. Ensuring the receiving nurse understands the medications is vital for managing the child’s post-operative recovery.
B: Current vital signs. While important, vital signs alone do not encompass the comprehensive medication and treatment plan necessary for the child’s care transition.
C: Potential for blood pressure to drop. Although a valid concern, simply stating the potential does not provide the necessary details about the child’s current treatment and management needs.
D: Drip rate for the intravenous infusion. While relevant, the drip rate alone lacks sufficient context regarding the overall medication strategy and patient stability during the transfer.
E: Time of the most recent dose of pain medication. This information is useful but does not encompass the broader aspects of medication management critical for ongoing care in the new unit.
A child is admitted with a fracture of the femur and placed in skeletal traction. What should the nurse assess first?
Rationale:
Assessing the pin sites for signs of infection should be the nurse's first priority. This is crucial to prevent complications such as osteomyelitis and to ensure the integrity of the skeletal traction.
A: The pull of traction on the pin. Evaluating the traction's pull is important, but it is secondary to monitoring potential infection at the pin sites, which can lead to serious complications.
B: The Ace bandage. While checking the Ace bandage is necessary for support, it does not address immediate concerns related to infection, which poses a higher risk to the patient's health.
D: The dressings for tightness. Assessing dressings for tightness is relevant, yet it does not prioritize the critical evaluation of pin sites for infection, which can significantly impact recovery and safety.
A preschooler with a fractured femur of the left leg in traction tells the nurse that his leg hurts. It is too early for pain medication. The nurse should:
Rationale:
C: Assess the feet for signs of neurovascular impairment. Evaluating neurovascular status is crucial in cases of traction to ensure proper blood flow and nerve function, which can alleviate pain and prevent complications.
A: Place a pillow under the child's buttocks to provide support. While support is important, it does not address potential neurovascular issues that could be causing the child's pain.
B: Remove the weight from the left leg. This action could disrupt the traction's effectiveness, potentially leading to further complications and increased pain for the child.
D: Reposition the pulleys so the traction is looser. Loosening traction may worsen the fracture alignment and increase discomfort, failing to address the child's immediate pain concerns effectively.
A diagnosis of hemophilia A is confirmed in an infant. Which of the following instructions should the nurse provide the parents as the infant becomes more mobile and starts to crawl?
Rationale:
B: Sew thick padding into the elbows and knees of the child's clothing. Padding is essential for protecting the infant's joints and soft tissues from injury, reducing the risk of bleeding episodes as mobility increases during crawling.
A: Administer one-half of a children's aspirin for a temperature higher than 101°F (38.3°C). Aspirin can exacerbate bleeding tendencies in hemophilia A, posing significant health risks for the child.
C: Check the color of the child's urine every day. While urine color monitoring is useful for various conditions, it does not specifically address the unique bleeding risks associated with hemophilia A.
D: Expect the eruption of the primary teeth to produce moderate to severe bleeding. While bleeding can occur during teething, it typically does not result in the severity described, especially with proper management in hemophilia A.
When planning home care for the child with Legg-Calvé-Perthes disease, what should be the primary focus for family teaching?
Rationale:
Management of the corrective appliance. This focus is crucial as the appliance directly supports the child’s hip joint during recovery, promoting proper alignment and preventing further complications associated with Legg-Calvé-Perthes disease.
A: Need for intake of protein-rich foods. While nutrition is important, it does not directly address the primary concerns of mobility and alignment needed for effective management of this condition.
B: Little stretching exercises for both legs. Stretching may not be appropriate as it could potentially exacerbate the condition; careful management is essential, prioritizing stabilization over flexibility.
D: Relaxation techniques for pain control. Although beneficial for comfort, pain management alone does not contribute to the core therapeutic goal of ensuring proper hip alignment and functionality.
A child undergoes rehydration therapy after having severe gastroenteritis. After teaching the parents about dietary management, the nurse understands that the teaching plan has been successful when the parents tell the nurse that they will follow which type of diet?
Rationale:
D: Soft. After severe gastroenteritis, a soft diet is beneficial as it is easy to digest, helps in recovery, and minimizes gastrointestinal irritation, allowing the child to gradually resume normal eating habits safely.
A: Regular. A regular diet may include foods that could be harsh on a recovering digestive system, potentially leading to discomfort or exacerbating symptoms after gastroenteritis.
B: Clear liquid. While clear liquids are important initially for hydration, they do not provide the necessary nutrients for recovery, making them unsuitable as a long-term dietary choice post-gastroenteritis.
C: Full liquid. A full liquid diet can still be too rich for a child recovering from gastroenteritis, possibly causing gastrointestinal distress instead of easing the transition back to regular foods.
The nurse should instruct the family of a child with newly diagnosed hyperthyroidism to:
Rationale:
C: Promote interactions with one friend instead of groups.
Encouraging limited social interactions helps manage overstimulation and potential anxiety in children with hyperthyroidism. This tailored approach allows for supportive relationships while minimizing overwhelming experiences that may exacerbate their condition.
A: Keep their home warmer than usual. Maintaining a warmer environment can increase discomfort for hyperthyroid children, who may already experience heightened sensitivity to temperature and increased metabolic activity.
B: Encourage twenty or outdoor activities. Engaging in excessive physical activity can lead to fatigue and exacerbate symptoms, making it essential to focus on moderation rather than promoting high-energy pursuits.
D: Limit bathing to prevent skin irritation. Hyperthyroid patients may experience skin changes, yet proper hygiene is crucial for their health. Limiting bathing could lead to hygiene issues rather than skin protection.
Which of the following actions indicates that the parents of a 12-month-old with iron deficiency anemia understand how to administer iron supplements?
Rationale:
A: They administer iron supplements in combination with fruit juice. This method enhances iron absorption due to the vitamin C in fruit juice, demonstrating the parents' understanding of effective administration for their child's iron deficiency anemia.
B: They administer iron supplements with meals. Taking iron with meals can hinder absorption, indicating that the parents may not fully grasp the optimal way to enhance the supplement's effectiveness.
E: They decrease dietary intake of foods fortified with iron. Reducing iron-rich foods contradicts the goal of addressing iron deficiency anemia, suggesting a lack of understanding about dietary management in conjunction with supplementation.