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(Davis's Success Plus) Margot R. de Sevo PHD LCCE IBCLC RNC - Pediatric Nursing - Content Review PLUS Practice Questions-F.a. Davis Company (2014)
(Davis's Success Plus) Margot R. de Sevo PHD LCCE IBCLC RNC - Pediatric Nursing - Content Review PLUS Practice Questions-F.a. Davis Company (2014)
www.FADavis.com
Why This Book Is Necessary The pediatric content is divided into 25 chapters. In
addition, a comprehensive final exam is included in
Most beginning nursing students have information over- Chapter 26.
load. They must possess knowledge about a variety of • The first group of chapters—Chapters 1 to 9—focus
subjects, including anatomy and physiology, psychology, on foundational information needed by the pediatric
sociology, medical terminology, diagnostic and labora- nurse.
tory tests, and growth and development, to mention a few. • The first chapter discusses the child in the context
In addition, with the expanding roles and responsibilities of a family because families differ in relation to
of the nursing profession, the nursing information that such aspects as composition, cultural norms, and
beginning nursing students must learn is growing in religion. Brief descriptions of these differences are
depth and breadth exponentially. The quantity of infor- discussed.
mation is more than any nursing student can possibly • Chapters 2 through 6 focus on the five stages of
absorb, remember, and apply. Pediatric Nursing: Content child growth and development. Unless the nurse is
Review PLUS Practice Questions provides nursing stu- familiar with the norms of each stage, he or she
dents with additional educational support! may miss important assessments or intervene in
inappropriate ways.
Who Should Use This Book • Chapters 7 to 9 include essential skills required of
the nurse in relation to child physical assessment,
Pediatric Nursing: Content Review PLUS Practice Ques- care of the sick child, and medication
tions provides beginning nursing students with need-to- administration.
know information as well as questions to practice their • Chapters 10 through 25 focus on specific content
ability to apply the information in a simulated clinical areas related to care of the child. They begin with an
situation. This textbook is designed to: examination of children who are in imminent danger
• Be required or recommended by a nursing program and, therefore, in need of emergent care, and progress
to be used in conjunction with a traditional pediatric through the many systems of the body, concluding
nursing textbook. with care of the child with sensory deficits.
• Be used by nursing students who want to focus on • Each chapter ends with a “Putting It All Together”
the essential information contained in a pediatric case study, encouraging students to put the content
nursing course. into practice. Students are quizzed on the relevant
• Be used by nursing students to learn how to be more objective and subjective information presented in a
successful when answering National Council scenario and asked to identify a primary nursing
Licensure Examination (NCLEX)–type multiple- diagnosis and interventions and to provide patient
choice and alternate-item format nursing questions evaluation at discharge.
early in their nursing education. • Chapter 26 is a comprehensive final exam containing
• Be used by nursing students preparing for the a 75-item pediatric nursing examination that
NCLEX-RN examination to review pediatric nursing integrates questions spanning content from
theory and practice. throughout the textbook. Each question contains
rationales for correct and incorrect answers and the
What Information Is Presented NCLEX-RN test plan categories.
Each chapter presents need-to-know information in
in This Textbook an outline format, eliminating nice-to-know, extraneous
This textbook begins with an introduction, which includes information. Just essential information is included, limit-
information to help students maximize their ability to ing the challenge of wading through excessive material.
study effectively and achieve success when studying pedi- This approach assists students to focus on what is most
atric content and when taking nursing examinations. important. The chapters include definitions of key words
General study strategies, specific study strategies, test- and practice questions specific to their content. Multiple-
taking tips for answering multiple-choice questions and choice questions as well as all the alternate-type questions
alternate-format questions, and the test plan categories included on NCLEX examinations are incorporated. Of
for the NCLEX examinations are discussed. the approximately 450 questions in the textbook, almost
one-fifth of them are alternate-format questions. Each 152-question comprehensive test, which is posted online
question is coded according to the NCLEX-RN test plan at www.DavisPlus.com. Like the practice questions in the
categories: Integrated Processes, including the Nursing book, each question includes the rationale for correct and
Process, Client Need, and Cognitive Domain. In addition, incorrect answers and coding for the NCLEX test plan
every question has the rationale for correct and incorrect categories.
answers. Studying rationales for the right and wrong Students should use every resource available to facili-
answers to practice questions helps students learn new tate the learning process. I believe that this textbook will
information or solidify previously learned information. meet the needs of beginning nursing students who expe-
To provide even more opportunities to practice rience information overload!
NCLEX-type questions, the book includes an additional
Dawn Babbage, RN, MS, CNE Judith Drumm, DNS, RN, CPN
Associate Professor of Nursing Associate Professor
Jamestown Community College Palm Beach Atlantic University
Jamestown, New York West Palm Beach, Florida
Vicky H. Becherer, PhD, RN Patricia Durham-Taylor, RN, PhD
Assistant Teaching Professor Faculty
University of Missouri-St. Louis Truckee Meadows Community College
Education Consultant Reno, Nevada
Cardinal Glennon Children’s Medical Center
Joyce Estes, RN, BSN, MSN
St. Louis, Missouri
Nursing Faculty
Kate K. Chappell, MSN, APRN, CPNP Catawba Valley Community College
Clinical Assistant Professor Hickory, North Carolina
University of South Carolina College of Nursing
Catherine Folker-Maglaya, MSN, APN/CNM,
Columbia, South Carolina
IBCLC
Julie C. Chew, RN, MS, PhD Assistant Professor, Nursing
Resident Faculty Truman College/City Colleges of Chicago
Mohave Community College Chicago, Illinois
Lake Havasu, Arizona
Norene Gachignard, RN, MSN, CNE
Georgina Colalillo, MS, RN, CNE Professor
Associate Professor, Nursing Department North Shore Community College
Queensborough Community College/CUNY Danvers, Massachusetts
Bayside, New York
Debora L. Geis, MS, RN, CNE
Leslie Collins, MS, RN Professor
Assistant Chair/Instructor Rhodes State College
Division of Nursing Lima, Ohio
Northwestern Oklahoma State University
Sharlene Georgesen, RN, MSN
Alva, Oklahoma
Assistant Professor, Nursing
Fleurdeliza Cuyco, BS Morningside College
Instructor/Compliance Director Sioux City, Iowa
Preferred College of Nursing, Los Angeles
Wanda Golden, RN, CCRN, PhD(C)
Los Angeles, California
Associate Professor of Nursing
Nancy Danou, RN, MSN, CPN Abraham Baldwin Agricultural College
Professor Emeritus and Adjunct Associate Professor, Child Tifton, Georgia
Health Nursing
Mindy L. Herrin, PhDc, RN
Viterbo University
Director of Assessment and Associate Professor
La Crosse, Wisconsin
Lakeview College of Nursing
Peggy Dermer, RNC, MSN, WHCNS Danville, Illinois
Faculty/Nursing Instructor
Jill Holmstrom, Ed.D., RN, CNE
Tri-County Technical College
Associate Professor
Pendleton, South Carolina
Concordia College
Debbie Diamond, MSN, ARNP, FNP-BC Moorhead, Minnesota
Assistant Professor
Nova Southeastern University
Miami, Florida
vii
I would like to thank a number of individuals without Management, were wonderfully supportive and helpful
whom this book would never have been published: while overseeing the entire project. I could not have com-
The assistance of Mary T. Hickey, EdD, WHNP-BC, pleted the book without the expertise and guidance of
Clinical Associate Professor at NYU College of Nursing, John Tomedi, Developmental Editor at Spring Hollow
was invaluable when writing the chapter entitled, “Pedi- Press. His many suggestions made the book clearer and
atric Medication Administration.” Her expertise mark- more complete. His assistance and patience throughout
edly strengthened the chapter content. The support of the process were invaluable. Marsha Hall and the copy-
faculty with whom I teach at Adelphi University College editing staff at Progressive Publishing Alternatives edited
of Nursing and Public Health was vital for the book’s the prose and made the book more readable for future
success. students. Daniel Domzalski, F.A. Davis Illustration Coor-
F.A. Davis Publisher Robert Martone’s faith in me has dinator, and the staff at Graphic World Illustration Ser-
now extended to the publication of a second text. I thank vices created beautiful images that bring many of my
him for his confidence in me and for this opportunity. words to life.
Elizabeth (Liz) Hart, F.A. Davis Content Product Manager Finally, these words of acknowledgment would not be
II, and, while Liz was on maternity leave, Catherine complete without a thank you to the members of my
Carroll, F.A. Davis Manager of Project and eProject family, who are always there when I need them.
ix
Introduction xiii
xi
This book is one piece in a series published by F.A. Davis Use This Book as One
designed to assist student nurses successfully to graduate
from nursing school and, ultimately, successfully to pass Educational Strategy
the NCLEX-RN examination. In particular, the book The first step to take when studying pediatric content is
focuses on pediatric nursing care (i.e., the nursing care of to study and learn the relevant material. Learning does
children). Children are different from adults. In fact, chil- not mean simply reading textbooks and/or attending
dren have different physiological characteristics, behave class. Learning is an active process that requires a number
differently, think differently, and, in a number of cases, of complex skills, including reading, discussing, and orga-
experience different illnesses than do adults. Not only is nizing information.
the large group of children different from the large group
of adults, each subgroup of children—infant, toddler, pre-
schooler, school-age child, and adolescent—exhibits dif- Read Assignments
ferences from each other subgroup. In addition, children Students must first read their assignments. By far the best
are members of a family, and families exist within cul- time to read the assigned material is before the class in
tural, ethnic, and religious contexts. To disclose those which the information will be discussed. Then, if students
differences, this book presents chapters on the nursing have any questions about what was read, they can ask the
care of each of those age groups as well as chapters on instructor during class and clarify anything that is confus-
important considerations that nurses must take into ing. In addition, students will find discussions much more
account when caring for and administering medications meaningful when they have a basic understanding of the
to children. To provide comprehensive information, the material.
book includes a chapter on each system of the body and
the nursing care required of children suffering from dis-
eases of each system. Discuss the Information
In each chapter, the reader finds brief descriptions of During class time, material should be discussed with stu-
the chapter’s focus as well as a summary, in outline form, dents rather than fed to them. Teachers have an obligation
of the important content related to that focus. Each to provide stimulating and thought-provoking classes, but
chapter is followed by two critical thinking sections. First students also have an obligation to be prepared to engage
is a case study, entitled “Putting It All Together,” that in discussions on entering the classroom.
relates directly to the content in that chapter. At the end Although facts must be learned, nursing is not a fact-
of the case is a series of critical thinking questions, requir- based profession. Nursing is an applied science. Nurses
ing the student nurse to determine how he or she would must use information. When a nurse enters a client’s
act in that situation. Answers to those questions follow room, the client rarely asks the nurse to define a term or
the case. After the case study are a number of NCLEX- to recite a fact. Rather, the client presents the nurse with
RN-style questions, with correct responses, rationales, a set of data that the nurse must interpret and act on. In
and test-taking tips, related to the chapter content. other words, the nurse must think critically. Students,
Although the majority of the questions are multiple therefore, must discuss client-based information by asking
choice, the reader will also find multiple-response, fill-in- “why” questions rather than simply learning facts by
the-blank, drag-and-drop, and ordered-response items in asking “what” questions.
the text.
It is important for the reader to realize that this book
is not meant to be a primary nursing text on pediatrics.
Organize the Information
Rather, it has been written to supplement comprehensive While reading and discussing information, nursing stu-
pediatric texts. For the book to be of best use to the dents must begin to organize their knowledge. Nursing
student nurse, therefore, he or she must have a founda- knowledge cannot be memorized. There is too much
tional understanding of pediatric nursing. To gain that information, and, more important, memorization nega-
understanding, the student nurse must read and study an tively affects the ability to use information. Nurses must
inclusive, pediatric nursing textbook. be able to analyze data critically to determine priorities
xiii
and actions. To think critically, nurses develop connec- example, a client’s physical well-being must take prece-
tions between and among elements of information. dence over emotional well-being. It is essential that the
There are several steps for organizing basic informa- nurse consider the client’s priorities and the goals and
tion, including understanding the pathophysiology of a orders of the client’s primary health-care provider.
problem; determining its significance for a particular
client; identifying signs and symptoms; and using the
steps of the nursing process.
Implement the Care
Once the plan is established, the nurse implements it. The
plan may include direct client care by the nurse and/or
care that is coordinated by the nurse but performed by
Use the Nursing Process other practitioners. If assessment data change during
The nursing process is foundational to nursing practice. implementation, the nurse must reanalyze the data,
To provide comprehensive care to their clients, nurses change diagnoses, and reprioritize care.
must understand and use each part of the nursing One very important aspect of nursing care is that it be
process—assessment, formulation of a nursing diagnosis, evidence based. Nurses are independent practitioners.
development of a plan of care, implementation of that They are mandated to provide safe, therapeutic care that
plan, and evaluation of the outcomes. has a scientific basis. Nurses, therefore, must engage in
lifelong learning. It is essential that nurses realize that
Assess much of the information in textbooks is outdated before
Nurses gather a variety of information during the assess- the text was even published. To provide evidence-based
ment phase of the nursing process. Some of the informa- care, nurses must keep their knowledge current by access-
tion is objective, or fact-based. For example, a client’s ing information from reliable sources on the Internet, in
hematocrit level and other blood values in the chart are professional journals, and at professional conferences.
facts that the nurse can use to determine a client’s needs.
Nurses also must identify subjective data, or information Evaluate the Care
as perceived through the eyes of the client. A client’s The evaluation phase is usually identified as the last phase
rating of pain is an excellent example of subjective infor- of the nursing process, but it also could be classified as
mation. Nurses must be aware of which data must be another assessment phase. When nurses evaluate, they are
assessed because each client situation is unique. In other reassessing clients to determine whether the actions taken
words, nurses must be able to use the information taught during the implementation phase met the needs of the
in class and individualize it for each client interaction to client. In other words, “Were the goals of the nursing care
determine which objective data must be accessed and met?” If the goals were not met, the nurse is obligated to
which questions should be asked of the client. Once the develop new actions to meet the goals. If some of the goals
information is obtained, the nurse analyzes it. were met, priorities may need to be changed, and so on.
As can be seen from this phase, the nursing process is
Formulate Nursing Diagnoses ongoing and ever changing.
After the nurse has analyzed the data, a diagnosis is made.
Nurses are licensed to treat actual or potential health
problems. Nursing diagnoses are statements of the health Types of Questions
problems that the nurse, in collaboration with the client
There are four integrative processes upon which ques-
and the primary health-care provider, has concluded are
tions in the NCLEX-RN examination are based: “Nursing
critical to the client’s well-being.
Process,” “Caring,” “Communication and Documenta-
tion,” and “Teaching/Learning” (2013 NCLEX-RN
Develop a Plan of Care Detailed Test Plan, Candidate Version, 2013, p 5). The test
The nurse develops a plan of care, including goals of care, taker must determine which process(es) is (are) being
expected client outcomes, and interventions necessary to evaluated in each question. The test taker must realize
achieve the goals and outcomes. The nurse determines that because nursing is an action profession, the NCLEX-
what he or she wishes to achieve in relation to each of the RN questions simulate, in a written format, clinical situ-
diagnoses and how to go about meeting those goals. ations. Therefore, critical reading is essential.
One very important part of this process is the develop- Most of the questions on the NCLEX-RN exam are
ment of the priorities of care. The nurse must determine multiple choice. Other types of questions, known as alter-
which diagnoses are the most important and, conse- nate-type questions, include fill-in-the-blank questions,
quently, which actions are the most important. For multiple-response questions, drag-and-drop questions,
and hot-spot items. In addition, any one of the types of and-drop questions because the test taker will move the
questions may include an item to interpret, including items with his or her computer mouse. Needless to say, in
lab data, images, and/or audio or video files (2013 NCLEX- this book, the test taker will simply be asked to write the
RN Detailed Test Plan, 2013, p 46). The types of questions responses in the correct sequence.
and examples of each are discussed below. A nurse is studying the psychosocial development of chil-
dren. Place the following stages, as defined by Erik Erikson,
Multiple-Choice Questions into the correct chronological order:
In these questions, a stem is provided (i.e., a situation is 1. Trust versus mistrust
presented, and a question is asked). The test taker must 2. Initiative versus guilt
then choose the best answer to the question among four 3. Industry versus inferiority
possible responses. Sometimes, the test taker is asked to 4. Identity versus role confusion
choose the best response, sometimes to choose the first 5. Autonomy versus shame and doubt
action that should be taken, and so on. There are numer- Answer: 1, 5, 2, 3, 4
ous ways that multiple-choice questions may be asked. The correct order, as developed by Erikson, is trust
Following is one example: versus mistrust in the infancy period, autonomy versus
The nurse is assessing the growth and development of a shame and doubt in the toddler period, initiative versus
12-month-old child. Which of the following behaviors guilt in the preschool period, industry versus inferiority in
would the nurse expect the child to exhibit? the school-age period, and identity versus role confusion in
1. Sits with assistance the adolescent period.
2. Walks independently
3. Feeds self bite-sized foods using a neat pincer grasp Multiple-Response Questions
4. Holds a cup with one hand without spilling the The phrase “Select all that apply” following a question
contents means that the examiner has included more than one
Answer: 3 correct response to the question. Usually, there will be five
The test taker must know, for example, that although responses given, and the test taker must determine which
many children walk independently at 12 months of age, the of the five responses are correct. There may be two, three,
majority of children are expected to walk independently by four, or even five correct responses.
15 months of age. A nurse is caring for a 3-year-old child who has had 6
loose, green stools in the past 12 hr. Which of the following
Fill-in-the-Blank Questions assessments should the nurse perform at this time? Select
These are calculation questions. The test taker may be all that apply.
asked to calculate a medication dosage, an intravenous 1. Height
(IV) drip rate, a minimum urinary output, or other factor. 2. Weight
Included in the question are the units that the test taker 3. Skin turgor
should have in the answer. 4. Patellar reflex
The nurse is caring for a 2-year-old child who saturated 5. Fontanel tension
her blanket with vomitus. To determine the volume of Answer: 2 and 3
emesis, the nurse weighed a clean blanket (2,223 g) and the Because this child is at high risk for dehydration, the
soiled blanket (2,338 g). How many milliliters of emesis has nurse should assess for weight loss and poor skin turgor.
the client vomited? Neither the child’s height nor patellar reflexes are directly
mL related to the diagnosis of dehydration. In addition, both
Answer: 115 mL fontanels are closed by the time a child reaches 3 years
The test taker must subtract 2,223 g from 2,338 g of age.
to determine that the client has vomited 115 g of emesis.
Then, knowing that 1 g of fluid is equal to 1 mL of fluid, Hot-Spot Items
the test taker knows that the client has lost 115 mL of These items require the test taker to identify the correct
emesis. response to a question about a picture, graph, or other
image. For example, a test taker may be asked to place an
Drag-and-Drop Questions “X” on a picture of an infant.
In drag-and-drop questions, the test taker is asked to A nurse is assessing an infant’s rooting reflex. Place an
place four or five possible responses in chronological or “X” on the following image of the infant at the site where
rank order. The responses may be related to such things the nurse would assess the infant’s rooting reflex.
as actions to be taken during a nursing procedure or steps Answer: The test taker should place an “X” on one of the
in growth and development. The items are called drag- infant’s cheeks. When an infant exhibits a rooting reflex, he
impression is usually the correct response. Only if the based on a number of different factors.
test taker knows that he or she misread the question Understanding why answers are wrong also may
should the answer be changed. transfer over to other questions.
• Read the rationales for each question: In this book, • Read all test-taking tips: Some of the tips relate
rationales are given for each answer option. The directly to test-taking skills, whereas others include
student should take full advantage of this feature. invaluable information for the test taker.
Read why the correct answer is correct. The rationale If the test taker uses this text as recommended above,
may be based on content, on interpretation of he or she should be well prepared to be successful when
information, or on a number of other bases. taking an examination in any or all of the content areas
Understanding why the answer to one question is represented. As a result, the test taker should be fully
correct is likely to transfer over to other questions prepared to care for children as a beginning registered
with similar rationales. Next, read why the wrong professional nurse.
answers are wrong. Again, the rationales may be
Bar mitzvah—In the Jewish faith, a coming-of-age Communal family—A type of nontraditional family in
ceremony for a 13-year-old boy, after which he is which several family units live together.
responsible, morally and ethically, for his actions. Curandero—Among Hispanics and Latinos, a faith
Bat mitzvah—In the Jewish faith, a coming-of-age healer.
ceremony for a 12-year-old girl, after which she is Haj—A journey to the holy city Mecca, which a
responsible for her actions, morally and ethically. member of the Muslim faith is expected to make
Blended family—A type of nontraditional family in once in his or her lifetime.
which one or both parents is single, divorced, or Halal—The types of foods members of the Muslim
widowed, and children from former relationship(s) faith are permitted to eat; non-Halal foods include
may live together. pork and alcohol, among others.
Bris—The ritual circumcision of the penis, practiced by
members of the Jewish faith.
ii. Based on the teachings of the prophet, iii. Rituals at many developmental periods of
Mohammed. a child’s life.
(1) Mohammed received God’s word. iv. Marriage rituals.
(2) Teachings are written in the Book of v. Death rituals, including cremation with
Quran. transition to the next life.
b. Basics. vi. Vegetarianism commonly is practiced.
i. Although there is no ordained clergy in B. Ethnic and racial groups: customs based on a family
Islam, those who lead Muslim member’s country of origin and/or racial
communities are often referred to as background often markedly influence his or her
imams. cultural practices. In addition, the child’s or parent’s
ii. Muslim houses of worship are called primary language, if other than English, can affect
mosques. care. If communication is hampered, children’s and
c. Practices common to Muslims, of which the family members’ comfort levels can be negatively
majority are guided by the five pillars of the affected as well as the children’s ultimate recovery.
faith: Based on the 2010 U.S. census, it is determined that
i. Male is the head of household and the as of 2012, in addition to the predominant non-
decision maker. Hispanic or Latino white population, i.e., the
ii. Recitation of the principles of Islam. “original peoples of Europe, the Middle East, or
iii. Five mandatory times for prayer during North Africa,” who comprise 63% of the U.S.
each day. population (U.S. Census, 2012), the following groups
iv. Providing charity to those in need. reside in the United States:
v. Fasting during the sacred month of 1. Asian and Pacific Islanders.
Ramadan. a. 5.3% of the U.S. population.
vi. Performing Haj or making the b. Individuals whose origins have their roots in
pilgrimage to Holy City of Islam— the “Far East, Southeast Asia, or the Indian
Mecca in the current country of Saudi subcontinent including, for example,
Arabia—at least once during one’s Cambodia, China, India, Japan, Korea,
lifetime. Malaysia, Pakistan, the Philippine Islands,
vii. Dietary restrictions (i.e., Halal) prohibit, Thailand, and Vietnam” (U.S. Census, 2012).
for example, the consumption of pork and Those from the Islands of the Pacific (e.g.,
alcoholic beverages. Hawaii, Guam, Samoa) also often identify with
4. Hinduism is the primary religion of the majority the Asian culture.
of individuals living in or from India and Nepal. c. Common beliefs among many Asian and
Hindu practices are quite diverse (e.g., some Pacific Islanders.
Hindus are polytheistic, while others believe in i. Importance of and respect for the family,
one Supreme Being). especially the wisdom of the elderly.
a. Fundamental principles. ii. Importance of self-control and personal
i. Most believe in Dharma (there is no direct honor.
translation into English), a Hindu word iii. Diet primarily comprised of vegetables,
loosely translated as guiding principle or rice, and fish.
duty. 2. Blacks.
ii. The four Vedas are the scriptures of a. 13.1% of the U.S. population.
Hinduism: Rig Veda, Sama Veda, Yajur b. Individuals whose “origins [are] in any of the
Veda, and Atharva Veda. The Vedas help Black racial groups of Africa” (U.S. Census,
to guide the daily lives of Hindus. 2012).
b. Basics. c. Common beliefs among many Blacks.
i. There is no one clergyperson who leads i. Precepts of Christianity and the guidance
Hindu worship but rather a number of of the preacher are followed while some
priests and teachers. Blacks follow the Muslim faith.
ii. A Hindu house of worship is called a ii. Illnesses are often viewed as having been
temple. sent by God.
c. Practices common to Hindus. 3. Native Americans.
i. Personal sacrifice and purification. a. 1.2% of the U.S. population.
ii. Pregnancy and birthing rituals, including b. People who adhere to the rituals and beliefs of
a naming ceremony. the “original peoples of North and South
America (including Central America)” and objective assessments in collaboration with his or
who identify with their native tribe (U.S. her client. Throughout this text, nursing diagnoses
Census, 2012). are identified. The diagnoses in this text are based
c. Common beliefs among many Native on those developed by the North American Nursing
Americans. Diagnosis Association (NANDA). Other diagnostic
i. Supremacy of the family and especially the terms (e.g., those of Nursing Interventions
elders of the community. Classifications [NIC] or simple problem statements)
ii. Often wish to consult with the Native may also be used.
American healer who may employ rituals
and the consumption of herbs as healing 1. Parental role conflict, characterized by, for
practices. example:
4. Hispanics and Latinos. a. A parent whose child is ill feels incapable of
a. 16.9% of the U.S. population. caring for the child.
b. Those whose origins are from “Spain, the b. A parent who feels that a child’s illness is
Spanish-speaking countries of Central or adversely affecting him or herself or other
South America, or the Dominican Republic” members of the family.
(U.S. Census, 2012). 2. Interrupted Family Processes characterized by, for
c. Hispanic people may be of any racial example:
background. a. Siblings who are assuming parental roles
d. Common beliefs among many Hispanics. because their parents must care for a sick
i. Extended families are common and brother or sister.
provide great comfort during periods of b. Siblings who resent the time spent by parents
stress. caring for a sick brother or sister.
ii. The male, who is usually the head of c. Changes in the distribution of resources
household, should be consulted when because of the expense of a child’s health care.
decisions are made. 3. Caregiver Role Strain characterized by, for
iii. Hispanics are usually Christian, with example:
Catholicism being the primary faith a. Physical and/or emotional fatigue experienced
practiced. by the parents of a hospitalized child or a child
iv. Faith healers, or curanderos, may be at home who needs extensive care.
consulted when a child is ill, and b. Physical and/or emotional fatigue experienced
traditional remedies are often used. by parents of the sandwich generation—those
who must care for their children as well as
IV. Parent-Child Relationships their elderly parents.
c. Abuse of substances in response to the stress
The relationships between parents and children, as well as of the severe illness or death of a child.
parents’ disciplinary practices, are grounded in the cul- 4. Deficient Knowledge related to inability to speak
tural practices of the family. Parenting is not learned in a or understand English, characterized by, for
classroom, rather one learns to parent from watching the example:
behaviors of one’s parents. a. Parents and/or child falsely communicating—
A. Discipline (see also “Growth and Development,” by the nod of the head, for example—that the
Chapters 2–6). health-care regimen is understood.
b. Anger and/or frustration with the inability to
communicate or understand what is being said.
V. Nursing Considerations B. Interventions: specific interventions are dependent
on individual circumstances, but many include any
A. Nursing diagnoses: based on a nurse’s assessment, a
or all of the following:
number of nursing diagnoses may be important for
1. Educating the parents and family members
the nurse to identify.
regarding the child’s illness and health-care needs.
DID YOU KNOW? 2. Providing emotional support to parents and
The development of nursing diagnoses is one family members during periods of stress.
of the key components of the nursing process— 3. Assisting parents and family members to identify
assessment, diagnosis, planning, implementation, coping mechanisms for times of stress, including
evaluation. The diagnoses are determined by the prayer or other religious practices, meditation,
nurse after he or she identifies the subjective and and exercise.
4. Providing grief counseling to parents and family 6. Assisting parents to access available community
members when appropriate. resources by referring parents to social services
5. Identifying support systems for parents and and government agencies (e.g., Women, Infants,
family members for times of stress, including and Children nutrition services and
extended family members, community leaders, neighborhood clinics).
members of religious organizations, and siblings’ 7. Providing the parents and/or child with a
educators. language interpreter.
1.
2.
3.
4.
B. What objective assessments indicate that the client is experiencing a health alteration?
1.
2.
3.
4.
Continued
1.
D. What interventions should the nurse plan and/or implement to meet this child’s and his family’s needs?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing interventions?
1.
2.
3.
4.
1.
G. What psychological characteristics should the child and family exhibit before being discharged home?
1.
It is the goal of health-care providers to promote health development, standardized tools should always be
and to prevent illness in their clients. When caring for used. The growth charts published by the Centers for
children, that goal is translated into four main actions: Disease Control and Prevention (CDC) (www.cdc.gov/
• To monitor children’s biological growth and growthcharts/clinical_charts.htm) as well as the Denver
maturational development on a regular basis in order Developmental Screening Test II (DDST-II) (www
to identify alterations from the norm. .denverii.com/), the Ages and Stages Questionnaires
• To intervene when needed to return children to (http://agesandstages.com/), and the Parents’ Evaluation
normal growth and development. of Developmental Status (PEDS) (www.pedstest.com/
• To provide interventions that increase children’s default.aspx) are but a few of those tools.
likelihood of maintaining health. The section “Language and Social Development”
• To educate caregivers regarding ways to provide covers a number of concepts, of which three are based on
children with healthy and safe lifestyles. the research conducted by well-known theorists:
The next five chapters discuss the five major age • Language development, or the maturation in growth
periods in a child’s development: infancy, toddlerhood, and function of a child’s ability to communicate.
preschool age, school age, and adolescence. While out- • Psychosocial development, or the changes in
lining the milestones of each period of development, children’s emotional and social growth, based on the
these chapters provide information that enables nurses work of Erik Erikson.
to achieve the stated goals. To that end, these chapters • Cognitive development, or the maturation in relation
are divided into four sections: “Biological Development,” to a child’s intellectual abilities, based on the work of
“Language and Social Development,” “Nursing Con- Jean Piaget.
siderations: Health Promotion/Parent Education,” and • Moral development, or the maturation of a child’s
“Nursing Considerations: Disease Prevention/Parent understanding of his and others’ ethical behaviors, as
Education.” discussed by Lawrence Kohlberg.
The section “Biological Development,” which concerns In addition, the chapters on growth and development
growth in size, shape, and function of the body, covers a include important information related to health-promo-
number of important concepts, including the height, tion strategies (e.g., healthy eating and exercise) that help
weight, and normal vital signs for children at the desig- children to stay well and disease prevention protocols
nated ages, as well as the motor development that is (e.g., immunization administration and dental hygiene)
expected of children at each age level. Although these that help to keep children from becoming sick. Nursing
chapters provide benchmarks, it is important to note considerations and parent education related to both
that for complete and objective assessments of a child’s health promotion and disease prevention are included.
11
I. Description
The infancy period is defined as the age period between
a child’s birth and first birthday. The first 28 days of life,
however, are called the neonatal period. This age period
is considered separate because the characteristics and
behaviors of the newborn are impacted by the newborn’s
fetal environment and transition to extrauterine life. The
neonatal period is discussed in depth in maternity texts.
This chapter focuses on the remainder of the infancy
period, from 28 days to 1 year of life.
DID YOU KNOW?
Children change dramatically during their infancy. Fig 2.1 Measurement of head circumference.
They begin the period as persons who are unable to
perform any independent actions. They must rely
on their caregivers for food, warmth, transport, and Lambdoid suture
safety. By the time they reach their first birthday,
however, infants are able to walk, albeit often with Posterior fontanel
some assistance; feed themselves; and speak in a
Sagittal suture
rudimentary language. The transition is quite
astounding.
Coronal sutures
Fig 2.3 Always educate parents to put babies to sleep on ! When educating parents about activities that will enable
their children to grow and develop, it is essential that the
their backs to help prevent SIDS.
nurse stress the importance of safety. When the baby is
placed on the floor, the area must be free of small objects,
2. To prevent strangulation, parents should be electrical cords, and other hazards that could injure the
advised that: infant. In the same way, objects given to the child for small
a. Slats of a crib should be no wider than 2⅜ in. motor development must not pose a choking threat.
apart. d. Burn threats.
b. Cribs should have rigid sides (i.e., the i. Safety plugs should be inserted into all
sides of the crib should not move up electrical sockets.
and down). ii. Electrical cords should be kept out of
c. Sleep areas should be placed away from blinds reach. Infants can pull on the cords and
and curtain strings that can be wrapped dislodge appliances that then can land on
around the neck. their heads (e.g., an iron can be pulled off
from an ironing board or a lamp off from
V. Nursing Considerations: Disease a side table).
Prevention/Parent Education e. Possible falls.
i. Babies require constant supervision when
A. It is important for nurses to educate parents about lying on elevated surfaces and when in
baby-care skills, including diapering, feeding, and such apparatuses as strollers and high
bathing. chairs.
1. Diapers should be changed frequently to prevent ii. Gates should be placed at tops and
diaper rash. bottoms of all stairs and should be
2. When bathing an infant: attached to all windows.
a. The baby should never be left alone in or near iii. Infant walkers should never be used.
water to prevent drowning. f. Choking hazards (see the previous section,
b. All needed supplies should be collected before “Nursing Considerations: Health Promotion/
immersing baby in the water. Parent Education”):
c. The bath water should be approximately 105°F i. Toys of older siblings are potential
to prevent chilling and burns. dangers.
B. Safety issues should be emphasized. g. Possible strangling.
1. Childproofing the home should be started by 4 i. Pacifiers should never be tied to a string
months of age. that could encircle the neck.
ii. Never place cribs next to blinds or curtain g. Pot handles should be turned away from the
cords. front of the stove.
iii. Children should never be put to sleep with h. The knobs on stoves and ovens should be
a bib in place. covered with child covers.
i. Adults should stay away from children when
! Parents should be encouraged to learn emergency eating or drinking hot substances or when
action skills for choking, infant and child CPR, and first aid.
smoking cigarettes.
Parents will become guilt ridden if they are unable to help
j. Children should be kept away from such
their children during a life-threatening emergency.
things as grills, fireplaces, stoves, and
2. Travel safety. radiators.
a. In cars. 4. Lead poisoning prevention (see Chapter 10,
i. Parents should only use car seats that have “Pediatric Emergencies”).
been designed for infant use. Many bucket a. At 9 months of age, blood lead screening
seats are safely used only until a baby should be performed, with hematocrit and
reaches 20 lb. hemoglobin assessments and with blood lead
ii. Children’s car seats should be placed rear levels.
facing in the back seat of the car—for 2 b. Parent education.
full years—or until the child has reached i. Parents should be advised to wash their
the weight limit for the seat. children’s hands and face frequently,
iii. Child safety door latches should be in especially before eating, to prevent
place at all times. ingestion of lead.
ii. Parents should be advised to clean their
! Children should NEVER be left unattended in a car, even homes regularly to remove potential
for a few minutes. They may be abducted or may be locked
sources of lead.
in the car by mistake. Children left in a car may die from
5. Personal safety: infants are much too young to
overheating or freezing.
protect themselves. They need constant
b. In airplanes, it is not required to restrain a supervision at all time, including when in the
child who is under 2 years of age, but both the presence of strangers.
Federal Aviation Administration (FAA) and 6. Other.
the AAP recommend that children be in a a. In addition to smoke and fire detectors,
child restraint system until they are 4 years of houses should also be equipped with carbon
age. monoxide detectors.
3. Burn safety and sun exposure. b. Poison control hotline and other emergency
a. Children should be kept out of direct sunlight, numbers should be placed by every telephone
especially between 10 a.m. and 4 p.m. (see Box 2.1 for a list of indications regarding
i. For the first 6 months of life, infants should when parents should call their child’s health-
have no sun exposure unless it is care provider).
unavoidable. C. Immunizations: the latest immunization schedule
b. Methods should be used to protect children published by the Advisory Committee on
from sun exposure (e.g., they should wear Immunization Practices (ACIP) of the CDC
clothing covering the skin, UVA and UVB should always be checked (www.cdc.gov/vaccines/
protectants, and sunglasses).
i. Sun protectants:
(1) Should be applied at least every
2 hours and always reapplied if child Box 2.1 When to Have an Infant Seen by a
gets wet. Health-Care Professional
c. Fire and smoke alarms should be located
throughout the home. When the child:
1. Has a temperature of 100°F or higher.
d. Yearly fire drills should be conducted with all 2. Has a rash.
members of the family. 3. Refuses to eat.
e. Dangerous items (e.g., matches, electrical 4. Is not able to be roused from sleep.
cords, and electrical sockets) should be kept 5. Has fewer than the recommended numbers of wet or
out of reach of children. soiled diapers.
6. Has diarrhea or is vomiting.
f. Hot water heaters should be set at 120°F or 7. Has yellow-tinged (jaundice) skin or sclerae.
lower.
1.
2.
3.
4.
5.
1.
2.
3.
C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse assign to this client?
1.
D. What interventions should the nurse plan and/or implement to meet this child’s and his family’s needs?
1.
2.
3.
4.
5.
6.
7.
8.
E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing interventions?
1.
2.
F. What physiological characteristics should the child exhibit before being discharged home?
1.
2.
7. The nurse is visiting the home pictured above. A 8. A mother visits her child’s primary health-care
6-month-old child lives in the home. Please select the provider for the child’s 12-month visit. The child
image in the picture that the nurse should inform the weighed 2,800 grams at birth. Which of the following
parents presents a potential danger to the child. weights is most consistent with the expected weight
for this child?
1. 7,500 grams
2. 8,000 grams
3. 8,500 grams
4. 9,000 grams
9. The nurse assesses a 2-month-old girl. The baby 10. A 6-month-old child received the following
weighed 3,400 grams at birth, 3,800 grams at 1 play things as a gift from a relative. The nurse
month, and 4,000 grams at 2 months of age. The should advise the parents that which of the
nurse plots the information on the scale below. items is potentially dangerous for the child to
Which of the following conclusions and actions play with?
would be appropriate for the nurse to make? 1. Stuffed animal
1. Conclusion: the child’s growth is normal. 2. Balloon
Action—no change: the baby is growing 3. Toy cell phone
appropriately, therefore no feeding changes are 4. Shape sorter
needed.
2. Conclusion: the child’s growth is excessive.
Action—change: the baby is overweight, and the
information should be reported.
3. Conclusion: the child’s growth is inconsistent.
Action—no change: the baby’s weight was larger
than normal at birth, but the current weight is
appropriate.
4. Conclusion: the child’s growth is below expected.
Action—change: the baby’s weight is markedly
lower than normal, and the information should be
reported.
11. A mother of an 8-month-old boy states that the 13. A mother questions the nurse regarding car seat
family is vacationing in a beach house for the next 2 safety for her infant. Which of the following
weeks. Which of the following information should information should the nurse include in the
the nurse educate the mother about in relation to sun discussion?
exposure? Select all that apply. 1. Place the infant car seat rear facing in the back
1. Reapply sun lotions to all exposed skin every 4 to seat of the car.
6 hours. 2. Move the car seat to the forward-facing position
2. Use sun lotions that protect against both UVA when the child reaches 1 year of age.
and UVB rays. 3. Keep the child in a bucket seat until the child is at
3. Have the baby wear child-sized sunglasses least 12 months of age.
whenever he is in the sun. 4. Tighten the straps of the seat so that only an adult
4. Avoid exposing the child to the sun between the fist fits under the straps.
hours of 12 and 2 p.m.
5. Dress the child in lightweight clothing that covers
the majority of his skin.
12. The mother of an 11-month-old states, “My child has
8 teeth. I brush them every morning with bubble
gum-flavored toothpaste. My child loves it.” Which of
the following responses by the nurse is appropriate?
1. “That is great. Even though they are baby teeth, it
is very important to brush them with toothpaste.”
2. “I am so glad to hear that your child loves the
toothpaste. So many babies get cavities because
they refuse to use toothpaste.”
3. “I am very happy to know that you are cleaning
your baby’s teeth, but I am afraid that the bubble
gum flavor will spoil him.”
4. “It is wonderful that you are brushing your child’s
teeth, but it is recommended for you not to use
toothpaste.”
REVIEW ANSWERS 3. Because the antibodies cross the placenta and may
inhibit the active immune response in infants, measles,
1. ANSWER: 3 mumps, rubella, and varicella vaccines are all administered
Rationale: in the second year of life.
1. Infants roll from back to front at about 6 to 7 months of 4. The polio vaccine is administered in infancy.
age. TEST-TAKING TIP: It is important to note that because of
2. Infants smile when they are 1½ to 2 months of age and potential serious side effects, the Sabin oral polio vaccine
laugh out loud when they reach 6 to 7 months of age. is no longer being administered in the United States.
3. At one month of age, children still perform basic skills Rather, the injectable vaccine is being administered at 2, 4,
like moving their heads from side to side. and 6 months of age during the first year of life.
4. Infants begin to hold rattles, if placed in their hands, at Content Area: Pediatrics—Infant
about 3 months of age. Integrated Processes: Nursing Process: Implementation;
TEST-TAKING TIP: Development is progressive. Although Teaching/Learning
babies develop a social smile at 6 to 8 weeks of age, Client Need: Health Promotion and Maintenance: Health
they usually do not laugh out loud until they are Promotion/Disease Prevention
much older. Cognitive Level: Application
Content Area: Pediatrics—Infant
4. ANSWER: 1
Integrated Processes: Nursing Process: Implementation;
Rationale:
Teaching/Learning
1. This response is correct. Infants should have their
Client Need: Health Promotion and Maintenance:
needs met in a timely manner.
Developmental Stages and Transitions
2. It is not recommended that infants cry themselves to
Cognitive Level: Application
sleep each night.
2. ANSWER: 1 and 5 3. It is not recommended that infants be disciplined for
Rationale: breaking items.
1. 8-month-old children do play peek-a-boo with their 4. Mothers who sneak out when they are leaving their
parents. children are not promoting a sense of trust in their
2. Children are not expected to walk independently until children.
they reach 15 months of age. TEST-TAKING TIP: The Eriksonian psychosocial stage of the
3. It is too early for a child to be expected to feed him/ infancy period is trust versus mistrust. Infants develop
herself with a spoon. trust when they become assured that their parents will
4. Children are able to stack blocks into a 2-block tower at meet their needs (e.g., feed them when they are hungry,
about 18 months of age. change their diapers when they are wet or soiled). Parents
5. Babies can transfer objects from hand to hand at 7 who meet their children’s needs in a timely fashion are
months of age. promoting a sense of trust in their children.
TEST-TAKING TIP: The key to answering multiple response Content Area: Pediatrics—Infant
items correctly is to view each response independently. In Integrated Processes: Nursing Process: Implementation;
other words, read the first response after carefully reading Teaching/Learning
the stem of the question. If it is accurate, it should be Client Need: Health Promotion and Maintenance:
chosen. Then read the second response, and compare it Developmental Stages and Transitions
to the stem. If it is accurate, then it should be chosen. Cognitive Level: Application
Continue to compare each response independently until
5. ANSWER: 2
all responses have been reviewed.
Rationale:
Content Area: Pediatrics—Infant
1. This is an appropriate question to ask, but it is not the
Integrated Processes: Nursing Process: Assessment
priority.
Client Need: Health Promotion and Maintenance:
2. This is the priority question. Babies should consume
Developmental Stages and Transitions
either breast milk or a commercially prepared formula
Cognitive Level: Application
until 1 year of age.
3. ANSWER: 4 3. This is an appropriate question to ask, but it is not the
Rationale: priority.
1. Because the antibodies cross the placenta and may 4. This is an appropriate question to ask, but it is not the
inhibit the active immune response in infants, measles, priority.
mumps, rubella, and varicella vaccines are all administered TEST-TAKING TIP: Pure cow’s milk contains fats, proteins,
in the second year of life. and carbohydrates that are in much different proportions
2. Because the antibodies cross the placenta and may than those found in breast milk and formula. Children are
inhibit the active immune response in infants, measles, unable to digest the nutrients in cow’s milk effectively
mumps, rubella, and varicella vaccines are all administered until they have reached 1 year of age.
in the second year of life.
Content Area: Pediatrics—Infant placed near the table, he or she could grasp the cord and
Integrated Processes: Nursing Process: Implementation; attempt to chew it or to pull down on the cord and
Teaching/Learning topple the lamp. Babies do not understand the potential
Client Need: Health Promotion and Maintenance: Health dangers that cords present.
Promotion/Disease Prevention Content Area: Pediatrics—Infant
Cognitive Level: Application Integrated Processes: Nursing Process: Assessment
Client Need: Health Promotion and Maintenance: Health
6. ANSWER: 2 Promotion/Disease Prevention
Rationale: Cognitive Level: Application
1. Two months of age is too early to expect a child to roll
over independently. 8. ANSWER: 3
2. This is an appropriate question to ask. Rationale:
3. This question, although related to the child’s 1. The nurse would expect the baby to weigh about 8,500 g.
development, will not elicit information needed to respond 2. The nurse would expect the baby to weigh about 8,500 g.
to the mother’s concerns. 3. The nurse would expect the baby to weigh about
4. This question, although related to the child’s 8,500 g.
development, will not elicit information needed to respond 4. The nurse would expect the baby to weigh about 8,500 g.
to the mother’s concerns. TEST-TAKING TIP: Infants usually triple their birth weights
TEST-TAKING TIP: Babies often develop plagiocephaly by 12 months of age. 2,800 × 3 = 8,400 g. A weight of
when they are placed on their backs all day every day. To 8,500 g is most consistent with the expected weight for
prevent this disfigurement, parents are strongly this child.
encouraged to place their babies on their tummies each Content Area: Pediatrics—Infant
day. Tummy time should only occur, however, when a Integrated Processes: Nursing Process: Analysis
caregiver is directly supervising the child. Client Need: Health Promotion and Maintenance: Health
Content Area: Pediatrics—Infant Screening
Integrated Processes: Nursing Process: Implementation; Cognitive Level: Analysis
Teaching/Learning
Client Need: Health Promotion and Maintenance: Health 9. ANSWER: 4
Promotion/Disease Prevention Rationale:
Cognitive Level: Application 1. The infant’s weight is not increasing at the appropriate
rate. A complete assessment is needed.
7. ANSWER: The test taker should select the image of 2. The infant’s weight is not increasing at the appropriate
the electrical cord hanging from the table. rate. A complete assessment is needed.
Rationale: 3. The infant’s weight is not increasing at the appropriate
TEST-TAKING TIP: Once babies develop the ability to rate. A complete assessment is needed.
grasp objects, they explore their environment by grasping 4. The infant’s weight is not increasing at the appropriate
and playing with items within their reach. If the child were rate. A complete assessment is needed.
TEST-TAKING TIP: After plotting the weights on the girl’s Client Need: Health Promotion and Maintenance: Health
weight chart, the test-taker would see that the percentiles Promotion/Disease Prevention
dropped from the 50th at birth to about the 25th Cognitive Level: Application
percentile at 1 month to about the 10th percentile at 2
months. This baby needs to have a thorough physical 12. ANSWER: 4
assessment, and the parents need to be thoroughly Rationale:
queried regarding the child’s feeding, urinary, and 1. This response is not appropriate. Until children can spit
stooling patterns. out the toothpaste on command, they should not have
Content Area: Pediatrics—Infant their teeth brushed with toothpaste.
Integrated Processes: Nursing Process: Analysis 2. This response is not appropriate. Until children can spit
Client Need: Health Promotion and Maintenance: Health out the toothpaste on command, they should not have
Screening their teeth brushed with toothpaste.
Cognitive Level: Analysis 3. This response is not appropriate. Although the bubble
gum-flavored toothpaste may result in the child only
10. ANSWER: 2 allowing the sweet toothpaste to be used, until children can
Rationale: spit out the toothpaste on command, they should not have
1. Stuffed animals are safe toys for infants to play with as their teeth brushed with toothpaste.
long as they are not placed in the crib when the child is 4. This response is correct. Until children can spit out the
put to sleep. toothpaste on command, they should not have their teeth
2. Balloons are potentially dangerous items for young brushed with toothpaste.
children. TEST-TAKING TIP: The vast majority of toothpaste on the
3. Toy cell phones are safe and appropriate toys for infants market contains fluoride. When exposed to toothpaste, no
to play with. matter which flavor, infants will swallow it simply because
4. Shape sorters are safe and appropriate toys for infants to they have yet to learn how to spit out on command. To
play with. prevent a fluoride overdose, it is recommended that
TEST-TAKING TIP: It is very important to be aware of toys toothpaste not be used until the child is able to spit out
that are safe and appropriate to the growth and on command.
development of the child. Although older children can Content Area: Pediatrics—Infant
safely play with balloons, infants and toddlers should not Integrated Processes: Nursing Process: Implementation
play with them. A young child could easily inhale either an Client Need: Health Promotion and Maintenance: Health
uninflated or a broken balloon and suffocate when putting Promotion/Disease Prevention
the item in his/her mouth during play. Cognitive Level: Application
Content Area: Pediatrics—Infant
Integrated Processes: Nursing Process: Implementation 13. ANSWER: 1
Client Need: Health Promotion and Maintenance: Health Rationale:
Promotion/Disease Prevention 1. This is the correct response.
Cognitive Level: Application 2. This is incorrect. An infant’s car seat should be moved to
the forward-facing position when the child reaches the age
11. ANSWER: 2, 3, and 5 of 2 or when the child reaches the weight limit for the
Rationale: infant seat.
1. Incorrect. Sun lotions should be reapplied at least every 3. This is incorrect. An infant’s car seat should be moved to
2 hours. the forward-facing position when the child reaches the age
2. Correct. Sun lotions should only be used if they protect of 2 or when the child reaches the height or weight limit
against both UVA and UVB rays. for the infant seat.
3. Correct. Not only should the skin be protected from 4. This is incorrect. The straps should be tightened until an
the sun. The eyes also should be protected. adult can just insert the fingers under the straps.
4. Incorrect. Parents should avoid exposing their children TEST-TAKING TIP: It is important for test takers to be
to the sun between 10 a.m. and 4 p.m. current in their practice. Prior to 2012, it was
5. Correct. Clothing will help to protect the skin from recommended that infants remain rear facing until they
sun exposure. were 1 year of age. As a result of further research,
TEST-TAKING TIP: There is a misconception among some however, the recommendation was changed for those still
parents that sun exposure is healthy for children. meeting the height and weight requirements of the seats
Unfortunately, over time, sun exposure can lead to to stay rear facing until 2 years of age.
changes in the DNA of the skin, with the potential of Content Area: Pediatrics—Infant
developing skin cancer. Parents should be advised Integrated Processes: Nursing Process: Implementation
regarding actions that they should take to protect their Client Need: Health Promotion and Maintenance: Health
children’s, as well as their own, bodies from the sun. Promotion/Disease Prevention
Content Area: Pediatrics—Infant Cognitive Level: Application
Integrated Processes: Nursing Process: Implementation
Parallel play—A form of play exhibited by toddlers Toddlerhood—The age period between a child’s first
in which children play side by side but birthday and third birthday.
independently. Transition object—A large number of toddlers have
Physiological anorexia—Reduced appetite seen in one or two objects to which they are especially
toddlers due to slower growth in this age period. attached (e.g., blanket, doll, pacifier). During times
Telegraphic speech—Shortened, simple speech of stress, toddlers hold the transition objects close
consisting of two or more words (e.g., “Me do it”). in order to feel more secure.
29
4. Head circumference.
a. Anterior fontanel: closes between 12 and 18
months of age (posterior fontanel is already
closed).
b. By age 2, the toddler’s head is approximately
90% of the size of the adult head.
B. Vital signs (average).
1. Temperature.
a. 98.6°F (36°C).
b. Except oral, any method of measuring
temperature is acceptable (e.g., axillary, aural,
temporal artery) unless absolutely accurate
reading is required. Then rectal is considered
to be the most accurate.
c. Safe insertion with a rectal probe is critical to
prevent injury.
2. Apical heart rate.
a. 70 to 110 bpm.
b. Radial artery may be used to assess pulse rates
in children over 2 years of age.
3. Respiratory rate.
a. 20 to 30 rpm.
4. Blood pressure.
a. At 3 years of age: 100/59 mm Hg for boys;
100/61 mm Hg for girls.
b. Pressures above these values should be
Fig 3.1 A toddler walking. considered hypertension.
c. Blood pressures are rarely taken until children
reach 3 years of age. If taken, an electronic
2. Height. method, including the correct size cuff, should
a. Toddlers grow on average 7.5 cm/year (3 in./ be used.
year). C. Dentition.
3. Body mass index (BMI). 1. After 1 year of age, teeth erupt slowly over time.
a. BMI should be calculated for all children 2 2. By 2½ years, toddlers should have a full set of
years of age and older. 20 teeth.
b. The following criteria should be used to 3. Parent education.
interpret BMIs: a. By 2½ years of age, children should have their
i. BMI less than the 5th percentile: child is first dental exam and should be seen every 6
defined as underweight. months thereafter.
ii. BMI between the 5th and the 85th b. Teeth should be cleaned at least twice daily by
percentiles: healthy weight for the child’s the parent with a soft child’s toothbrush—no
height. toothpaste should be used until child can spit
iii. BMI greater than the 85th percentile: child out on command.
is defined as overweight. i. It is recommended that children’s teeth also
iv. BMI greater than the 95th percentile: child be flossed daily.
is defined as obese. ii. After the parent cleans the teeth, the child
can practice doing so.
c. Prevent dental caries.
MAKING THE CONNECTION i. Dental caries can endanger the
To calculate the BMI, the following formula should be development of the secondary teeth.
used: ii. Children should never be put to sleep with a
bottle filled with anything other than water.
Child’s weight in kilograms divided by the child’s height d. Fluoride supplementation.
in meters squared, that is, BMI = kg/m2 i. If water is not supplemented, children
should receive 0.25 mg/day.
(1) “Would you like to take your nap now the information to an understandable event or
or in 10 minutes?” rather than “Would concept such as:
you like to take a nap?” If the child i. “You eat your breakfast at the same time
were to say “No” to taking a nap, the that Sesame Street is on the TV.”
parent must either ignore the child’s ii. “We eat dinner every night right after
response or forgo the nap. Mommy and Daddy get home from
c. If a new baby is born into a toddler family, the work.”
parents must be forewarned that the toddler iii. “You brush your teeth every morning right
may act out in a number of ways, for example, before we go to day care.”
temper tantrums, regressing, refusing to go to c. When providing toddlers with explanations,
bed. parents as well as health-care providers should
C. Cognitive development. use understandable language, for example:
1. Toddlerhood is defined by Piaget as the stage of i. “The doctor is going to take a picture of
preoperational thought. your insides,” rather than “You are going
a. Toddlers view and experience the world to have an x-ray.”
directly—they are unable to conceptualize (1) The word x-ray is too abstract for the
things or events. child to understand.
b. Language development speeds up during this ii. “The hairdresser is putting paint on
period but is very “me” oriented. Mommy’s hair,” rather than “Mommy’s
i. Language as self-entertainment: toddlers hair is going to be dyed.”
often talk simply because they find it is (2) The child will hear the word “died”
enjoyable to hear themselves. rather than “dyed.”
ii. Language as interpersonal communication. D. Moral development.
(1) Toddlers do talk with others, but their 1. Stage 1, or premorality, is described by
language is still egocentric. Kohlberg.
(2) To toddlers, “I” and “me” are the most a. Toddlers believe that actions are only wrong if
important words in the vocabulary. they are punished. Similarly, they believe that
c. Ritualism: toddlers begin to learn that certain actions are good if they are not punished or if
actions occur at the same time or same they are rewarded.
sequence each day (e.g., stories and bath 2. Parent education.
precede bedtime every night). a. It is important for parents to begin to use
d. Animism: toddlers believe things such as toys appropriate means of limit setting and
and dolls possess human abilities. For example, discipline (see the section “Toddler Behavior
a toddler will scold a toy or a chair for getting and Discipline”) in preparation for later, more
in his or her way. sophisticated stages of moral development.
e. Toddlers begin to see differences between
many things.
i. They learn that some children are boys IV. Nursing Consideration: Health
and some are girls and often imitate the Promotion/Parent Education
behavior of the same-sex parent.
ii. They begin to notice the differences A. Nutrition.
between such things as colors, shapes, and 1. The toddler period is characterized by what is
clothes. called physiological anorexia, marked by slower
2. Parent education. growth and decreased appetite.
a. Parents should be encouraged to incorporate a. Growth slows and interest in the environment
learning into play, daily conversation, and grows.
everyday activities, for example: b. Toddlers often stop eating regular meals,
i. “You are wearing a red shirt today.” becoming finicky eaters who snack and graze.
ii. “What color is dolly’s dress?” 2. Parent education.
iii. “Look, you are eating sandwich a. Parents should be forewarned that toddlers
triangles!” often refuse to sit to eat.
iv. “Look, your waffle is a circle!” i. They stand at the table to eat or walk
b. Parents should establish rituals and inform while eating.
their children of patterns. In addition, parents ii. If they are allowed to walk and eat, safety
as well as health-care providers should connect concerns must be considered (see below).
b. Food fads are very common in this population should be consumed as a calcium and protein
(e.g., a child might eat only blueberries and source, it should no longer be the child’s primary
crackers on Monday and eat only cheese and source of nutrition.
peas on Tuesday).
v. If the child is still using a bottle at night,
i. Parents should be advised that they should
only water, never milk, should be put into
not worry.
the bottle to prevent dental caries.
ii. After a few days, the vast majority of
g. Parents should be advised that vitamin and
children somehow consume a balanced
mineral supplements, other than fluoride, as
diet.
discussed earlier, are not required but, if given
c. The important principle to teach parents is
safely, are not harmful either. However:
that they should always serve their children
i. Parents must be reminded never to leave
nutritious foods.
vitamin pills where their child can access
i. Foods that are high in calories, fat, and/or
them.
sodium and low in nutritional value
(1) A child may consume an entire bottle
should be served as infrequently as
of vitamins because he or she thinks,
possible.
“If the one vitamin that Mommy gives
d. Parents should be advised to give their
me is good, more is probably better.”
toddlers child-size portions.
ii. Parents must be advised never to call
i. If too much food is put on a young
vitamin pills “candy.”
toddler’s plate, he or she will often not
(1) Simply because vitamins are sweet to
even try to eat. The quantity is simply too
taste and often look like cartoon
overwhelming.
characters is enough incentive for
e. Parents should be advised to continue to be
toddlers to want to consume more
concerned about choking hazards.
than one.
i. Popcorn, carrot chunks, and hot dog
B. Sleep.
chunks should not be served to toddlers.
1. The risk of SIDS is no longer an issue. Toddlers
ii. All foods should be soft and cut into small
may have such things as pillows, soft toys, and
bites, especially if the child is allowed to
quilts in their beds.
eat on the run.
2. Toddlers need up to 14 hours of sleep per day and
f. Information should be conveyed to parents
usually take at least one nap per day.
regarding milk intake.
3. Parent education.
i. Once children reach 1 year of age, they
a. To prevent tantrums (see the section “Toddler
have developed the ability to digest
Behavior and Discipline”), forewarning a child
unaltered cow’s milk, although if the
that bed or nap time is coming is often helpful
mother is still breastfeeding, that certainly
(e.g., 30 minutes before, state, “Bedtime in 30
is still appropriate.
minutes,” then 15 minutes before, state,
ii. To take in the fats needed for optimal
“Bedtime in 15 minutes”).
brain growth, parents should be advised to
b. To prevent injury, parents should be advised to
feed their children whole milk until at
move their children from a crib to a bed once
least the age of 2.
they can climb out.
iii. After age 2, depending on the child’s
c. If parents establish a bedtime routine and stick
growth pattern, children may continue to
to it, they rarely have bedtime difficulties.
consume whole milk or may be switched
i. Toddlers find rituals comforting, enabling
to low fat, skim, or soy.
them to assert their autonomy without
iv. During the toddler period, children
becoming too anxious.
should ingest most of their calories from
(1) A sample routine that should remain
food rather than from milk. Those who
consistent every night is: bath (fun
drink large quantities of milk often
and relaxing), read two books, brush
become anemic because iron is not found
teeth, have one sip of water, hugs and
in milk.
kisses, get tucked in with special
DID YOU KNOW? blanket, and sleep.
As long as they are safe to eat, toddlers should be C. Toilet training.
eating most of the same foods as the rest of the 1. Parents must be advised that child readiness is
family—just in bite-size portions. Although milk essential.
a. Both physical and emotional readiness are ii. Toddlers do not understand long
needed. explanations.
b. If child is not ready, frustration and possible b. Toys should always be safe and consistent with
abuse, verbal or/and physical, may result. the child’s development.
2. Girls often train before boys. i. Parents should be encouraged to check the
3. Bowel training usually precedes bladder training. Consumer Product Safety Commission’s
4. Day training usually precedes night training— Web site regarding the safety of children’s
night training may not occur until many years toys (www.cpsc.gov).
later. ii. The toilet paper roll test should still be
5. Toileting accidents are very common, especially used to assess the safe size of toys (see
when toddlers are engaged in active play. Chapter 2).
6. Parent education. c. Appropriate toys that parents should be
a. Parents should obtain a potty chair or toilet encouraged to provide for their toddlers
potty seat. include:
ii. Sitting on an adult toilet can be scary for i. Push-pull toys, large blocks, balls, and
toddlers. They fear that they may fall in. trucks that help to promote and reinforce
b. Parents should be advised to be attentive to gross motor development.
cues from the child that he or she is ready. ii. Paint, sand and water play (all supervised),
i. Some children want their diaper changed large crayons, and large puzzles that help
immediately after wetting or soiling. to promote and reinforce small motor
ii. Some children communicate, verbally or development.
behaviorally, when they are wetting or iii. Musical toys and books that help to
soiling their diapers. promote and reinforce language
iii. Some children want to be like an older development.
sibling, a parent, or a friend at preschool. E. Toddler behavior and discipline.
c. Parents should be encouraged to place their 1. Tantrums.
child onto the potty seat shortly after eating or a. They are relatively common but need not
when their child usually has a bowel persist.
movement. b. Tantrums usually occur when:
d. Parents should be encouraged to praise their i. Toddlers are abruptly told that they must
child for success but not to punish the child if leave an activity.
he or she is not successful or if he or she has ii. Limit setting is inconsistent.
an accident. iii. The child simply cannot get his feelings
e. If accidents are frequent, it is advisable to across verbally because his or her language
recommend to parents to abandon the training skills are so immature.
until the child is more ready. c. Parent education.
f. Problem: children who are repeatedly i. Suggestions that should be provided to
punished for accidents may develop feelings of parents as means of preventing a tantrum.
shame toward themselves and/or fear of their Parents should be encouraged to:
parents. (1) Forewarn their child that an activity
D. Play and toys. will end soon (e.g., “In 10 minutes, we
1. Toddlers engage in parallel play, in which two or will be leaving the park,” then 5
more toddlers will play independently but side by minutes later, “In 5 minutes, we will
side. be leaving the park”). The change in
a. They love to play with other toddlers, but they activity is no longer a surprise.
rarely interact with each other during the play. (2) Consistently limit the child’s behavior
b. They often grab toys from one another, (e.g., bedtime is always at 8 p.m.
exhibiting their egocentrism. preceded by a bath and book reading).
2. Parent education. (3) Be patient when the child is trying to
a. If a toddler needs to be taught that taking a communicate something.
toy or hitting is unacceptable, the child should ii. Suggestions for limiting the length of a
be reprimanded using very simple language, tantrum.
for example: (1) The parent should ignore the behavior.
i. “No, you must not grab the toy from The parent should NOT abandon the
Johnny,” or “You must not hit.” child but simply turn his or her
attention somewhere else (i.e., say, “I grabs a toy from another child, provide the
will speak with you when you stop child with an alternative).
screaming”), then turn around and say d. Once the child is exhibiting appropriate
nothing more. behavior, or once time out is complete, the
(2) Once the child is acting appropriately, child should be praised (hugging is a
the parent should then quickly wonderful action) for correct/appropriate
provide a hug and verbal praise for the behavior.
appropriate behavior. e. Spanking is not recommended because
toddlers may interpret the spanking as, “If
! If an activity is unsafe, a child must not be allowed to Mommy and Daddy can hit, then it must be
engage in that activity, even though a tantrum may be
acceptable for me to hit.”
triggered.
F. Day care and nursery school.
iii. Parents must be advised that limit setting 1. Often very positive experiences for children.
and discipline (see the section a. Provides opportunity for interacting with
“Discipline”) are very important, but the children and adults.
form of discipline must be appropriate to b. Provides opportunity for learning.
the child’s age and understanding. 2. Parent education.
2. Sexual exploration: toddlers often engage in a. Before sending the child, the parents should be
masturbation and body exploration. advised to inspect the facility carefully and
a. Very natural. interview the staff.
b. Parent education. b. Before sending the child, parents must be
i. Parents should be advised to try not to advised fully to prepare the child.
discipline their child for sexual exploration i. The child should be given a simple, clear
because the negative remarks may lead to rationale for the experience.
feelings of guilt or shame. ii. The parents should tell the child that day
ii. Rather, parents should be encouraged to: care is not a punishment.
(1) Advise the child that masturbation iii. The parents should let the child take his or
should be performed in private. her transition object for security.
(2) Redirect the child to another activity.
3. Discipline.
a. Limit setting: parents must be encouraged to V. Nursing Considerations: Disease
set realistic limits on their children’s behavior Prevention and Parent Education
beginning in the toddler period.
i. There are certain items that children may A. Safety.
not play with or touch. 1. Toddlers as “mini-scientists.”
(1) Parents should be encouraged to move a. Toddlers are highly inquisitive. It is exhausting,
the items, if possible. challenging, potentially dangerous, and fun to
(2) Parents should consistently advise watch young children.
their child to refrain from playing or b. Parent education.
touching those items. i. Parents must be advised that toddlers
ii. There are certain behaviors that are not must be watched at all times because they
acceptable (e.g., biting, hitting, throwing may endanger themselves and/or others
sand in someone’s face, running into the during their explorations. Examples of
street). potential dangers include the following:
iii. Parents’ responses to unacceptable (1) Toddlers often play with light
behaviors should be consistent. switches—in every room—to make
b. Time out is an excellent form of discipline for sure that the same thing happens in
toddlers. each location. However, one of those
i. Moving and exploring are important to switches may be for a portable heater
children of this age. or a portable fan—either of which
ii. The time out should only last for a few could seriously injure the child.
minutes (usually the same number of (2) Toddlers often remove everything
minutes as the age of the child). from places such as closets and
c. Parents should be encouraged to redirect the drawers to check out what treasures
child to an acceptable activity (e.g., if the child they contain. However, dry cleaner
bags that are fun to play with are iii. Toy phones and pull toys with long strings
potential suffocation hazards. should never be given to toddlers, unless
ii. An appropriate response to parents who the children are supervised.
become frustrated by toddler behaviors h. If they have not already done so, parents
might be, “Toddlers do not get in trouble should be encouraged to learn or be recertified
because they are defying their parents. in emergency action skills for choking, infant
They get in trouble because they simply and child CPR, and first aid.
cannot help it.” 3. Travel safety.
iii. If parents are well educated about toddler a. In cars.
behavior, they likely will refrain from i. Infant seats: toddlers should remain rear
punishing the child for actions that are facing in the back seat of the car in an
related to growth and development. infant seat for 2 full years, unless the child
2. Childproofing the home. has reached the weight limit on the seat
a. Toddlers are at high risk for accidental injury. before age 2.
b. There are a number of possible poisoning ii. Forward-facing car seats: 2-year-old and
threats in a toddler’s environment. older children should be in forward-facing
i. Plants should be kept out of reach. car seats until they reach the weight limit
ii. Medicines should be kept out of reach in a on that seat.
locked cabinet. (1) Forward-facing seats should
iii. Cleaning supplies should be kept in locked always be placed in the back seat
cabinets. of the car.
iv. Other: homes should be kept clean to (2) It is recommended that seat placement
prevent ingestion of such harmful be checked at a designated police
materials as lead from dust and paint facility.
chips. iii. Child safety car door latches should be in
c. Drowning threats. place at all times.
i. Buckets of water should be emptied.
ii. Bathtubs should only be filled for bathing,
! Children should NEVER be left unattended in a car, even
for a few minutes. They may be abducted or may be locked
and children should be supervised in the
in the car by mistake. Children left in a car may die from
bath at all times.
overheating or freezing.
iii. Bathrooms should be locked.
d. Burn threats. b. As pedestrians:
i. Electrical sockets: safety plugs should be i. Toddlers must be supervised at all times
inserted into all sockets. and, if anywhere near traffic, must always
ii. Electrical cords: should be kept out of hold hands.
reach because a toddler could pull on a ii. Young children can dart quickly
cord, and the appliance could land on the behind and/or in front of a moving
child’s head (e.g., an iron could fall from vehicle.
an ironing board). c. In airplanes.
e. Possible falls. i. The FAA (Federal Aviation
i. Constant supervision is needed when Administration) does not require a child
young children are lying on elevated to be restrained in an airplane until the
surfaces and when they are in such items child is 2 years of age.
as strollers and high chairs. ii. However, both the FAA and the American
ii. Gates should be placed at the tops and Academy of Pediatrics (AAP) recommend
bottoms of all stairs. that children be in a child restraint system
iii. Gates should be attached to all windows. on airplanes until they are 4 years of age.
f. Choking hazards (see the section “Nutrition”): (1) Not all car seats are compatible with
i. Small toys and toys of older siblings are airline seats.
potential dangers. 4. Burn safety and sun exposure.
g. Possible strangling. a. Cigarette smoking should not be allowed
i. Cribs should never be placed next to within the vicinity of the child.
blinds and curtain cords. i. Many toddlers have been burned when
ii. Children should never be put to sleep accidentally running into a lit cigarette
wearing a bib. that is held by an adult.
b. All homes should be equipped with fire, 6. Near drownings (see Chapter 10, “Pediatric
smoke, and carbon monoxide detectors. Emergencies”).
i. Families should have periodic fire drills a. There is a high incidence of drownings in the
for home safety. toddler age group.
(1) The child must be taught where to b. Toddlers must never be left alone in or near
meet his/her parents if an alarm is water (e.g., bath water, pool, brook, or even a
sounded. mop bucket).
(2) Children must be instructed not to c. All supplies should be collected for a toddler’s
hide under the bed or in a closet bath before immersing the child.
during a fire. 7. Personal safety: toddlers are much too young
c. Water heaters should be set to no higher than to protect themselves from sexual abuse.
120°F. They need to be supervised around others
i. Toddlers are often able to turn on the at all times.
water. Higher temperatures can burn a B. Health screenings: at each age level, children are
toddler’s skin. assessed for possible diseases or illnesses. If the
ii. Bath water should be approximately 105°F screenings are positive, an intervention is
to prevent both chilling and burns. implemented. (See “Recommendations for Pediatric
d. Children should be kept out of direct sunlight, Preventive Health Care” for a complete list of
especially between 10 a.m. and 4 p.m. procedures.)
e. Methods should be used to protect children 1. By 18 months: autism screening should be
from sun exposure (e.g., clothing covering the performed.
skin, UVA and UVB protectants, and 2. 2 years.
sunglasses). a. Lead and hemoglobin assessments: lead
i. Sun protectants should be applied at least prevention principles are consistent with those
every 2 hours and always reapplied if cited in Chapter 2, “Normal Growth and
children get wet. Development: Infancy.”
f. Dangerous items, such as matches, electrical b. Other, if indicated.
cords, and electrical sockets, should be kept i. Screening for hypercholesterolemia and/or
out of the reach of children. tuberculosis.
i. Children should be kept away from such C. Immunizations (see current Advisory Committee on
things as grills, fireplaces, stoves, and Immunization Practices [ACIP] schedule).
radiators. 1. 15 months.
ii. In the kitchen, pot handles should be a. Haemophilus influenzae type B (Hib); measles,
turned away from the front of the stove. mumps, and rubella (MMR); varicella; and
(1) Toddlers love to “help” Mommy and, pneumococcal (if not given at 1 year).
therefore, may try to move pots and b. Hepatitis B (Hep B) (if not given earlier).
pans on the stove. c. Flu (every year).
iii. Stove and oven knobs should be covered 2. 2 years.
to prevent toddlers from accidentally or a. Catch up on any vaccines that have not yet
purposefully turning on the oven or a been administered.
burner. b. Flu (every year).
g. Parents should be advised to stay away from D. Child abuse issues.
their children when eating or drinking hot 1. Shaken baby syndrome (SBS).
substances or when smoking cigarettes. a. Parents should be educated regarding actions
5. Poisonings (see Chapter 10, “Pediatric that can lead to SBS.
Emergencies”). 2. Toilet training and other developmental issues.
a. Very high incidence of poisonings in a. One of the most significant causes of
the toddler (and preschool) populations, child abuse in the toddler period is
including: parental misunderstanding of normal child
i. Acute poisonings (e.g., medications, behavior.
vitamins, and gasoline) b. Nurses must educate parents regarding normal
ii. Chronic poisonings, primarily lead. growth and development, including:
b. Parents must have the poison control hotline i. Psychosocial norms.
and other emergency numbers visible by every ii. Cognitive norms.
telephone. iii. Readiness for toilet training.
1.
2.
3.
4.
5.
1.
2.
3.
4.
5.
C. After analyzing the data that has been collected, what primary nursing diagnoses should the nurse assign to this client?
1.
2.
D. What interventions should the nurse plan and/or implement to meet this child’s and her family’s needs?
1.
2.
3.
4.
5.
6.
7.
8.
9.
E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing interventions?
1.
2.
3.
4.
F. What physiological characteristics should the child exhibit before being discharged home?
1.
2.
3.
10. A 15-month-old child, who is being dropped off at 13. A nurse is providing education to the parents of a
nursery school, throws himself onto the floor, kicks, toddler. Which of the following information should
and screams, “No! No!” Which of the responses by the nurse include? Select all that apply.
the mother should the nursery school nurse 1. The child should receive an influenza vaccination
recommend the mother change in the future? every year.
1. The mother turns her back on the child while he 2. The child should brush his or her teeth with
is kicking and screaming. toothpaste every morning and night.
2. The mother bends during the tantrum and states, 3. The child should consume foods from all food
“Honey, why are you so upset? We need to discuss groups every day.
your behavior.” 4. The child should continue to drink formula until
3. After the tantrum is over, the mother turns he or she is two years old.
around and states, “I am so proud of you when 5. The child should be allowed to take his or her
you act like a big boy.” special object to nursery school.
4. After the tantrum is over, the mother bends down
14. The parents of a toddler, who is toilet trained and no
and gives her son a hug.
longer drinks from a bottle, are expecting a new
11. A mother reports to the nurse that she administers a baby. The nurse should advise the parents that the
vitamin to her toddler every morning. The nurse toddler may respond in which of the following ways?
should praise the mother for using which of the Select all that apply.
following methods of administration? 1. Kiss the baby whenever the baby is near.
1. Mother gives her child a vitamin each morning. 2. Repeatedly have temper tantrums.
When doing so, she states, “Here’s your medicine. 3. Ask to drink milk from a bottle.
It tastes just like candy.” 4. Have a number of toileting accidents.
2. Mother leaves the vitamin pill bottle on the 5. Hit the baby on the head.
kitchen table. In the morning, mother states,
15. The nurse is providing anticipatory guidance to the
“Take out your vitamin, and chew it up good.”
parents of a 12-month-old child regarding bedtime
3. Mother locks the vitamins in the medicine
issues. Which of the following statements is
cabinet. When giving her child the vitamin,
appropriate for the nurse to include?
mother states, “Remember, only Mommy is able
1. “Don’t put your child to bed each night until he
to give you the medicine.”
appears to be really sleepy.”
4. Mother keeps the vitamins on top of the
2. “Make sure to keep blankets, pillows, and stuffed
refrigerator. When giving the child the vitamin,
toys out of your child’s bed.”
mother states, “Remember, you must never climb
3. “Forewarn your child a few minutes before that it
on the counter to get your vitamins.”
is time to go to bed. In other words, tell him
12. A mother of a 2½-year-old calls the health-care when it is ten minutes before and then five
provider and states, “I don’t know what to do. My minutes before bedtime.”
son keeps taking off his diaper in public and playing 4. “Make bedtime different and special every night.
with his penis.” Which of the following responses by Some nights you could read him a story, other
the nurse is appropriate? nights play a game with him, and other nights
1. “Slap his hand, and tell him that that behavior is sing a song with him.”
unacceptable.”
2. “He should be given a time out every time he
does that.”
3. “Laugh at him, and say that you understand that
it feels good to play with his penis.”
4. “Simply put his diaper back on, and tell him that
he should do that in his own bedroom.”
Client Need: Health Promotion and Maintenance: Health 3. It is possible that the child will regress and ask to drink
Promotion/Disease Prevention from the bottle again.
Cognitive Level: Application 4. It is possible that the child will have toileting accidents.
5. It is possible that the child may hit the baby on the
13. ANSWER: 1 and 5 head.
Rationale:
TEST-TAKING TIP: Because parents are excited and in love
1. Children should receive the influenza vaccine every
with the new baby as well as their older child, they often
year.
do not realize that the toddler may not have the same
2. This statement is not correct. Parents should brush
feelings. Indeed, the new baby is taking his or her parents’
children’s teeth until the children have the dexterity, at
time and attention away from him or her. As a result,
about 6 years of age, to brush their teeth themselves.
toddlers often regress and become angry.
Toothpaste should only be used when the child is able to
Content Area: Pediatrics—Toddlers
spit out voluntarily.
Integrated Processes: Nursing Process: Implementation
3. This statement is not correct. Toddlers go on food fads,
Client Need: Health Promotion and Maintenance: Health
although they usually consume a balanced diet after about
Promotion/Disease Prevention
a week.
Cognitive Level: Application
4. This statement is not correct. Children are physically
able to consume unaltered cow’s milk after they turn 1 year 15. ANSWER: 3
of age. Rationale:
5. This statement is correct. Transition objects should 1. This statement is inappropriate. Rituals and consistency
accompany toddlers during new experiences. are best for toddlers.
TEST-TAKING TIP: Educating parents regarding health-care 2. This statement is incorrect. The threat of SIDS is past
practices is an important role of the nurse. It is important once a healthy child reaches 1 year of age.
that the nurse provide accurate information. 3. This statement is appropriate. Toddlers accept change
Content Area: Pediatrics—Toddlers much easier when they are forewarned of the change.
Integrated Processes: Nursing Process: Implementation; 4. This statement is inappropriate. Rituals and consistency
Teaching/Learning are best for toddlers.
Client Need: Health Promotion and Maintenance: Health TEST-TAKING TIP: Bedtime rarely is difficult when parents
Promotion/Disease Prevention establish a set prebedtime routine and follow the routine
Cognitive Level: Application consistently.
Content Area: Pediatrics—Toddlers
14. ANSWER: 2, 3, 4, and 5 Integrated Processes: Nursing Process: Implementation;
Rationale:
Teaching/Learning
1. It is unlikely that the toddler will kiss the baby whenever
Client Need: Health Promotion and Maintenance: Health
the baby is near.
Promotion/Disease Prevention
2. It is possible that the toddler will have temper
Cognitive Level: Application
tantrums.
Associative play—A type of play in which children Nightmare—A frightening dream that awakens a child.
play with one another in an activity that is not Night terror—Crying, screaming, or other physical
directed toward a goal. unrest during sleep.
Magical thinking—a preschool-age child’s conception
that his or her thoughts can cause something to
happen.
45
4. By the time children reach the preschool period, b. By 4 years of age, preschoolers should be
head circumference is no longer measured. able to:
a. If head growth is a problem, it will have been i. Hop on one foot.
identified by age 3. ii. Balance on one foot for a few seconds.
B. Vital signs: all vital signs are consistent with those of c. By 5 years of age, preschoolers should be
the toddler. able to:
1. Temperature. i. Walk heel to toe.
a. 98.6°F (36°C). ii. Skip.
b. Any method is acceptable (e.g., axillary, aural, iii. Jump rope.
temporal artery). 2. Fine motor development.
i. Rectal temperature should be taken in a. At 3 to 4 years of age, preschoolers begin using
preschoolers only when absolutely a fork.
necessary. b. By 4 years of age, preschoolers are able to copy
2. Heart rate may be taken either apically or radially. a circle.
a. 65 to 110 bpm. c. By 4½ years of age, they are able to copy a
3. Respiratory rate. cross.
a. 20 to 25 rpm. d. By 5 years of age, they:
4. Blood pressure: always using an appropriately i. Begin to use a dull knife for cutting.
sized cuff. ii. Can draw a person with at least six
anatomical parts that are drawn in their
DID YOU KNOW? correct locations.
An easy method that can be used to calculate the
lowest safe blood pressure of preschool-age
children is: 70 mm Hg plus two times the child’s age
III. Language and Social Development
in years.
A. Language development.
C. Dentition. 1. 3-year-old children:
1. Children should have a full set of 20 primary a. Still use telegraphic speech.
teeth at start of the preschool period. b. Talk nonstop to whomever will listen,
2. Many preschoolers will start losing their primary including toys.
teeth when they are 4½ or 5 years of age. c. Ask many questions, often beginning with
3. Parent education. “Why?”
a. Preschool children should be allowed to 2. 4- to 5-year-old children:
practice brushing their teeth, but a complete a. Have a vocabulary that is becoming quite
brushing should be performed by their large.
parents. b. Speak using all parts of speech.
b. Parents should also floss their children’s c. Frequently use irregular verbs incorrectly (e.g.,
teeth. “I seed a kitten,” rather than “I saw a kitten.”).
c. If a child is able to keep substances in his/her d. Have vivid imaginations, making up and
mouth without swallowing, toothpaste may be telling very elaborate tales.
used. e. Sometimes use “bad” language and look for a
D. Senses. response from their parents.
1. Hearing, smell, and touch are fully developed. i. If parents ignore the comments, the
2. Vision—the normal visual acuity: children often stop using the inappropriate
a. Of 3- to 4-year-old children is 20/50 to 20/40. language.
b. By age 5 should be 20/30. ii. If parents laugh or act appalled, children
3. Taste. often continue using them as a means of
a. Preschool children are often more adventurous getting attention.
eaters than they were as toddlers. B. Psychosocial development.
E. Motor development. 1. Preschoolers have entered into Erikson’s
1. Gross motor development. developmental stage of initiative versus guilt.
a. At 3 years of age, preschoolers should be able a. The major goal of the stage is the development
to: of behavior that is appropriate and self-
i. Ride a tricycle. directed, while the potential problem
ii. Perform the broad jump. associated with the stage is a child who is
iii. Walk on tip toes. guilt ridden.
i. Because of “magical thinking” (see the d. Preschoolers’ fears are often unrelated to
section “Cognitive Development”), reality, for example:
preschool children believe that they are i. When they have an injection, they often
bad or have caused bad things to happen fear that their insides will fall out through
simply because they have had bad the injection site.
thoughts. ii. They fear that they will go down the drain
ii. When punished for inappropriate when the water in the bathtub is let out.
behaviors, preschoolers think to 3. Parent education.
themselves, “I am bad,” rather than “I have a. Parents of preschoolers should continue to
acted inappropriately.” reinforce learning and language through:
iii. Children often masturbate at this age. If i. Reading to their children each night.
reprimanded or punished, they may ii. Talking with their children.
develop feelings of guilt. iii. Restricting the children’s time spent
2. Parent education. watching television and, when television is
a. Because of the potential for guilt, when watched, primarily allowing the children
disciplining a preschooler, it is important to to view educational programing.
explain clearly that his or her action is bad, iv. Playing simple games with the children,
NOT that the child is bad. such as:
b. If a sibling or a parent becomes ill, it is (1) Naming shapes, colors, and letters will
important to explain to the child that he or she help the child to be prepared to enter
did not cause the condition. school.
c. If the child did have a role in an accident, the (2) Putting together jigsaw puzzles help
parent must explain that he or she is not angry preschoolers to develop spatial
with the child. relationships and logical reasoning.
d. If a child masturbates, the parent should be b. Preschoolers begin to learn about reality by
advised: pretending to perform behaviors that they see
i. Not to reprimand or punish the child. their parents perform. To assist with that
ii. Simply to inform the child that the learning, parents can provide children with
behavior should be performed in private, imaginary play materials (e.g., dress-up
not in public. clothes, play kitchen utensils, and food items).
C. Cognitive development. c. Parents of preschoolers should be advised that
1. Piaget’s stage of preoperational thought continues their children may make some unusual
throughout the preschool period to the age of 7 requests or may act in unusual ways, for
(see Chapter 3, “Normal Growth and example:
Development: Toddlerhood,” for characteristics of (1) A child may refuse to take a bath in
the stage and for suggestions of parent education). the bathtub for fear of being washed
2. Magical thinking. down the drain.
a. Preschoolers believe that inanimate objects (2) A child may mandate that adhesive
(e.g., toys and chairs) are sentient and are able bandages be placed on all injuries to
to think and act. prevent their insides from leaking out.
i. This behavior is exhibited in their play, for D. Moral development: Kohlberg’s first stage of
example, the child may communicate that: premorality.
(1) A tricycle is bad if the child fell from 1. The preschooler is still egocentric in his or her
the trike. moral behavior.
(2) A doll house is mad if it falls over a. Preschoolers primarily follow rules in order to
during play. stay out of trouble.
b. Preschoolers believe that whatever they think
is real and will happen. They cannot IV. Nursing Considerations: Health
distinguish between reality and fantasy. Promotion/Parent Education
c. Just as in toddlerhood, preschoolers
understand terms very literally, for example: A. Nutrition.
i. Rather than hearing and understanding 1. The food fads and anorexia of the toddler period
that “Mommy dyed her hair,” the eventually subside.
preschooler hears, “Mommy died a. The less attention paid to eating problems, the
her hair.” easier mealtime usually becomes.
ii. Teach child how to call 911 and how to Chapter 10, “Pediatric Emergencies,” for an in-depth
respond appropriately when he or she discussion).
calls 911. 1. Poisoning: steps that can prevent the accidental
(1) Preschoolers should know their full poisoning of preschool children include:
names, parents’ names, address, and a. Plants should be kept out of children’s reach.
telephone number. b. All medicines, including vitamins, should be
B. Preschool behavior and discipline. kept out of reach and in a locked cabinet.
1. Preschool behavior and discipline. c. All caustic powders and liquids, including
a. Preschoolers understand rules, although they cleaning supplies and gasoline, should be kept
will misbehave occasionally. out of reach and in a locked cabinet.
b. The tantrums of the toddler period fade d. The home should be kept clean of dust and
rapidly in the preschool period. dirt and other potential sources of lead,
c. Parent education. including paint chips.
i. Periods of time out usually work as well in 2. Drowning and near drowning is another possible
the preschool period as they did in the cause of injury and death in preschool children
toddler period. (see also Chapter 10, “Pediatric Emergencies”).
ii. The period of time for time out can be a. High incidence of accidental drownings in
extended to 4 or 5 minutes. preschoolers. They must never be left
C. Health screenings: at each age level, children are unattended around water. Preschool children
assessed for possible diseases or illnesses. If the should still be supervised at all times while in
screenings are positive, an intervention is the bathtub and near a pool or any other large
implemented. (See “Recommendations for Pediatric body of water.
Preventive Health Care” for a complete list of b. Preschool children can and do drown in “kiddy”
procedures.) pools and other shallow bodies of water.
1. Hearing.
a. Audiometric testing should be performed.
! Childproofing must continue in the preschooler’s
household. Even though preschool children appear much
2. Vision.
more reliable than infants and toddlers, they often are not.
a. Eye test should be performed using animal
Parents may supervise their preschoolers less well than they
figures or tumbling E charts.
did when the children were younger because they feel the
b. Glasses should be provided for any deviations
children are more responsible. When childproofing is
from normal.
abandoned, however, many children do become injured.
3. Lead.
a. If child’s behavior indicates, blood lead levels 3. Burn threats.
should be assessed (see Chapter 10, “Pediatric a. Electrical sockets: safety plugs should be
Emergencies,” for additional information on inserted into all sockets.
lead exposure). b. Electrical cords should still be kept out of
4. Cholesterol and tuberculosis screenings should be children’s reach.
performed, if indicated. c. Because preschoolers’ dexterity enables them
D. Immunizations. to light matches, candles, and lighters, those
1. Vaccines due for administration between 4 and 6 items must be kept locked up and out of the
years of age are: children’s reach.
a. Fifth dose of DTaP (diphtheria, tetanus, and 4. Falls.
acellular pertussis). a. Preschoolers are much more capable than
b. Fourth dose of IPV (inactivated polio vaccine). toddlers. As a result, they may fall from high
c. Second dose of MMR (measles, mumps, and places if unsupervised.
rubella vaccine). b. Preschoolers should be watched carefully
d. Second dose of VAR (varicella vaccine). during play on playgrounds and when around
e. Yearly influenza vaccine. such things as ladders.
2. Any recommended vaccines that the child has yet 5. Choking hazards.
to receive should be administered per the a. Preschool children should still have high-risk
Advisory Committee on Immunization Practices’ foods cut into manageable pieces.
catch-up vaccine schedule (www.cdc.gov/ b. Preschoolers should be discouraged from
vaccines/schedules/hcp/index.html). playing while eating.
E. Childproofing issues: preschool children are at 6. If they have not already done so, parents should
especially high risk for accidental injury (see be encouraged to learn or be recertified in
emergency action skills for choking, infant and i. Physically or emotionally abusing a child
child CPR, and first aid. who has yet to be trained can adversely
F. Child abuse issues. affect the child’s current and future
1. Stemming from developmental issues. self-image.
a. Nurses must reinforce the need for parents to c. Nurses must educate parents regarding
understand normal child behavior. normal growth and development,
b. Even though most children will be toilet including:
trained by the time they are preschoolers, i. Psychosocial norms.
many still have daytime accidents, and a ii. Cognitive norms.
number will yet to be fully trained at night. iii. Physiological norms.
1.
2.
3.
4.
5.
1.
2.
3.
4.
Continued
1.
D. What interventions should the nurse plan and/or implement to meet this child’s and her family’s needs?
1.
2.
3.
4.
5.
E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing interventions?
1.
2.
1.
10. The mother of a 5½-year-old child who is 36 inches 11. A nurse is educating the parents of a 4½-year-old
tall and who weighs 42 pounds states that the child child regarding personal safety issues. Which of the
complains every time she attempts to strap her child following statements should the nurse include in the
into the car seat. The nurse searches the Internet and teaching? Select all that apply. The parents should:
finds the specifications of the child’s car seat are as 1. Choose a safety word for the child to remember
follows: in cases of an emergency.
• Maximum weight forward facing: 40 lb 2. Warn the child to report any unfamiliar adult who
• Minimum weight forward facing: 22 lb offers the child candy or toys.
• Maximum weight rear facing: 40 lb 3. Inform the child that it is safe to be alone with
• Minimum weight rear facing: 5 lb any of the parents’ friends or neighbors.
• Maximum height forward facing: 40 in. 4. Advise the child to report any adult who attempts
• Minimum height forward facing: 28 in. to touch the child’s shoulders and back.
Which of the following statements would be 5. Instruct the child regarding the information that
appropriate for the nurse to make at this time? should be given when a 911 call is made.
1. “Because your child is not yet 40 inches tall, the
12. A nurse is educating a group of parents regarding
child should still sit in the car seat.”
disciplinary actions that they can take if their
2. “Because your child is over 40 pounds, the child
preschool child disobeys. Which of the following
should now be sitting in a booster seat.”
recommendations should the nurse make?
3. “The minimum height of 28 inches means that
1. “Up to a 5-minute time out is often very effective
your child would be safer if the child were sitting
when a preschooler disobeys.”
in a booster seat.”
2. “At this age, it is appropriate and effective to
4. “The minimum weight for forward facing is 22
spank the child lightly on the behind.”
pounds, so your child may now sit in a booster
3. “When preschool children disobey, it is very
seat in the car.”
effective to send them to their rooms without
supper.”
4. “An excellent form of punishment when a
preschooler disobeys is to take away the child’s
favorite toy for a few days.”
Client Need: Health Promotion and Maintenance: 2. This response is appropriate. The behavior is normal
Developmental Stages and Transitions and natural, but it is not appropriate to perform in
Cognitive Level: Application public.
3. This statement is inappropriate. Masturbation is a
6. ANSWER: 3 normal, natural act.
Rationale: 4. This statement is inappropriate. Masturbation is a
1. The nurse should not suggest that the mother give the normal, natural act.
child a small present if he goes to bed when he is asked to.
TEST-TAKING TIP: Masturbation is a normal, natural act
2. The nurse should suggest that the child engage in quiet
that is evident throughout childhood and adulthood. It is
play before bedtime.
inappropriate to scold a child or to frighten a child when
3. The nurse should suggest that she develop a bedtime
he or she masturbates. It is appropriate, however, to
routine that is followed every night.
remind a child that private acts should be performed in
4. The nurse should not suggest that the mother let the
private places (i.e., in one’s bedroom).
child stay up late on weekends if he goes to bed on time on
Content Area: Pediatrics—Preschool
weeknights.
Integrated Processes: Nursing Process: Implementation
TEST-TAKING TIP: Just as in the toddler period, routines Client Need: Health Promotion and Maintenance:
help preschool children to know what is expected of Developmental Stages and Transitions
them. Children then are more able to meet those Cognitive Level: Application
expectations. If the child is not always able to go to sleep
at bedtime, he or she can look at books in bed. Children 9. ANSWER: 3
should not have major distractions in their rooms, such as Rationale:
televisions or computers. 1. Children rarely remember their night terrors.
Content Area: Pediatrics—Preschool 2. Night terrors and nightmares are common problems of
Integrated Processes: Nursing Process: Implementation the preschool period. Night lights can reduce children’s fear
Client Need: Health Promotion and Maintenance: of the dark, but they do not prevent night terrors or
Developmental Stages and Transitions nightmares.
Cognitive Level: Application 3. This statement is true. Night terrors usually go away on
their own. It is recommended that parents be available to
7. ANSWER: 1, 3, 4, and 5 their child if he or she does awaken but not to wake the
Rationale: child up themselves.
1. The parents should wait patiently for the child to 4. This child is experiencing a night terror. Children
complete her sentences. usually awaken themselves if they are having a nightmare.
2. The parents should not give the child a treat whenever
TEST-TAKING TIP: Nightmares and night terrors are slightly
she speaks clearly.
different phenomena. When children have a nightmare,
3. The parents should look directly at the child while she
they wake up frightened. Parents should comfort their
is speaking.
child and sit close by until the child settles back to sleep.
4. The parents should respond to the child by speaking
In contrast, night terrors are characterized by crying and
slowly and clearly.
agitation while still asleep. Children usually remain asleep
5. The parents should refrain from making any comments
and calm down spontaneously. It is best not to awaken
about the stuttering.
children from night terrors.
TEST-TAKING TIP: Parents frequently state that their Content Area: Pediatrics—Preschool
preschoolers stutter. However, if the parents respond Integrated Processes: Nursing Process: Implementation
appropriately, the behavior rarely becomes a lifelong Client Need: Health Promotion and Maintenance:
problem. The best way to respond to the child is to bring Developmental Stages and Transitions
as little attention, either verbally or nonverbally, to the Cognitive Level: Application
problem as possible. When parents patiently wait for the
child to speak, the child will be able to organize his or her 10. ANSWER: 2
thoughts and communicate them to the parents. Parents Rationale:
who speak slowly and clearly to their child are role 1. This statement is incorrect. The child has exceeded the
modeling a proper speech pattern for the child. weight limit for the car seat.
Content Area: Pediatrics—Preschool 2. This statement is correct. The child has exceeded the
Integrated Processes: Nursing Process: Implementation; weight limit for the car seat.
Teaching/Learning 3. This statement is incorrect. The minimum height is not
Client Need: Health Promotion and Maintenance: relevant at this time.
Developmental Stages and Transitions 4. This statement is incorrect. The minimum weight is not
Cognitive Level: Application relevant at this time.
TEST-TAKING TIP: The National Highway Traffic Safety
8. ANSWER: 2 Administration recommends that once preschool
Rationale:
children exceed the height and weight limits of their car
1. This statement is inappropriate. Masturbation is a
restraint systems, they should be seated in the back seat
normal, natural act.
of cars in booster seats until shoulder and lap belts fit like. They should be taught a safety word that only they
correctly. and their parents know in case an emergency requires that
Content Area: Child Health someone other than their parents must care for them.
Integrated Processes: Nursing Process: Evaluation They also should be taught when and how to call 911 and
Client Need: Health Promotion and Maintenance: Health how to respond to the emergency operator who answers.
Promotion/Disease Prevention Content Area: Child Health
Cognitive Level: Application Integrated Processes: Nursing Process: Implementation
Client Need: Health Promotion and Maintenance: Health
11. ANSWER: 1, 2, and 5 Promotion/Disease Prevention
Rationale: Cognitive Level: Application
1. This statement is correct. The parents should choose a
safety word for the child to remember in case of an 12. ANSWER: 1
emergency. Rationale:
2. This statement is correct. The parents should warn the 1. This response is correct. Time out is often effective
child to report any unfamiliar adult who offers the child with preschoolers as well as with toddlers.
candy or toys. 2. It is inappropriate to deprive a child of his or her supper.
3. This statement is incorrect. Although it would be 3. Spanking is not the best disciplinary action to use with
inappropriate to advise the child that friends and/or children.
neighbors are dangerous, parents should remember that 4. Because preschoolers are still in Piaget’s preoperational
sexual abuse of children is most commonly performed by stage of cognitive development, this form of discipline is
persons known to the child rather than by strangers. not recommended.
4. This statement is incorrect. The child should be advised TEST-TAKING TIP: Preschool children are unable to
to report any adult who attempts to touch the child’s conceptualize the meaning behind depriving them of a
“private parts.” favorite toy for a number of days. It is much more
5. This statement is correct. The parents should instruct effective to discipline the child immediately after the
the child regarding the information that should be given infraction by giving the child a time out for a few minutes.
when a 911 call is made. Content Area: Pediatrics—Preschool
TEST-TAKING TIP: Preschool children should be taught, in Integrated Processes: Nursing Process: Implementation
a matter of fact way, regarding personal safety. They Client Need: Health Promotion and Maintenance: Health
should be advised to report unwanted touching and Promotion/Disease Prevention
strangers who try to entice them with candy, toys, and the Cognitive Level: Application
59
increasingly expected to use more and more i. Provide appropriate positive reinforcement
sophisticated language. when their child is successful in whatever
B. Psychosocial development. constructive endeavor the child may
1. School-age children are in Erik Erikson’s stage of engage whether that activity be, for
industry versus inferiority. example:
2. Major goal: Achievement in school and in other (1) In an academic setting.
activities, including playing cooperatively with (2) As an athlete.
others. (3) As a musician.
a. School-age children thoroughly enjoy d. It is especially important for parents to work
succeeding at activities. to develop and maintain a strong bond with
i. Every child succeeds at something. their school-age children.
b. Socializing. i. The adolescent years can provide a
i. Parents are still the most important people challenge for any parent-child relationship.
in the lives of school-age children, ii. When parents and children have strong
however: relationships during the school-age period,
ii. Same sex peers and other adults become they will more likely be able to endure the
more and more important. difficult times that lie ahead when the
(1) Group activities (e.g., girl scouts, boy children become adolescents.
scouts, little league) are excellent C. Cognitive development.
activities for children in this age 1. Piaget’s concrete operational stage is reflected
group. in the cognitive development of the school-age
3. Potential problem: feelings of inferiority. child.
a. Develop when a child is unable to achieve or is a. School-age children’s thinking is fairly
criticized for poor performance. sophisticated, but they need to see and feel
b. Children must receive some positive when they are learning about new information
reinforcement for their actions or they will feel in order to truly internalize the information,
inferior. for example:
c. When children feel inferior, they seek i. When learning multiplication, they will
attention in less acceptable ways, for example, more quickly understand that 10 × 10 =
by acting out in school and/or in social 100 when they see 10 groups of 10 blocks
situations. and are able to count, touch, and work
4. Parent education. with the objects.
a. Parents should be encouraged to support their ii. Similarly, when teaching school-age
children’s interests, as long as they are children about an illness in their body,
constructive and physically appropriate, for they will more clearly understand the
example: process if they are provided with pictures,
i. Same-sex group memberships. videos, or replicas of the organs that are
ii. Team sports. adversely affected.
iii. Solitary activities, such as reading and b. During this period, children develop the
painting. ability to understand the concepts of
b. Parents should be forewarned that their reversibility and conservation, for example,
children may try a number of activities before they will learn that:
they find the one(s) that they are most i. 3 + 4 = 7 and 4 + 3 = 7 are the same and
interested in pursuing. that 7 – 3 = 4 and 7 – 4 = 3 are similarly
i. Although economic considerations related.
may preclude children from becoming ii. When an equivalent amount of water is
too choosy, children should not be poured into two glasses, one tall and
reprimanded unnecessarily for changing skinny and one short and wide, even
their minds. though they appear to have different
ii. Parents should encourage their children quantities of water in them, the
to pursue at least one or two aerobic amount of water in each is truly
activities. the same.
c. Because of the potential for children to c. School-age children can organize items into
develop inferior self-concepts, it is important groups, see the logic of jokes, and deduce
for parents to: information from a scenario.
b. It is important to remove televisions, b. Once they reach the height or weight limit,
computers, and other electronic distractions they should be placed in a booster seat in the
from children’s bedrooms. backseat of the car.
i. If a child is not yet ready for sleep at the c. If they outgrow the booster seat, they should
stated bedtime, he or she should be continue to sit in the backseat of the car but
encouraged to read in bed; they should in the adult restraint system.
not be allowed to stay up later than the 2. In and around school buses.
established bedtime or to watch television a. Parents must always wait until the bus is fully
or play on their electronic gadgets. stopped before allowing their children to
C. Play, toys, and leisure activities: play is still part of a approach the school bus.
school-age child’s “work” and should reflect the b. Parents must urge their children to follow the
child’s growth and development. guidance of the school bus driver at all times,
1. School-age children engage in all forms of play, including:
including: i. Crossing the street well in front of the
a. Solitary play, such as video gaming and puzzle bus after the bus has come to a full stop
solving. and the driver has given the child
b. Associative play, such as building with blocks permission.
without a definite goal in mind. ii. Remaining seated at all times while the
c. Cooperative play, such as playing a board bus is moving.
game with another child or playing a iii. Fastening their seat belts, if required.
competitive team sport. iv. Speaking in an acceptable tone of voice
2. A variety of toys and activities are appropriate for while on the bus.
this age group. v. Speaking in a polite manner to
a. Riding toys, such as bikes, skateboards, and the driver as well as to all other
scooters. children.
b. Sports equipment. 3. As pedestrians.
c. Action figures. a. Young, school-age children should be
d. Books for leisure reading. supervised when walking as pedestrians.
e. Board games. b. Once the children are reliable when walking
f. Computer games. alone, or when they have reached an
3. Parent education. appropriate age, they must be reminded
a. When choosing toys and activities for children always to:
from 6 to 12 years of age, parents must i. Walk on the sidewalk or on the left-hand
consider the abilities and interests of the child. side of the road facing traffic.
i. To prevent a feeling of inferiority, parents ii. Cross the road at the crosswalk.
should not provide items that are too far iii. Look both ways before crossing.
beyond the ability of the child. 4. In airplanes.
ii. To prevent an expression of disinterest, a. School-age children should be restrained in
parents should query their children about the same seat belt system as the adults.
which items and activities to which they 5. On bicycles.
are most attracted. a. The bicycle should:
b. When providing children with activities and i. Be sized properly for the child.
toys, the children’s safety must always be ii. Have reflectors on the front and back of
considered (see “Safety”). the bike.
b. The child should wear a properly sized safety
helmet at all times.
V. Nursing Considerations: Disease c. The bicycle should be ridden on the same
Prevention/Parent Education side of the road as the rest of traffic.
d. The child should be taught the proper
A. Safety. use of hand signals in order to signal
1. In cars. his or her intentions when riding on
a. School-age children should continue to travel the road.
in forward-facing seats, in the rear of the car, 6. On in-line skates, skateboards, and scooters.
until they reach the weight or height limit on a. The child should wear reflective clothing
that seat. when riding the device.
b. The item should be ridden in a safe location ii. Children must be warned never to dive
(e.g., many communities have created into shallow water.
skateboard and skating parks). (1) Can result in severe head and/or
c. The child should wear a properly sized safety neck injuries that can result in
helmet, as well as knee, elbow, and wrist paralysis.
pads, at all times. 10. Personal safety.
7. Burn safety and sun exposure (see also Chapter a. School-age children are at risk of personal
3, “Normal Growth and Development: and sexual abuse because:
Toddlerhood”). i. They are often separated from their
a. Sun exposure. parents while traveling to and from
i. Children must be reminded to school, at sports practice, at music
reapply sunscreen at least every lessons, and at many other times.
2 hours and more frequently if they b. Parent education.
become wet. i. Educate the child about appropriate
b. Fire and burns. physical touching and inappropriate
i. Because of their increasing abilities, touching.
school-age children, especially those who ii. Advise child to report any inappropriate
are older, often are asked to assist in such touch to a parent or other trusted adult.
activities as lighting fires and food (1) Child should be reminded that he or
preparation. she will not be blamed for the
(1) Children must be taught regarding inappropriate behavior of the adult.
appropriate safe use of matches, iii. Educate the child never to go with a
stoves, ovens, and grills. stranger unless the stranger uses a
ii. Fireworks. predefined safety word.
(1) The misuse of fireworks can be (1) Remind the child never to divulge
dangerous. the safety word to anyone.
(2) Fireworks, if lawful, should only be 11. Self-care: children.
used in the presence and guidance of a. In many states, there is no law regarding the
an adult. age when a child is old enough to be left
8. Poisonings (see also Chapter 10, “Pediatric alone.
Emergencies”). b. Because of parents’ work obligations and
a. The poison control hotline and other financial constraints, many children, even as
emergency numbers should still be available young as 6 years of age, return from school
by every telephone. to an empty home.
b. The intentional ingestion of poisons, c. There are many potential consequences
including alcohol and prescribed and illicit resulting from children who are home alone.
drugs, becomes a problem starting in the i. Potential positive result.
school-age population. (1) Many children learn to be
c. Parent education. independent and to problem solve.
i. Educate parents to communicate clearly ii. Potential negative results.
to their children that such things as (1) Children can develop a number of
alcohol and medications are not to be fears and can become anxious.
ingested by the children. (2) Because of the lack of supervision,
ii. If needed, all potentially hazardous items they can develop a number of
that may be ingested should be kept in maladaptive behaviors, such as
locked cabinets. smoking, alcohol and drug use, and
9. Near drownings (see also Chapter 10, “Pediatric poor school performance.
Emergencies”). d. Parent education.
a. All children, by the time they are of school i. When it is necessary to leave their
age, should be registered in swim lessons children home unattended, parents
until they are capable swimmers. should be encouraged to develop specific
b. Parent education. strategies to promote positive outcomes,
i. Parents should admonish children never including:
to swim when alone or where there is no (1) Being in frequent contact with the
lifeguard. child, such as via telephone and text.
(2) Insisting that the child complete as electronic communication devices now
much of his or her homework as available, via the Internet.
possible while waiting for the ii. Parent education.
parents’ return. (1) Parents should be encouraged to
(3) Insisting that the child never answer query their children periodically
the door while alone. regarding the children’s relationships,
(4) Insisting that the child have no both positive and negative.
friends in the home while alone. (2) If a child does report being a victim
12. Childproofing issues. of bullying, the parent should:
a. If they have not already done so, parents (a) Immediately report the problem
should be encouraged to learn or be to the school and/or legal
recertified in emergency action skills for authorities, if appropriate.
choking, child CPR, and first aid. (b) Educate the child regarding
13. Child abuse issues. actions that he or she can take in
a. See child abuse information included in response to the bullying (e.g.,
chapters related to children at earlier ages. reporting the episodes to an
14. School phobias and bullying. appropriate adult, avoiding
a. Parents should be forewarned that even contact with the bully when
though school is usually a positive experience possible, clearly telling the
for the child, fostering children’s bully that the behavior is
psychosocial, cognitive, and moral inappropriate).
development, some children find the school B. Behavior and discipline.
experience difficult. 1. All children expect and want limits, but they will
b. School refusal: also called school phobia or misbehave.
school avoidance. 2. Common improper behaviors seen in school-aged
i. When children complain of vague children are disobeying and/or ignoring rules,
symptoms (e.g., stomachaches and stealing, and lying.
headaches that resolve once the parents 3. Parent education.
allow the children to stay home from a. When a school-age child misbehaves, the
school), school refusal should be parent must impose a consequence that is
suspected. equal to the infraction.
ii. Etiologies of school refusal. b. If the parent imposes no consequence, the
(1) Bullying by another student. child becomes confused and never truly learns
(2) Poor school performance. right and wrong.
(3) Boredom. c. Discipline should be directed at the child’s
(4) Fear of teacher. action, not at the child, to prevent the child
(5) Embarrassment, for example, over from developing feelings of inferiority.
how he or she is dressed. C. Health screenings. (See “Recommendations for
c. Parent education. Pediatric Preventive Health Care” for a complete list
i. When school refusal is suspected, parents of procedures.)
should be encouraged to: 1. As discussed in previous chapters, if screenings are
(1) Solicit the assistance of school positive, an intervention should be implemented.
personnel to determine the specific
problem that is leading to the refusal.
(2) Deal with bullying or other MAKING THE CONNECTION
potentially dangerous issues as Examples of disciplinary actions that are equal to the
quickly as possible, if necessary infractions.
(see “Bullying”). • Child steals from a store: parent accompanies the
(3) Inform the child that the parent child to the store and requires the child to return
understands the child’s discomfort. the article to a store employee.
(4) Gently, but firmly, require the child • Child lies about his or her action: parent requires
to attend school. the child to apologize to the individual to whom he
d. Bullying. or she lied and to tell the individual the truth.
i. Children may be victims of bullying by • Child ignores a rule: parent requires the child to go
others who they are in face-to-face without video game playing for 1 full day.
contact with or, because of the many
1.
2.
3.
4.
5.
6.
1.
C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse assign to this client?
1.
D. What interventions should the nurse plan and/or implement to meet this child’s and her family’s needs?
1.
2.
3.
4.
5.
6.
7.
E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing interventions?
1.
2.
3.
4.
F. What physiological characteristics should the child exhibit before being discharged home?
1.
7. A child’s 3rd grade teacher informs the parents, 9. The nurse is providing prehospital admission
“Your child’s handwriting is quite poor. It is education to a 9-year-old child and family.
important that your child practice skills that might Which of the following methods would be most
improve the handwriting.” Which of the following appropriate for the nurse to utilize during the
activities could the parents encourage the child to teaching session?
perform? Select all that apply. 1. Have the child speak with another child who was
1. Throw a ball back and forth recently discharged from the hospital.
2. Begin to play a musical instrument 2. Verbally explain to the child what the child will
3. Build a model of a favorite structure experience while in the hospital.
4. Learn a new and popular dance 3. Play a board game about hospitals and medical
5. Draw or paint a colorful picture procedures with the child.
4. Take the child on a tour of the pediatric unit,
8. The nurse working in a local school district is
and introduce the child to the nurses.
developing the curriculum for a new sex education
program for the 2nd grade students. Which of the 10. During a well-child visit, the nurse asks the parents
following content would be appropriate to include and their 11-year-old child about safety issues. In
in the class? which of the following situations should the nurse
1. External genitalia of males and females provide disease prevention education?
2. List of names of the registered sex offenders 1. When playing in the sun, the child applies
living in the school district sunscreen every 4 hours.
3. Difference between heterosexual contact and 2. When riding in the car, the child sits in the
homosexual contact backseat in a car restraint system.
4. Etiology of human immunodeficiency virus 3. When rollerblading on the driveway, the child
wears body and head protection.
4. When baking something in the oven, the child
wears 2 oven mitts and is assisted by a parent.
73
sex characteristics. In the last year or two of the (2) Stage 5: culminates with appearance
school-age period, many children will enter of facial hair and ejaculation (wet
Tanner stage 2 and, as the child becomes more dreams).
mature, he or she progresses through the 3. Growth charts (see Appendix B).
remaining Tanner stages. a. Accelerated height and weight changes are
a. Stage 1: the pre-pubertal stage. depicted on growth charts.
b. Stage 2: b. Teens usually maintain the same growth
i. Females begin to exhibit breast budding. patterns that they established when they were
ii. Males. younger.
(1) Testicular enlargement begins. 4. BMI assessments: growth charts (see
(2) In addition, breast enlargement may Appendix B).
occur. a. The same BMI criteria are employed
(a) Boys must be advised that the throughout the adolescent period as are
breast changes will recede. employed for younger children.
c. Stages 3 to 5: i. BMI less than 5%: child is defined as
i. Females: stage 5 culminates with ovulation underweight.
and menarche. ii. BMI 5% to 85%: healthy weight for the
(1) Most females grow up to 2 inches after child.
menarche. iii. BMI greater than 85%: child is defined as
ii. Males. overweight.
(1) Stages 3 to 4: occur at the same time iv. BMI greater than 95%: child is defined as
that boys’ voices change. obese.
B. Vital signs: once a child reaches 13 years of age, require more strength than they currently
adult parameters are applied. possess.
1. Temperature. 2. Fine motor development.
a. 98.6°F. a. Adolescents have the fine motor ability to
2. Heart rate. perform any and all fine motor skills.
a. 60 to 100 bpm. b. To perfect skills (e.g., playing of a musical
3. Respiratory rate. instrument, studio arts, knitting and other
a. 15 to 20 rpm. crafts) teenagers must be encouraged to
4. Blood pressure. practice the skills on a daily basis.
a. 90/60 to 120/80 mm Hg.
C. Dentition.
1. Third molars (i.e., wisdom teeth) usually appear,
III. Language and Social Development
if present, between ages 17 and 21.
A. Language development.
a. High incidence of impacted wisdom teeth (i.e.,
1. Adolescents possess the ability to express
teeth that are unable to erupt normally because
themselves well both orally and in a written
there is insufficient room for them in the jaw).
format.
i. Impacted teeth often cause pain, crowd
2. Those who read sophisticated literature possess
adjacent teeth, become infected, and may
a larger vocabulary than those who rely on
result in cyst development within the
television or simple conversation for their
bones of the mouth.
language development.
ii. When wisdom teeth are impacted, they
3. Internet e-mailing, texting, tweeting, and other
are usually removed.
such forms of communication have led many
DID YOU KNOW? teens to use an altered, encrypted language form.
Because they are dependent on the child’s overall a. Although the language form is valued among
health, the method of removal of wisdom teeth, their peers, teens must be reminded that
the place where the removal will occur, the type of Internet language and standard
anesthesia used during the extraction, and other communication are not synonymous.
questions should be thoroughly reviewed and B. Psychosocial development.
discussed with the patient and with the parents. 1. Adolescents are in the Eriksonian stage of identity
versus role confusion.
b. Even when wisdom teeth erupt normally, there
a. During this stage, it is expected that teenagers
is a high incidence of dental caries in the teeth
will develop a true sense of themselves as
because of the difficulty in reaching the area
separate and independent from people such as
with a toothbrush.
friends and parents.
2. Orthodontic work may continue from the
i. Peers are important in the process (e.g.,
school-age period.
adolescents compare and contrast
3. Parent/teen education.
themselves to their peers).
a. Parents and teens must be reminded that
ii. Body image is of particular import to
dental hygiene continues to be important.
teenagers.
b. When adolescents participate in contact sports,
b. The adolescent period often is divided into
they and their parents must be advised to have
three phases.
the teens’ teeth protected by wearing a
i. Early adolescence: period of conformity.
well-fitting mouth guard.
(1) When conformity with peers is a goal:
D. Senses.
(a) Young teens do such things as
1. All senses are fully developed.
dress alike and wear their hair in
E. Motor development.
similar styles.
1. Gross motor development.
a. With the acquisition of increased muscle mass, ! It can be traumatic for teens who feel that they
especially in young men, adolescents are able are unable to conform because they believe that
to perform virtually all gross motor skills, everyone is looking at them and judging them. An
including playing contact sports. inability to conform may be related to a lack of money
i. Teens must be monitored carefully to purchase the latest style clothes, an inability to style
because they are at high risk for soft tissue one’s hair like his or her friends’ hair, or as significant
and orthopedic injuries when they engage as the inability of a gay teen to be attracted to the
in repetitive actions and/or activities that opposite sex.
c. Parents should be encouraged to allow their a. During adolescence, accidental poisonings are
teenagers to “sleep in” on the weekends in replaced by purposeful ingestion of poisons
order to recoup sleep lost during the school (i.e., alcohol, illicit drugs, prescription
week. medications).
C. Physical activity. 3. Swimming and diving accidents.
1. Adolescence is an excellent time for children to a. Often occur when alcohol or drugs have been
engage in physical activities that they may ingested.
continue to pursue throughout their lives, for b. May occur when teens swim in locations
example: where there is no lifeguard.
a. Team sports, such as baseball and basketball. c. Diving into shallow places can result in severe
b. Swimming. head and neck trauma.
c. Golf. d. Parent/adolescent education.
d. Tennis. i. Teens must repeatedly be forewarned
2. Parent/adolescent education. regarding the perils of swimming and/or
a. Adolescents and parents must be reminded of diving in places where there is no
the importance of seeking medical attention supervision.
whenever an injury occurs. ii. Teens must be counseled that engaging in
water play when under the influence of
substances is especially dangerous.
V. Nursing Considerations: Disease 4. Sun exposure.
Prevention/Parent Education a. Tanning beds and tanning studios are quite
popular among adolescents because many
A. Safety. teens believe that a tan improves one’s
1. Car safety. appearance.
a. As a driver. b. Parent/adolescent education.
i. Even if not required by law, all teens i. Frequent application of sunscreen while
should pass a driver’s education program swimming or sunbathing must strongly be
as a means of encouraging safe driving encouraged.
practices. ii. Teens must be counseled regarding the
ii. Seat belts should be worn at all times. dangers of tanning beds and tanning
iii. It is important to note that: studios.
(1) The younger the driver, the more 5. Personal injury.
high risk the teen is of having a car a. Violence is one of the leading causes of death
accident. in teens.
(2) Whenever there is a passenger in the b. The media, including movies, television, and
car with an adolescent, the incidence video games, expose teens to a great deal of
of accidents rises. violence, and that violence is often portrayed
b. As a passenger. as transient.
i. Teens must be taught to refrain from c. Gang membership, which increases markedly
distracting the driver. during the teen years, places adolescents in
ii. Again, safety restraints are important. situations that escalate the likelihood of their
c. Parent/adolescent education. being victims of violence.
i. If the teen is under the influence of d. Suicide is especially prevalent in the teen
alcohol or drugs, the child should know population (see Chapter 24, “Nursing
that the parent would be willing to pick Care of the Child With Psychosocial
the child up. Disorders.”)
(1) This is not the time to teach the teen a e. Parent/adolescent education.
lesson. The child must be transported i. Firearms must be locked up, with
home safely. ammunition locked in a separate location,
(2) Once the child is sober and both the to prevent teens from accessing their
child and parents are in a better state parents’ weapons.
of mind, a discussion of the child’s ii. Peer mediation programs are an important
behavior must take place. method of educating teens how to control
2. Poisonings: see Chapter 24, “Nursing Care of the their behavior and prevent violent
Child With Psychosocial Disorders.” interactions.
iii. Parents and educators must be aware of b. Adolescents must be taught regarding all
behaviors that place children at high risk aspects of sexual health, including:
of personal injury. i. Safe sex practices, including the use of
B. Tattoos (tats) and piercings: tats and piercings are infection control measures.
popular among adolescents. ii. Contraceptive choices.
1. Piercings. iii. Hazards of oral and rectal intercourse as
a. Teens are having many locations of their well as genital penetration.
bodies pierced, including the clitoris, breast, c. All adolescents should be encouraged to
nipple, penis, and scrotum. receive the full three-dose vaccination series
b. If performed under unsanitary conditions, the to prevent the transmission of human
potential exists for the teen to contract papillomavirus.
blood-borne diseases and infections. D. Adolescent behavior and discipline.
c. Unlike tattoos, piercings are removable. 1. Teens are risk takers, and they will misbehave, but
d. Parent/adolescent education. even adolescents expect to have limits placed on
i. Piercings should be performed only by a their behavior.
reputable practitioner who uses sterile 2. Disciplinary practices must be employed
equipment. in light of the fact that teens are developing
ii. Adolescents must be advised that piercings a sense of morality as well as their
take a long time to heal. independence.
(1) Teen must be taught how to cleanse 3. Parents, as well as all other adults who are taking
the piercing using aseptic techniques. responsibility for teens’ behaviors, must
2. Tats: the forced injection of ink into the skin via a continually counsel teens about the potential
needle. consequences of poor choices.
a. Teens are tattooing their bodies in multiple a. One of the best places to have in-depth
locations. discussions with teens is while driving in
b. There are many possible complications that are a car.
associated with tattoos, including infections, i. Teens feel less threatened because the
allergies to the dyes, granulomas developing at discussion is not taking place face to face.
the site of the tattoos, and scarring. Rather, both the adult and the teen are
c. Tats are impossible to remove completely, even facing forward.
with new laser techniques. ii. Teen is unable to leave the discussion
i. The laser therapy, as well as the tattooing because he or she is in a moving
procedure, can be very painful. automobile.
d. If the teen gains or loses weight, the shape of b. Adults must advise teens that there will be
the tat will change. consequences if they misbehave.
e. Parent/adolescent education. i. But, only realistic and enforceable
i. Tattooing should be performed only by a punishments should be established, for
reputable practitioner who uses sterile example:
equipment. (1) Realistic and enforceable punishments:
ii. It is usually required that a person must the teen may not drive the car for
wait a minimum of 1 year to donate blood 1 week or may not go to the party on
after being tattooed. Friday night.
iii. If iron oxide is used as a tattooing agent, it (2) Unrealistic and punitive punishments:
can cause serious injury during an MRI. the teen is grounded for the rest of the
C. Sexual activity: a full discussion of reproductive year or never allowed to associate with
health is beyond the scope of this book. Please refer a friend again.
to a text on women’s health and maternity for a c. One expert on adolescent behavior,
comprehensive discussion of the topic. Michael Nerney (2014), often includes
1. The incidence of sexual activity in adolescents is an excellent framework for monitoring
on the decline but is still an important health teenagers’ behavior called the five A’s
issue. of parenting teens into his lectures
2. Parent/adolescent education. (Box 6.1).
a. By adolescence, children must receive E. Health maintenance. (See “Recommendations for
education regarding their own bodily Pediatric Preventive Health Care” for a complete list
functions and on reproduction. of procedures.)
1.
2.
3.
B. What objective assessments indicate that the client is experiencing a health alteration?
1.
2.
3.
C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse assign to this client?
1.
D. What interventions should the nurse plan and/or implement to meet this child’s and his family’s needs?
1.
2.
3.
4.
E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing interventions?
1.
F. What physiological characteristics should the child exhibit before leaving the clinic?
1.
9. A school nurse is providing an education session for 11. A school nurse is providing an educational session
parents of high school students. Which of the regarding actions parents can take to assess whether
following information should be included in the or not their child is engaging in risk-taking
teaching session? behavior. Which of the following actions should the
1. It is important for teens to catch up on their nurse recommend? Select all that apply.
sleep on weekends. 1. Periodically search their child’s room for illicit
2. Teens are less likely to get into an automobile substances.
accident if others are in the car with them. 2. The morning after a party, ask their child what
3. Adolescents are especially at high risk for drinks and foods were served.
accidental poisonings. 3. Have a conversation with their child when the
4. Tanning beds are safe as long as the child returns home from a date.
adolescent reapplies sunscreen every 4. Before allowing their child to leave for the
ten minutes. evening, know where the child will be.
5. Be alert for changes in the child’s usual behavior,
10. A student informs the school nurse that she is
including a change in friendship groups.
planning to get a tattoo. Which of the following
information should the nurse teach the student
about tattoos?
1. Tattoos are easily removed with lasers and
bleach.
2. The student should request that only blue and
red dye be used.
3. Infections are rare because tattoo needles and
inks are kept hot.
4. Skin lesions may develop where tattoos are
placed.
down into three phases: early, middle, and late. Early Content Area: Adolescent
adolescence is considered the phase of conformity, Integrated Processes: Nursing Process: Implementation;
middle adolescence as the phase of challenge, and late Teaching/Learning
adolescence as the phase of individuality. Client Need: Health Promotion and Maintenance: Health
Content Area: Adolescent Promotion/Disease Prevention
Integrated Processes: Nursing Process: Diagnosis Cognitive Level: Application
Client Need: Health Promotion and Maintenance:
Developmental Stages and Transitions 9. ANSWER: 1
Cognitive Level: Application Rationale:
1. This statement is true. Adolescents are often sleep
7. ANSWER: 2 deprived during the school week.
Rationale: 2. Teens are more likely to get into an automobile
1. The nurse should encourage parents to develop accident if others are in the car with them.
consequences that are reasonable and that are enforceable. 3. Adolescents are at less risk for accidental poisonings
2. The nurse should encourage parents to role model than are younger children. They are, however, at high risk
ethical and moral behavior in their everyday lives. for intentional ingestion of substances (e.g., alcohol, illicit
3. It is not recommended that parents take their child on drugs, prescription drugs).
a trip to the local jail to show what happens when adults 4. It is recommended that sun and ultraviolet light
break the law. exposure be minimized.
4. It is not recommended that parents require their child TEST-TAKING TIP: Teens often stay up late at night but
to sign an honor pledge never to break house rules or to must rise early for school. As a result, they sleep many
break the law. fewer hours than the recommended 8 or more hours
TEST-TAKING TIP: Adolescents are aware of rules and each weeknight. To make up for the lack of sleep, teens
laws and know that they are expected to abide by need to “catch up” on weekends, often sleeping 10 to 12
those restrictions. They challenge those expectations, hours each night. Unfortunately, parents often perceive
however, when they observe their parents and other the long sleep periods as laziness.
adults failing to comply with legal restrictions. When Content Area: Adolescent
parents role model appropriate behavior, they are Integrated Processes: Nursing Process: Implementation;
reinforcing the expectations that they are placing on Teaching/Learning
their children. Client Need: Health Promotion and Maintenance: Health
Content Area: Adolescent Promotion/Disease Prevention
Integrated Processes: Nursing Process: Implementation Cognitive Level: Application
Client Need: Health Promotion and Maintenance:
Developmental Stages and Transitions 10. ANSWER: 4
Cognitive Level: Application Rationale:
1. Tattoos are difficult to remove, even with lasers.
8. ANSWER: 1, 2, and 4 2. It is not necessary for teens to request that only blue
Rationale: and red dye be used, but they should be aware that iron
1. Energy drinks are high in sugar and caffeine. It is oxide can cause serious injury during an MRI.
recommended that teens limit their intake of energy 3. Infections are a common complication from tattooing.
drinks. 4. Granulomas do sometimes develop where tattoos are
2. Vegan diets are low in complete proteins. If teens placed.
choose to follow a vegan diet, they will need professional TEST-TAKING TIP: Tattooing and piercing are popular
assistance to make sure that they consume adequate among adolescents. Teens should be thoroughly
quantities of protein and other nutrients. educated regarding the pros and cons of the actions so
3. Fast foods are high in fat and cholesterol. It is that they can make informed decisions regarding whether
recommended that teens limit their intake of fast foods. or not to have them placed.
4. Sodas are high in sugar and empty calories. It is Content Area: Adolescent
recommended that teens limit their intake of soft Integrated Processes: Nursing Process: Implementation;
drinks. Teaching/Learning
5. Adolescence is a period of rapid growth. Although they Client Need: Health Promotion and Maintenance: Health
need to consume calories for growth, some teens engage Promotion/Disease Prevention
in weight-loss dieting, often because they wish to emulate Cognitive Level: Application
a favored model or actor. .
TEST-TAKING TIP: Because of the rapid growth during
11. ANSWER: 3, 4, and 5
adolescence, teenagers need to maintain an excellent Rationale:
dietary intake. Unfortunately, many teenagers eat poorly. 1. Unless the parents have reason to believe that their
It is important for nurses to encourage parents to child is engaging in risk-taking behavior, it is not
provide their children with easily accessible, nutritious recommended that parents search their child’s room for
foods and snacks. illicit substances.
2. The parent can ask regarding the drinks and foods that TEST-TAKING TIP: Michael Nerney has developed the five
were served at a party, but the conversation should take A’s of parenting: aware, alert, awake, assertive, and
place when the child returns home, not the morning after affirmation. The first four actions increase parents’
the party. attentiveness to their teenagers’ actions. The last action,
3. It is recommended that parents have a conversation repeatedly telling their children that they are loved,
with their child when the child returns home from a helps parents to maintain a bridge between them and
date. their child during the turbulent period of adolescence.
4. It is recommended that parents know where the child Content Area: Adolescent
will be before allowing their child to leave for the Integrated Processes: Nursing Process: Implementation;
evening. Teaching/Learning
5. It is recommended that parents be alert for changes in Client Need: Health Promotion and Maintenance: Health
the child’s usual behavior, including a change in Promotion/Disease Prevention
friendship groups. Cognitive Level: Application
Physical Assessment of
Children: From Infancy
to Adolescence
KEY TERMS
Apex beat—Also called the point of maximum Lordosis—Inward curvature of the lower spine.
impulse (PMI). The location on the chest where the Normotensive—Normal blood pressure.
left ventricular beat is felt most strongly. Nystagmus—Fast, involuntary eye movements.
Crepitus—A cracking or popping sound from the Patency—The quality of being unblocked
joints caused by trapped air. or open.
Head lag—In infants, the drooping of the head Philtrum—The indented segment between the upper
forward or backward from the trunk of the body. lip and the nose.
Hirsutism—Excessive hair growth. Prehypertensive—A condition of elevated blood
Hypotelorism—Narrowly spaced eyes. pressure that may lead to hypertension.
Hypertelorism—Widely spaced eyes. Red reflex—The reddish reflection that occurs when
Inspiratory stridor—A high-pitched wheezing sound light is shined into the retina.
resulting from a blockage in the upper airway. Scoliosis—Condition in which there is lateral
Kyphosis—Curvature of the spine resulting in a curvature of the spine.
slouched or hunchback position. Thrill—Palpable vibration of the heart.
89
Healthy Ill
Skin Color • Pink • Dusky (i.e., grayish coloration, indicates oxygen
depletion)
• Cyanosis indicates marked hypoxemia
Activity Level or • Usually consistent with growth and • Often see behavioral regression, disinterest in
Responsiveness development: toys or other activities, lying still, unexpectedly
Infant: eye contact, attracted by colors, moves napping, etc.
extremities with vigor • If unresponsive to painful stimulus: serious
Toddler and older child: actively playing, talking finding that may indicate:
with parents and/or other children, reading a Serious cardiorespiratory function and neurological
book, etc. deterioration
Posturing • Sitting up • Lying down, hugging parent, etc. (especially if
• Normal posture or other comfortable position toddler or preschooler)
• Tripod posturing or refusing to lie down often
indicates respiratory distress
(2) Conjunctiva.
Box 7.1 Examination of Facial Characteristics
(a) Should appear pink.
• Low-set ears: a sign present in some genetic/chromosomal (b) If reddened or with exudate,
disorders infection is likely present.
• Eye spacing (i.e., widely spaced [hypertelorism] or narrowly (3) Sclerae.
spaced [hypotelorism] eyes): signs seen in some genetic/ (a) Should be whitish in color.
chromosomal and/or congenital disorders
• Size and shape of nose and nasal bridge: deviations of
(b) Yellow appearance may indicate
which are seen in some genetic or chromosomal disorders liver dysfunction.
• Philtrum, the indented segment between the upper lip and (4) Iris and pupils.
the nose, absent or minimal in children with fetal alcohol (a) Should be the same size when
effects not manipulated. If the pupil size
• Lips: should be pink, moist, and without cracking. Thin lips
are seen in children with fetal alcohol effects
is unequal, central nervous
• Symmetry of movements: provides an assessment of cranial system assessment should be
nerve function conducted.
(b) Both pupils should contract and
expand in concert with each
(2) School-age and older children can other when the light from the
use the Snellen chart. ophthalmoscipe is shined into
(3) Child’s peripheral vision should also the eye.
be assessed. (c) The pupils should accommodate
when a moving object (e.g.,
DID YOU KNOW? finger, puppet, toy) is moved
Vision improves from the neonatal period through
from far away to within close
preschool age. As infants, children see clearly about
proximity of the eyes.
8 to 12 in. away from an object. Young children
7. Nose.
normally are hyperopic, or farsighted. Normal
a. Should be inspected for:
20/20 vision should be present by age 5.
i. Open and unblocked nostrils (i.e.,
iii. Color vision. patency of nostrils).
(1) Usually tested when the child is in ii. Presence and characteristics of discharge,
early elementary years using specially if present.
created color images. (1) Glove should be worn for protection.
(2) If unable to see the requisite images, (2) A child who repeatedly wipes the
the child likely has inherited a base of the nose could indicate the
recessive gene on the X-chromosome. presence of a discharge.
Boys are, therefore, more frequently iii. Sense of smell:
affected than are girls. (1) To assess, the child’s eyes should be
iv. Binocular vision. covered and the child should then be
(1) In early infancy, pseudostrabismus asked to sniff and identify a familiar
(i.e., the false appearance of crossed substance (e.g., spice).
eyes resulting from the baby’s weak iv. Characteristics of the nasal passages
musculature) may be present. should be examined with an otoscope.
(2) By 6 months of age, binocular vision (1) May need to be deferred to the end
should be intact, as evidenced by: of the exam because of the intrusive
(a) The light appearing at the same nature of the action.
spot in both eyes when the b. Inspect and palpate sinuses.
ophthalmoscope light is shined i. Inflammation may be present when:
into the eyes. (1) Puffiness and/or redness are
(3) Older children should be able to present.
track a finger, puppet, or other object (2) There are dark circles under the
through all fields of vision with no child’s eyes.
signs of nystagmus (i.e., involuntary 8. Mouth and throat.
eye movement) or other deviations. a. May need to be deferred to the end of the
v. All structures of the eye should be exam because of the intrusive nature of the
inspected. action.
(1) Lids, tear ducts, eyebrows, and eyelids b. The structures should be inspected for:
for symmetry and appearance. i. Frenulum for tongue-tie or injury.
ii. Buccal mucosa for color, injury, or signs ! When examining the tongue, it is wise for the nurse to
of dehydration. hold the child’s cheeks with the fingers and thumb of one
iii. Mouth for presence of odors. hand to prevent being bitten.
iv. Teeth for number and quality.
(1) Number of teeth should be vii. Hard and soft palates.
consistent with the child’s age and (1) Should be inspected for:
overall development (Fig. 7.1). (a) Color.
(2) Cavities may be present, especially if (i) Hard palate: should be
a young child is put to bed with a whitish pink with ridges.
bottle of formula. (ii) Soft palate: usually appears
v. Gums. pinker than the hard
(1) Should be inspected for: palate.
(a) Color: they should be pink. For (b) Shape: should be arched but not
an accurate assessment, peaked.
blanching may be needed in (c) Intact hard and soft palate:
children of color. especially important at delivery.
(b) Any ulcerations, abrasions, or (i) Both the hard and soft palate
other unusual appearance (e.g., should be palpated at birth
Koplik spots in a child with to verify that they are both
rubeola) (see Chapter 11, intact.
“Nursing Care of the Child With (d) Uvula: should move freely and
Infectious Diseases”). elevate slightly when the child
(2) Palpate: gums should feel firm. says, “ah.”
vi. Tongue (and structures under the tongue). viii. Throat and tonsils.
(1) Inspect both the upper and lower (1) Should be inspected with a tongue
aspects for: blade.
(a) Color: should be pink with slight (a) The tongue blade should be
whitish surface. carefully inserted along the side
(b) Intact papillae of the tongue. of the tongue until the nurse is
(c) Any ulcerations or abrasions. able to depress the back of the
(d) Symmetry: by having child stick tongue. At that time, the gag
out his or her tongue. reflex should be elicited.
(2) Palpate the tongue for hard or rigid (b) The size and shape of the tonsils
areas should be noted. Enlarged tonsils
Continued
1.
2.
3.
4.
1.
2.
3.
4.
5.
6.
C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse assign to this client?
1.
D. What interventions should the nurse plan and/or implement to meet this child’s and her family’s needs?
1.
2.
3.
4.
E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing interventions?
1.
2.
3.
4.
5.
F. What physiological characteristics should the child exhibit before being discharged home?
1.
G. What subjective characteristics should the child exhibit before being discharged home?
1.
16 16
7 AGE (MONTHS)
kg lb
12 15 18 21 24 27 30 33 36
14
6 Mother’s Stature Gestational
W Father’s Stature Age: Weeks Comment
E 12
Date Age Weight Length Head Circ.
I 5 Birth
G 10
H
T
4
8
3
6
2
lb kg
Birth 3 6 9
8. A nurse is assessing the weight chart of a boy 18 10. The nurse is assessing the dental development of a
months of age (above). Which of the following 7-month-old child. Which of the following findings
conclusions should the nurse make based on the would the nurse expect to see?
child’s growth pattern? 1. No teeth: drooling and chewing behavior
1. The child’s weight has been consistently below 2. Two teeth: lower incisors
normal. A complete diet history should be 3. Two teeth: upper incisors
obtained. 4. Four teeth: both upper and lower incisors
2. The child’s weight is consistent and within
11. The nurse is preparing to palpate a 2-year-old girl’s
normal limits.
tongue during a physical examination. Which of the
3. The child’s weight is increasing rapidly. A
following actions would help to prevent the nurse
nutrition consult is warranted.
from being bitten?
4. The child’s weight has dropped slightly but is still
1. Have the parent open the girl’s mouth.
within normal range.
2. Ask the child to open her mouth big and wide.
9. The nurse is assessing the accommodation of a 3. Hold the toddler’s cheeks with the fingers of one
child’s eyes. Which of the following techniques hand.
would be appropriate for the nurse to perform? 4. Place a tongue blade in the middle of the tongue.
1. Ask the child to follow the nurse’s fingers in all
six quadrants.
2. Have the child cover one eye and read from a
vision chart.
3. Use an ophthalmoscope to assess for the red
reflex.
4. Move a puppet away from and close into the
child’s field of vision.
12. The nurse is performing a whisper test when 15. The nurse has performed physical assessments on 4
assessing the hearing of a 10-year-old child. Which preschool children who have been referred for
of the following actions would be appropriate for potential genitourinary problems. It would be
the nurse to perform? appropriate for the nurse to report to the primary
1. While assessing the tympanic membrane, ask the health-care provider that which of the children’s
child to whisper the words, “It does not hurt findings is actually within normal limits?
when you do that.” 1. Circumcised male child: soft scrotal sac with no
2. Ask the child to whisper into the nurse’s ear in as palpable masses.
soft a voice as possible. 2. Female child: wide-spread labia majora.
3. Ask the child whether or not he hears his friends 3. Uncircumcised male child: foreskin that resists
when they whisper to him. being retracted.
4. While standing behind the child, whisper “stand 4. Female child: vaginal discharge with fishy odor.
on one leg” and observe to see if the child
16. The nurse is assessing the posture of a 13-month-
performs the command.
old child who has been walking for 1 month. Which
13. While performing a chest assessment on an of the following findings should the nurse
11-month-old child, the nurse palpates for the determine are within normal limits? Select all that
cardiac point of maximum intensity (PMI). The apply.
nurse would expect the PMI to be felt at the: 1. Flat-footedness
1. 3rd intercostal space, to the left of the sternum. 2. Kyphosis
2. 4th intercostal space, lateral to the midclavicular 3. Lordosis
line. 4. Wide, waddling gait
3. 5th intercostal space, at the midclavicular line. 5. Bow-leggedness
4. 6th intercostal space, to the right of the axilla.
17. The nurse is assessing the reflex development of a
14. The abdomen of a 7-year-old child, whose 5-month-old child. Which of the following
percentile weight is slightly lower than percentile rudimentary reflexes would the nurse expect still to
height, is being assessed. Which of the following be present?
findings would the nurse expect to see? 1. Moro
1. Umbilical hernia on inspection 2. Trunk incurvation
2. Liver below the right costal margin on palpation 3. Babinski
3. Aortic pulsations on inspection 4. Grasping
4. Spleen below the left costal margin on palpation
REVIEW ANSWERS nurse. It is best to auscultate the heart, lungs, and bowel
sounds while the child is quiet and sleeping.
1. ANSWER: 1, 3, and 4 Content Area: Child Health
Rationale: Integrated Processes: Nursing Process: Assessment
1. Children often communicate by drawing pictures. Client Need: Health Promotion and Maintenance:
2. A 4½-year-old is too young to be able to write a story. Techniques of Physical Assessment
3. Children often communicate while playing with Cognitive Level: Application
puppets.
4. Children often communicate when they are
4. ANSWER: 1
Rationale:
pretending to be speaking about someone else.
1. When the nurse waits to touch the toddler and
5. Such directed questioning is unlikely to elicit a
speaks directly to the child’s mother, the toddler
response in a young child.
begins to see that the mother trusts the nurse
TEST-TAKING TIP: Young children are wary of
and, therefore, is more likely to begin to trust
communicating with adults they do not know or trust.
the nurse.
Using forms of play, including drawing, puppetry, and
2. Children are often protective of their heads and may be
verbal storytelling, can often elicit responses in
wary of the nurse making direct eye contact immediately
children.
on entering the examination room.
Content Area: Child Health
3. Even though the nurse is smiling broadly, he or she is
Integrated Processes: Nursing Process: Implementation;
making direct contact with the child immediately on
Communication and Documentation
entering the examination room.
Client Need: Psychosocial Integrity: Therapeutic
4. The verbal skills of a 2-year-old usually are not
Communication
developed enough to be able to describe a favorite
Cognitive Level: Application
television show or favorite toy. Also, the nurse is
2. ANSWER: 3 questioning the child directly on entering the examination
Rationale: room.
1. Although this statement might elicit a child’s TEST-TAKING TIP: Toddlers often are the least
cooperation, it is not the best statement for the nurse to cooperative during physical examinations. They are
make. protective of their bodies and wary of strangers. The
2. Although this statement might elicit a child’s nurse allows the child to become familiar with the
cooperation, it is not the best statement for the nurse to surroundings and with the nurse as the nurse has a
make. conversation with the parent, asking questions
3. Asking the child whether he or she would like to hear regarding the child’s health. In this way, the
his or her own heart is an excellent way to get the child’s nurse is more likely to elicit the child’s
cooperation. cooperation.
4. Although this statement might elicit a child’s Content Area: Child Health
cooperation, it is not the best statement for the nurse to Integrated Processes: Nursing Process: Implementation
make. Client Need: Health Promotion and Maintenance:
TEST-TAKING TIP: Although no action is foolproof, Techniques of Physical Assessment
preschool children often want to play with the Cognitive Level: Application
equipment that the nurse is using. Giving the child the
5. ANSWER: 1, 2, 3, and 5
option of listening to his or her own heart with the
Rationale:
stethoscope would provide that opportunity.
1. “Do you have any pets at home?” should be asked.
Content Area: Child Health
2. “Can you tell me how many 1 plus 1 makes?” should be
Integrated Processes: Nursing Process: Assessment
asked.
Client Need: Health Promotion and Maintenance:
3. “Can you tell me the name of 1 of your school friends?”
Techniques of Physical Assessment
should be asked.
Cognitive Level: Application
4. “Can you tell me the names of any medicines that you
3. ANSWER: 2 take?” should be a question directed to the parents.
Rationale: 5. “What kinds of things do you like to play during recess
1. Obtaining an updated history can wait. at school?” should be asked.
2. The nurse should take the opportunity to auscultate TEST-TAKING TIP: The questions that the nurse is asking
the baby’s heart, lungs, and bowel sounds. the child will provide information regarding the child’s
3. The full assessment should wait. progress in school, the child’s environment, the child’s
4. The nurse should take the opportunity to auscultate the social interactions, and the child’s activity level. The
baby’s heart, lungs, and bowel sounds. parent, however, is responsible for medication
TEST-TAKING TIP: An 8-month-old is likely to be administration.
exhibiting signs of stranger anxiety. Once awake, Content Area: Child Health
therefore, he or she will likely cry when touched by the Integrated Processes: Nursing Process: Implementation;
Communication and Documentation
Client Need: Health Promotion and Maintenance: 4. The child’s weight is within normal limits. No special
Techniques of Physical Assessment intervention is needed.
Cognitive Level: Application TEST-TAKING TIP: This child’s weight is consistently at
the 25th percentile. Although the child’s weight is not
6. ANSWER: 1 average, it is consistent over time.
Rationale:
Content Area: Child Health
1. The nurse should immediately notify the primary
Integrated Processes: Nursing Process: Analysis
health-care practitioner of the findings.
Client Need: Health Promotion and Maintenance:
2. The nurse should immediately notify the primary
Techniques of Physical Assessment
health-care practitioner of the findings.
Cognitive Level: Application
3. The nurse should immediately notify the primary
health-care practitioner of the findings. 9. ANSWER: 4
4. The nurse should immediately notify the primary Rationale:
health-care practitioner of the findings. 1. Asking a child to follow fingers in all six quadrants
TEST-TAKING TIP: Bradycardia is an ominous sign in enables the nurse to assess the child’s binocular
children. A heart rate of less than 60 bpm with poor vision.
perfusion would warrant the beginning of chest 2. Having the child cover one eye and read from a vision
compressions. In addition, although this child is exhibiting chart enables the nurse to assess the child’s ability to see
satisfactory perfusion, the child’s blood pressure is low: distances.
9 × 2 + 70 (or 65) = a minimal systolic pressure of 88 (or 3. Using an ophthalmoscope and assessing for the
83). The primary health-care provider should be notified red reflex enables the nurse to assess the health of
of the child’s condition. the retina.
Content Area: Pediatrics 4. Moving a puppet away from and close into the
Integrated Processes: Nursing Process: Implementation child’s field of vision enables the nurse to assess visual
Client Need: Physiological Integrity: Physiological accommodation.
Adaptation: Medical Emergencies TEST-TAKING TIP: The muscles of the iris change when
Cognitive Level: Application the eye accommodates from distance to close vision.
The nurse can assess that change when a child looks at
7. ANSWER: 3 an object that is moving from close up to far from the
Rationale:
child.
1. A child’s behavior is not the best method to determine
Content Area: Child Health
his or her pain level.
Integrated Processes: Nursing Process: Assessment
2. Asking a child a general question regarding the severity
Client Need: Health Promotion and Maintenance:
of the pain is not the best method to determine his or her
Techniques of Physical Assessment
pain level.
Cognitive Level: Application
3. Providing a child with an age-appropriate pain rating
scale is the best method to determine his or her pain 10. ANSWER: 2
level. Rationale:
4. Asking the parent of a child regarding the child’s 1. No teeth, and drooling and chewing behavior usually
pain is not the best method to determine his or her are noted in 5- to 6-month-old babies.
pain level. 2. Two teeth: lower incisors are usually seen at 7 months
TEST-TAKING TIP: Just as when working with adults, of age.
when children use pain scales to rate their pain, the nurse 3. Two teeth: upper incisors usually appear at about 9
obtains an objective determination of the severity of the months of age.
child’s pain. There are pain scales for all age patients, 4. Four teeth: both upper and lower incisors usually are
from nonverbal neonates through to adults. present at 9 months of age.
Content Area: Pediatrics TEST-TAKING TIP: Although tooth development may
Integrated Processes: Nursing Process: Implementation be slightly early or slightly delayed, the progression
Client Need: Health Promotion and Maintenance: of tooth eruption is usually consistent. Also, it is
Techniques of Physical Assessment important for the nurse to educate the parents that
Cognitive Level: Application once the child begins to have teeth, they should be
cleaned each day.
8. ANSWER: 3 Content Area: Child Health
Rationale:
Integrated Processes: Nursing Process: Assessment
1. The child’s weight is within normal limits. No special
Client Need: Health Promotion and Maintenance:
intervention is needed.
Developmental Stages and Transitions
2. The child’s weight is within normal limits. No special
Cognitive Level: Application
intervention is needed.
3. The child’s weight is within normal limits. No special
intervention is needed.
TEST-TAKING TIP: If the test-taker remembers that 3. The Babinski reflex usually disappears at 1 year
the toddler has weak abdominal muscles and large of age.
abdominal organs, it is understandable that the 4. By 5 months of age, the grasp reflex has disappeared.
toddler would be lordotic. The wide, waddling TEST-TAKING TIP: When reflexes last longer than
gait helps toddlers to lower their center of gravity expected, especially the grasp reflex, the child should be
and, therefore, better enable them to walk on assessed for possible illness (e.g., cerebral palsy).
two feet. Content Area: Child Health
Content Area: Child Health Integrated Processes: Nursing Process: Assessment
Integrated Processes: Nursing Process: Assessment Client Need: Health Promotion and Maintenance:
Client Need: Health Promotion and Maintenance: Developmental Stages and Transitions
Developmental Stages and Transitions Cognitive Level: Application
Cognitive Level: Application
17. ANSWER: 3
Rationale:
1. By 5 months of age, the Moro reflex has disappeared.
2. By 5 months of age, the trunk incurvation reflex has
disappeared.
Assent—An implicit or explicit statement that a Protest—One of the three stages of separation in
treatment may be performed. which the child exhibits anger, physically and
Despair—One of the three stages of separation in verbally.
which the child is sad and withdrawn. Therapeutic holding—A form of physical restraint in
Detachment—One of the three stages of separation in which one or more nurses hold a child during a
which the child becomes emotionally separated painful or scary procedure.
from family and friends and becomes resigned to
the separation.
113
a. Children are both emotionally and cognitively ii. Age issues: separation is most difficult for
immature. The stress of illness can be as taxing older infants and toddlers, but all
to the child—both emotionally and children—even adolescents—are stressed
developmentally—as the illness itself. when separated from family and friends.
i. To minimize the stressors of hospitalization iii. Nursing considerations: risk for altered
as much as possible, both the child and the coping.
family members should be carefully (1) Encourage important individuals in
prepared for the experience. the child’s life, such as parents, family
ii. The comprehensiveness and method of the members, close friends, classmates,
preparation is dependent on the severity of and others (e.g., pets), to stay with
the illness, seriousness of the interventions and visit the child as much as possible.
that the child will experience, and the (a) Adolescents often find it difficult
developmental level of the child (see the to ask their parents to stay in the
“Growth and Development” sections for hospital with them. Nurses can
each age level). help teenagers to communicate
(1) Information must be accurate but their need for parental support.
geared to the cognitive level of the (b) When it is impossible for the
recipient. child to have family or friends
(a) Parents often will need much more with him or her at all times,
comprehensive education than is it is important for the nurse to
appropriate for the child. reassure family members that the
b. Separation: when a child must be hospitalized, child will receive the care and
he or she is being cared for in an unfamiliar comfort needed while he or she
environment. The separation from home can is alone.
be frightening. (c) When important individuals must
i. Stages of separation. leave the child, instruct them
(1) Occur when children must be cared never to sneak out while the child
for at a location far from family and is sleeping or to tell the child that
friends. they will return when they are
(2) The longer the separation, the more unable or unwilling to do so.
pronounced the responses seen in (i) The child may feel betrayed
children. by a parent who disappears
(a) Stages of separation (Box 8.1) are while the child is asleep.
seen less frequently today than in (d) Encourage parents to provide the
the past because of the multiple child with his or her cherished,
means of communication that are transition objects.
available (e.g., telephone, Skype, (i) Encourage parents and
FaceTime, Twitter). others to bring in objects to
remind the child of home and
friends.
(ii) Encourage parents and others
Box 8.1 Stages of Separation
to communicate frequently
1. Protest: child is angry and exhibits that anger both with the child using any and
physically and verbally. For example, the child cries, kicks, all forms of communication,
resists being consoled, pulls off bandages, and exhibits including, but not limited to,
other temper tantrum–like behaviors. This protest is most pictures, videos, Skype, phone
dramatically seen in older infants and toddlers. calls, and texts.
2. Despair: child is sad and withdrawn. He or she cries
infrequently, exhibits little interest in play or any activities, (2) Place the child with a roommate of a
is listless, and appears dispirited. similar developmental level and with a
3. Detachment: child becomes emotionally separated from similar illness, for example:
family and friends and resigned to the separation. The (a) If the child is a preschooler who is
child plays with staff, forms relationships with those in the bedbound, the roommate should
health-care facility, and pays little attention to family
and/or friends who do visit the child. also be a preschooler who is
bedbound.
(3) Assign the same nurse to take care of medications, as indicated by the
the child each day as much as possible. rating noted on an age-
c. Loss of control: because the child is in an appropriate pain rating scale.
unfamiliar setting and he or she must follow (b) The nurse must anticipate a child’s
unfamiliar rules and be subjected to prescribed pain needs because:
treatments and procedures, the child will (i) Children fear injections and,
experience a loss of control. therefore, often fail to ask for
i. Children’s responses to the loss of control pain medication.
during illnesses usually are directly related (ii) Children think adults know
to their developmental levels (Table 8.1). when they are in pain and,
d. Bodily injury and pain: Rarely are children therefore, may not ask for
hospitalized and not subjected to painful pain medication.
procedures. (2) Pharmacological pain management.
i. Lack of effective pain management has (a) Age: nurses should respond
crucial consequences for the child. to children in relation to
ii. Nursing considerations: pain/risk for their developmental and
altered coping. chronological age.
(1) Based on their weight and (b) Source of the pain: procedural
recommended dosage levels, children versus physiological in origin.
at all age levels, including infants, (i) If procedural (i.e., pain is
should receive adequate pain occurring because of a
medication, for example: medical procedure):
(a) Children who are postoperative, (I) The child must be told
in sickle cell crisis, immediately beforehand that the
postfracture, or in similar procedure will be
situations should receive narcotic painful.
ii. The nurse must not assume that because a b. Physical restraint must never be used as
child is in a bed that the child is in his or punishment or as a form of discipline.
her bed. c. When a responsible adult is present, restraints
(1) Children may be playing a game and are often not needed.
switching beds. d. Physical restraint is comprised of four main
2. Environmental factors that may pose a possibility categories, all of which may be employed when
of injury. caring for children.
a. Cribs present a distinct fall potential. i. Therapeutic holding.
i. Rails should always be kept up unless an (1) When a painful or scary procedure is
adult is present who is willing and able to being performed, children are often
take responsibility for the child. unable or unwilling to remain still.
b. Windows and elevator shafts pose fall (2) One or more nurses or other health-
potentials. care personnel will assist the child by
i. They should always be kept closed. holding him or her in position.
ii. Cribs should always be placed at a distance (3) No order is required for this action.
from all windows. (4) The mummy hold is one example of
c. Objects left on floors can cause injury. therapeutic holding.
i. Children often walk barefoot. ii. Transportation restraint systems.
3. Small children must have constant supervision (1) As stated above, when transported,
because they often wander into dangerous areas children should always have restraint
or simply get lost. straps fastened to prevent the child
4. Holding and transporting children. from injury.
a. Infants. (2) No order is required for this action.
i. Ideally, infants should always be placed in iii. Procedure restraint systems.
a crib, stroller, or other safe location. (1) When procedures are performed,
ii. If the child is held, either the cradle or the health-care professionals often must
football hold permits the nurse safely to act to protect the site from injury (e.g.,
utilize the other hand for child care. arm boards and padding are applied
b. All children. to prevent infants and toddlers from
i. When a child must be transported, he or removing or dislodging intravenous
she should always be placed in a crib with catheters).
rails up, stroller with straps fastened, (2) No order is required for this action,
stretcher with straps fastened and side rails but the nurse must assess the site
up, or wheel chair with straps fastened. regularly.
5. Physical restraint. iv. Physical restraint devices.
a. To ensure safety of children, restraints are (1) To prevent injury, physical restraint
often used in the pediatric setting. devices (e.g., elbow, jacket, wrist, or
other restraints) may be used in (4) The nurse must assess the restraint site
specific situations (e.g., elbow regularly.
restraints may be applied to an infant (a) Check site distal to the restraint
who is immediately post-op cleft lip for circulatory compromise by
surgery [Fig. 8.1] and jacket restraints assessing capillary refill, color,
[Fig. 8.2] may be applied to a toddler temperature, and movement.
who is in skeletal traction). (b) Assess under the restraint for
(2) The restraint device must be applied signs of altered skin integrity (e.g.,
safely. decubiti).
(3) An order with a rationale for the (c) Assess neurological status distal to
restraint and a time frame for restraint the site by monitoring pain levels
use is required. and movement.
E. Infection control.
1. Standard precautions: in general, nurses in the
pediatric setting follow the same infectious
disease procedures as nurses in other areas of the
hospital.
2. Contact precautions: in some situations, because
of the age of the child, nurses must use more
restrictive precautions than are used in other
hospital areas, for example:
a. Toddler with diarrhea: although an adult with
diarrhea may be maintained on contact
isolation in a multibedded room, to keep a
toddler from having physical contact with a
roommate or a roommate’s items would be
difficult. As a result, it would be more
appropriate to place the child on contact
isolation in a private room.
i. Assent: once a child reaches approximately b. Prior to the procedure, the nurse should check
7 years of age, it has become common that the consent has been signed and
practice to ask him or her to agree with witnessed.
procedures that are to be performed. c. Prior to the procedure, the nurse should make
2. Nursing responsibilities. sure that the parents and child, when
a. The nurse should refer to the laws and appropriate, have had all of their questions
regulations regarding informed consent of the answered.
state in which he or she is employed.
1.
2.
3.
4.
5.
B. What objective assessments indicate that the client is experiencing a health alteration?
1.
2.
3.
4.
1. Physiological diagnosis
2. Psychosocial diagnosis
D. What interventions should the nurse plan and/or implement to meet this child’s and her family’s immediate needs?
1.
2.
3.
4.
5.
6.
7.
8.
E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing interventions?
1.
2.
3.
4.
5.
F. What physiological characteristics should the child exhibit before being discharged home?
1.
2.
G. What psychological characteristics should the child and family exhibit before being discharged home?
1.
2.
7. A nurse has been assigned to care for a 12-year-old 10. A 5-month-old girl’s arms are encased in elbow
child who will likely die from his illness. The child restraints following facial surgery. Which of the
asks the nurse, “Do you think I am going to die?” following situations would warrant removal of the
Which of the following responses would be restraints?
appropriate for the nurse to make? 1. Narcotic medication has been administered, and
1. “Don’t talk like that. You are going to get better the child’s pain rating has dropped.
very soon.” 2. Infant has been put to sleep for the night in her
2. “It would be best if you were to ask your doctor crib lying on her back.
about that.” 3. The infant’s hands are pink with spontaneous
3. “Some children who have been diagnosed with movement and capillary refill of two seconds.
your illness do die.” 4. A responsible adult is holding the baby and
4. “It’s hard for me to talk about death. It would be preventing her from touching the operative site.
best if you were to ask your parents.”
11. A 13-year-old adolescent is in hospital for
8. A 7-year-old child, who must have a lumbar reconstructive surgery after a severe automobile
puncture, begins to cry and squirm when the nurse accident. During rounds, the nurse notes that the
advises him that he must lie curled on his side with teen is watching television and playing a video
his back facing the primary health-care provider. game. Which of the following should the nurse
Which of the following actions should the nurse assess regarding the patient’s well-being? Select all
perform at this time? that apply.
1. Advise the child that he must remain still during 1. Teen’s pain level
the procedure or else he will get injured. 2. How often friends visit the teen
2. Question the parents regarding how to get the 3. Level of healing of the teen’s surgical site
child’s cooperation for the procedure. 4. Teen’s progress on daily homework assignments
3. Request the assistance from another nurse to 5. How well the teen is performing on the video
hold the child still during the procedure. games
4. Tell the child that children who are in
12. The nurse is assessing whether or not an 8-year-old
elementary school are big enough to be still
child has given assent for a scheduled painful
during procedures.
procedure. Which of the following statements by
9. An 18-month-old child has just returned from the the child would reflect that the child has given
operating room with intravenous solution running assent?
into a vein in the right hand, a nasogastric tube in 1. “I know that the procedure is supposed to make
place, and a dressing covering the abdomen. Which me better.”
of the following actions by the nurse would be 2. “The procedure is going to be done at 10 a.m.
appropriate? Select all that apply. this morning.”
1. Administer an NSAID per the health-care 3. “Dr. Jones wants to perform the procedure on
provider’s orders. me.”
2. Place an intake and output sheet at the child’s 4. “My mother signed the form that the doctor
bedside. brought in.”
3. Request an order for an elbow restraint for the
child’s left arm.
4. Assess the child’s pain level using an age-
appropriate pain rating scale.
5. Compare the intravenous solution to the
health-care provider’s orders.
Pediatric Medication
Administration
KEY TERMS
Body surface area (BSA)—A measurement of body Metered dose inhaler (MDI)—A device used to deliver
mass based on the relationship between height and a measured amount of medication into the
weight. respiratory tract.
Daily maintenance volume (DMV)—The minimum Nebulizer—A machine that aerosolizes medication so
amount of fluid a child needs on a daily basis to that the medication can be inhaled into the
maintain his or her optimal health. respiratory tract.
Drop factor—The number of drops in one Nomogram—A tool used to calculate BSA based on
milliliter of fluid, labeled on the packaging the relationship between height and weight.
of IV tubing. Phlebitis—An inflammation of the vein that can be a
EMLA cream—An anesthetic cream (lidocaine 2.5% complication of IV therapy.
and prilocaine 2.5%). Spacer—A device used with an MDI that is employed
IV piggyback (IVPB)—A method of delivering when patients are unable to inhale their medication
medication into an existing IV line. at exactly the same time that the MDI is compressed.
129
1. Dosage units.
MAKING THE CONNECTION
a. The nurse must first determine whether the
To determine whether the BSA or the weight method
medication dose is ordered per kilogram (kg)
of calculating safe pediatric dosages should be used,
or per body surface area (BSA), which is a
the nurse must carefully read the recommended pedi-
measurement of body mass based on the
atric dosage information in a reliable medication
relationship between height and weight.
reference.
b. The nurse must then calculate the dosage that
If, for example, the reference states:
the child can safely receive.
i. The nurse must first consult a pediatric dosage is: 20 mg/m2 (i.e., per meters squared)
pharmacology reference to determine the
The nurse should determine the child’s BSA and calcu-
recommended units per kilogram or BSA.
late the safe dosage using the BSA formula.
ii. Second, the nurse must calculate the safe
However, if, for example, the reference states:
dose for the child.
iii. Finally, the nurse must determine whether pediatric dosage is: 20 mg/kg (i.e., per kilogram)
the primary health-care provider’s order is
The nurse should determine the child’s weight in kilo-
safe or unsafe.
grams and calculate the safe dosage using the weight
! Even though the primary health-care provider formula.
prescribes medications, it is the nurse’s responsibility,
along with the pharmacist, to make sure that the order is
safe. If the nurse were to administer an unsafe medication,
he or she would be responsible for any untoward effects
sustained by the child.
b. Children’s medication dosages are calculated in
2. Factors related to safe medication dosages. one of two ways.
a. Range of safety. i. Per kilogram (kg).
i. When only a maximum safe dosage limit ii. Per BSA (i.e., m2).
is cited in a reference text. c. BSA calculations (see Making the
(1) If a calculated safe dose is higher than Connection).
the primary health-care provider’s i. BSAs are based on the relationship
order, the order is safe. between the child’s height and weight.
(2) If a calculated safe dose is lower than ii. This method is used only when the drug
the primary health-care provider’s reference states that the medication is
order, the order is unsafe. administered per meters squared (i.e.,
ii. When a range of safety with both per m2).
minimum and maximum dosage limits is iii. A child’s BSA is determined by using a
cited in a reference text. nomogram (Fig. 9.1).
(1) The primary health-care provider’s (1) The nomogram is comprised of four
order must be between the minimum columns (the second column from the
and maximum calculated safe dosages. left, with the rectangle surrounding it,
b. Time. should not be used).
i. Both the calculated dosage and the (a) Height column—On the far left,
primary health-care provider’s order must calibrated both in inches and in
be in the same time units before they can centimeters.
be compared. (b) Weight column—On the far right,
c. Dosage units. calibrated both in pounds and
i. Both the calculated dosage and the kilograms.
primary health-care provider’s order must (c) BSA column (labeled S.A. m2) is
be in the same dosage units before they the body surface area column.
can be compared. iv. Procedure (see Box 9.1 for examples).
3. Method for calculating safe pediatric dosages. (1) Using the correct calibration, locate
(For a full discussion on calculating safe pediatric the child’s height on the height
dosages, please refer to a med math text.) column.
a. Recommended dosages are cited in nursing (2) Using the correct calibration, locate
drug handbooks, physicians’ desk references, the child’s weight on the weight
and other reliable medication references. column.
Nomogram
MAKING THE CONNECTION
Height For Children of S.A. Weight
cm in. Normal Height m2 lb kg
for Weight BSA Dosages May Be Calculated Using
Weight
Surface area
in square
Either the Ratio and Proportion or the
in pounds meters
180 80
Dimensional Analysis Method
90
80
1.30 160 70 Basic formula for ratio and proportion method:
1.20 2.0 140
70 1.10 1.9 130 60
240 1.8 120 recommended dosage safe pediatric dosage
90 1.00 1.7 110 50 =
child’s m2 (BSA )
220 60
85 1.6
1.5
100 1 m2
80 .90 90 40
200 50 1.4
75 80
190 .80 1.3
70
Once the calculation has been performed, if the time
180 70 40 1.2 30
170
65 .70 1.1 60 and/or dosage units in the result are different from
25
160
60
1.0
50
those in the order, the nurse must convert the results.
150 30 .60 0.9
140 55 .55
45 20 Formula for dimensional analysis method:
0.8 40
130 .50
50 35 recommended child’s BSA time unit
.45 0.7 15
120 20
45
30 dosage (m2) conversion conversion
110 .40 0.6
25
10
per m2/day (if needed) (if needed)
40 15
100 .35 0.5 20 9.0 = safe pediatric dosage
90 18 8.0
35 .30 16
0.4 7.0
80 10 14
6.0
30 9 .25 12
28 8 5.0
70 0.3
26 7
10 MAKING THE CONNECTION
9 4.0
24 8
60 6 .20
22 7
3.0
Weight Dosages May Be Calculated Using
20
5
0.2 6
2.5
Either the Ratio and Proportion or the
50
19 4 .15 5 Dimensional Analysis Method
18 2.0
17 4
Using the ratio and proportion method, the nurse may
40 16 3
1.5
need to complete a number of steps:
15
14
3 First, the child’s weight (in kilograms) must be
13
.10
0.1
determined.
2 1.0
12
If the child’s weight is cited in pounds (lb), the weight
30
must be converted to kilograms.
Fig 9.1 Nomogram. 1 kg x kg
=
2.2 lb child's weight in pounds
Then, the following formula should be used to calculate
safe pediatric dosage:
(3) Carefully place a straight edge to
connect the two points. recommended dosage safe pediatric dosage
=
(4) Note where the straight edge crosses the 1 kg child’s weight in kilograms
S.A. m2 column. This is the child’s BSA. Once the calculation has been performed, if the time
(a) Note: BSA is always calculated to and/or dosage units in the result are different from
the nearest hundredth (i.e., two those in the order, the nurse must convert the results.
places to the right of the decimal The following formula should be used for the dimen-
point). sional analysis method:
(5) Next, the safe dosage of the desired
medication must be calculated. This recommended child’s weight time unit
can be done using one of two dosage weight conversion conversion conversion
methods—ratio and proportion or per kg/day (if needed) (if needed) (if needed)
= safe pediatric dosage
dimensional analysis.
d. Weight calculations (see Making the
Connection).
i. This method is used only when the drug 4. Volume.
reference states that the medication is a. Once the dosage has been determined, the
administered per kilogram. nurse must calculate how much volume of the
ii. Procedure (see Box 9.2 for examples). medication is equal to the dosage.
b. Depending on the route of administration and a. Having another nurse check the arithmetic or
the form of the medication, the volume may b. If another nurse is unavailable, the same
be in a liquid measurement as numbers of nurse carefully rechecking his or her own
milliliters (mL) or a solid measurement as arithmetic.
numbers of tablets or capsules. B. The five rights of medication administration: prior
5. Finally, the nurse must establish confirmation of to administering any medication, a nurse must
the accuracy of all calculations by: always check the order, the patient’s medical record,
and the patient to determine that the five patient c. Only if the times are the same (within 30
rights have been met. minutes before or after the ordered time) may
the medication be administered.
DID YOU KNOW?
The Institute of Medicine (IOM) has reported that
adverse drug events are a leading cause of patient IV. General Guidelines Regarding
morbidity in the United States. Because nurses Administering Medications to Children
administer the majority of medications in hospitals,
it is reasonable to say that nurses are responsible A. Handwashing should always precede medication
for many of the errors. If nurses faithfully follow administration.
the five rights, they will be much less likely to B. Medication effects.
commit a medication error. 1. Carefully monitor the child for the desired effects.
a. Medications are given to treat a specific
1. Is this the right patient?
medical problem.
a. First, check the patient’s name and hospital
2. Carefully monitor the child for undesired effects.
number on the order sheet and the medication
a. All medications cause side effects, and some
record.
may be life threatening.
b. Next, compare them to the name and
C. Children are not small adults.
hospital number on the patient’s identification
1. Medication dosages must be adjusted according to
bracelet.
a child’s size and metabolism (see earlier).
c. Only if they are all the same may the
a. This consideration is especially important
medication may be administered.
when administering digoxin, insulin, and
2. Is this the right medication?
heparin.
a. First, check the name of the medication on the
2. What is the child’s growth and development?
order sheet and the medication record.
a. Pediatric drug therapy is guided by the child’s
b. Next, compare them to the name on the
age, weight, and level of growth and
medication label.
development.
c. Only if they are all the same may the
b. When appropriate, children should be
medication be administered.
3. Is this the right dosage of the medication? informed regarding why they are receiving
a. First, perform necessary calculations to make medications.
sure that the dosage that is ordered is safe. c. Give honest explanations using language based
b. Second, check the dosage of the medication on on the child’s level of understanding.
the order sheet and the medication record, and
compare them to the dosage on the medication V. Intravenous Infusions
label.
c. Only if the dosages are the same may the A. Inserting intravenous (IV) catheters.
medication be administered. 1. Sites where IVs may be inserted.
d. If the dosages are the not the same, additional a. Most common sites.
calculations must be performed to determine i. Hand, wrist, and antecubital veins.
how much of the medication should be ii. Dorsal foot: for infants who do not yet
administered, and that information must be crawl or walk.
communicated to the primary health-care iii. Scalp veins: for infants because there are
provider. no valves in the vessels, so the catheters
4. Is this the right route? can be inserted in either direction.
a. First, check the route stated on the order sheet 2. Catheter gauge: most commonly 20 to 24 gauge.
and the medication record. 3. Procedure: nurses must be approved before
b. Next, compare them to the form of the inserting IVs in children.
medication that is available. a. Check the five rights of medication
c. Only if the routes are the same may the administration plus:
medication be administered. b. Insert IVs in the treatment room, not in the
5. Is this the right time? child’s bed or in the playroom.
a. First, check the time frame stated on the order c. Obtain all equipment before child enters the
sheet and the medication record. room.
b. Next, compare them to the time when the i. IV catheter.
medication is being poured. ii. IV solution.
4. Procedure: check the five rights of medication f. Alcohol (or Betadine) the injection port (or
administration plus: the saline lock).
a. Check that the medication may be g. Attach the piggyback set to the primary line
administered via IV push. (or the saline lock).
b. Check compatibility of the medication with h. Gently mix the medication with the diluent
the IV solution. (either in new IV bag or in a volume-control
c. Calculate the safe dosage for the child and device).
compare with the order. i. Either set the infusion pump to the rate for the
d. Wash hands. infusion or manually adjust the rate for the
e. Assure the child that the procedure is piggyback infusion.
painless. j. After infusing, restart the IV infusion per
f. Assess the IV to make sure that the protocol.
catheter is patent (or flush as per hospital k. Document on both the MAR and on the
protocol). intake and output sheet.
g. Clamp the IV tubing above the injection port l. Monitor the child for physiological
that lies closest to the child. responses.
h. Alcohol (or Betadine) the injection port.
i. Attach the syringe to the port and administer VII. Administering Blood Products
at the recommended rate for that medication.
j. After infusing, remove the syringe, and clean A. Important considerations.
the port again with alcohol or Betadine. 1. Educate parents and child, using age-appropriate
k. Document on both the medication language, regarding the rationale for the
administration record (MAR) and on the transfusion.
child’s intake and output sheet. 2. Packed red blood cells usually are administered to
l. Monitor the child for physiological responses. children to prevent fluid overload.
3. Blood products should only be administered
VI. Administering IV Piggyback Medications piggyback with normal saline and through a
filter.
A. IV piggyback medications are delivered into an a. Small clots are captured by the filter in the IV
existing IV line. tubing.
1. Check important considerations from earlier plus: b. Dextrose solutions are contraindicated when
a. Recommended dilution amounts and infusing blood because blood hemolyzes when
recommended infusion rates for the exposed to dextrose.
medications. 4. Infants under 4 months of age need only one type
b. Compare the dilution amounts and infusion and cross match because they rarely develop
rates with the fluid volume that the child can antibodies.
safely receive. 5. Blood products should infuse over no more than
c. Administer via pump, if at all possible. 4 hr.
i. Only if no pump is available, administer via
volume-controlled device (e.g., Soluset,
Buretrol). MAKING THE CONNECTION
ii. In some institutions, syringe pumps are The process of blood administration is even more sensi-
used to administer IV medications. tive than is medication administration. Because of the
2. Procedure: check the five rights of medication possibility of blood incompatibility, it is essential that
administration plus: two professionals—either two nurses, two doctors, or
a. Calculate safe dosage for child and compare one nurse and one doctor—carefully check to make
with the order. sure that the correct patient is receiving the correct
b. Wash hands. blood product. In addition:
c. Draw up the prescribed medication and assess • Because of the potential for thrombi to be present
compatibilities. in the blood, it is essential that only tubing with a
d. Assure the child that the procedure is filter be used for the transfusion, and,
painless. • Because blood hemolyzes when exposed to
e. Assess IV flow (or flush as per hospital dextrose, it is essential that only normal saline
protocol) to make sure that the catheter is solutions be administered with blood products.
patent.
6. Because of the potential for serious transfusion iii. Send samples of the child’s urine and
reactions, all hospitals have protocols for blood to the blood bank.
identifying and verifying—with another RN or an iv. Monitor urine output hourly.
MD—that the blood being administered is i. After the transfusion, document per hospital
correct. protocol.
7. If the blood is very cold, it could affect the child’s j. Praise both the child and the parents.
core temperature. A blood warmer may be
needed. VIII. Administering Oral Medications
B. Administration.
1. Procedure: check the five rights of medication A. The oral (PO) route is the preferred route for most
administration plus: pediatric medications, however:
a. Identify the child, and verify the blood data 1. It should not be used if the child is vomiting, has
per hospital protocol. malabsorption syndrome, or refuses to swallow
b. Wash hands. the medication.
c. Ideally begin infusing blood within 15 min of B. Important considerations.
its arrival on the unit. 1. For children under 5 years of age, as well as some
i. The blood should not be infused if it has older children, who are unable to swallow tablets:
been over 30 min since its arrival on the a. Give liquid or a chewable form of the
unit. medication. The nurse should ask for an order
d. Vital signs. change, if needed.
i. Assess before administration. b. Only well-calibrated instruments should be
ii. After the transfusion is begun, monitor used to measure the medication, for example:
vitals every 15 min for 2 hr and every i. Oral syringes and medication cups rather
30 min until fully infused. than household teaspoons or tablespoons.
e. Rate. c. Divide scored tablets.
i. Some pumps can injure the cells in the d. Crush tablets only after a reliable source has
blood. Only infuse with an infusion pump been consulted to determine whether crushing
if it is identified as safe for the is contraindicated or not.
administration of blood. e. Empty and mix medication in capsules with
ii. Infuse slowly for first 15 min and monitor food or liquid only after a reliable source has
carefully for transfusion reactions. been consulted to determine whether
iii. Then shift to ordered rate. emptying is contraindicated.
f. Monitor child closely for transfusion 2. To dull the unpleasant taste of PO meds:
reactions. a. Mix distasteful medications or crushed tablets
i. Repeatedly assess lung fields of infants and with a small amount of applesauce, juice, or
toddlers throughout the transfusion gelatin.
period because of their poor i. Five to 10 mL only because larger
communication skills. quantities may be rejected.
ii. Closely monitor the child’s serum glucose ii. Honey should never be given to children
levels. under 1 year of age because the child may
(1) Children may become hypoglycemic develop infantile botulism.
after the dextrose infusion is iii. It is important to avoid using essential
stopped. foods, such as milk and formula, to
g. Advise parents and child, if appropriate, disguise the flavor of a medication because
immediately to report: the child may refuse to consume those
i. Chills. items in the future.
ii. Headache. b. Or, give the child something such as
iii. Nausea. a sip of fruit juice, a peppermint, or
iv. Pain, especially back or flank pain. a few ice chips before and after the
v. Difficulty breathing. medication.
vi. Bloody urine. 3. Be prepared for all types of reactions when
h. If a transfusion reaction occurs: administering medications.
i. Stop the transfusion immediately. a. Children are unpredictable!
ii. Notify the primary health-care provider, 4. Never threaten a child with an injection if he or
and continue to monitor vital signs. she refuses an oral medication.
Location of
gluteus medius
Injection point
(between the knuckle Clavicle
of the index finger &
middle finger) Acromion process
Scapula
Greater trochanter
Deltoid muscle
Axilla
Humerus
Deep brachial artery
Radial nerve
Vital Signs
Temperature: 103.8 ˚F
Heart rate: 124 bpm
Respiratory rate: 26 rpm
Blood pressure: 98/58 mm Hg
Lab Results
Lumbar Puncture
Pressure: 23 cm H2O (normal less than
20 cm H2O)
Color: cloudy (normal clear)
Blood: none (normal none)
White blood cells: 15 cells/microliter (normal 0–5
cells/microliter)
• Predominantly neutrophils
Culture: N. meningitides (normal none)
Protein: 80 mg/dL (normal up to 70 mg/dL)
Glucose: 18 mg/dL (normal 50–75 mg/dL)
Complete Blood Count
Red blood cell count: 5.5 million/mm3
Hemoglobin: 14 g/dL
Hematocrit: 42%
White blood cell count: 25,000/mm3
Platelet count 225,000/mm3
Urine: within normal limits
1.
2.
3.
4.
B. What objective assessments indicate that the client is experiencing a health alteration?
1.
2.
3.
4.
5.
6.
C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse assign to this client?
1.
D. What interventions should the nurse plan and/or implement to meet this child’s and his family’s needs?
1.
2.
3.
4.
5.
6.
E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing interventions?
1.
2.
3.
4.
F. What physiological characteristics should the child exhibit before being discharged home?
1.
2.
3.
G. What subjective characteristics should the child exhibit before being discharged home?
1.
9. A toddler is to receive a medication to take at home The following nomogram is available to answer all
that is administered via a metered dose inhaler relevant questions:
(MDI). Which of the following information should
10. A doctor is ordering a medication for a child who
the nurse include in the patient teaching regarding
weighs 26 lb and who is 43 in. tall. A reliable
the medication?
medication reference states that the recommended
1. The parent should attach a spacer onto the
pediatric dosage is 50 to 60 mg/kg/day in divided
mouthpiece of the MDI.
doses every 6 hr. Which of the following medication
2. The parent should position the child supine
orders is safe for the child?
while the medication is administered.
1. 100 mg every 6 hr
3. The parent should have the child inhale right
2. 150 mg every 6 hr
before the medication is administered.
3. 200 mg every 6 hr
4. The parent should place the face mask on the
4. 250 mg every 6 hr
child and attach it to the MDI.
Nomogram
11. A doctor is ordering a medication for a child who 15. A primary health-care provider has ordered a
weighs 15.2 kg and who is 112 cm tall. A reliable medication for a child—16 kg and 132 cm. A
medication reference states the recommended reliable medication reference states the safe
pediatric dosage is 10 to 20 mg/m2/day in 2 equal pediatric dosage is 250 mg/m2/day divided every
doses. Which of the following medication orders is 8 hr. Please calculate the maximum safe dosage of
safe for the child? the medication for this child. If rounding is needed,
1. 5 mg every 12 hr please round to the nearest hundredth.
2. 8 mg every 12 hr
mg every 8 hr
3. 10 mg every 12 hr
4. 13 mg every 12 hr
16. A primary health-care provider has ordered a
12. A primary health-care provider orders a medication for a child: 250 mcg PO every 4 hr. The
maintenance intravenous fluid volume of 2,500 mL medication is only available on the unit in scored
per day for a school-age child who weighs 82 lb and tablets: 0.125 mg. How much medication should the
is 5 ft 2 in. tall. The nurse caring for the child nurse administer per dose? If rounding is needed,
determines that which of the following responses is please round to the nearest tenth.
correct?
tablets every 4 hr
1. The order is safe, and the infusion pump should
be set at 100 mL/hr.
17. A primary health-care provider has ordered a
2. The order is safe, and the infusion pump should
medication for an infant: 250 mg PO every 4 hr.
be set at 118 mL/hr.
The solution is available on the unit in the following
3. The order is unsafe, and the correct volume
concentration: 500 mg/5 mL. How much
should be 1,575 mL per day.
medication should the nurse administer per dose? If
4. The order is unsafe, and the correct volume
rounding is needed, please round to the nearest
should be 1,845 mL per day.
tenth.
13. A primary health-care provider has ordered a safe
mL every 4 hr
volume—720 mL/day—of intravenous fluid for a
child. There is no pump available on the unit. Please
determine the drip rate using microdrip tubing. If
rounding is needed, please round to the nearest
whole number.
gtt/min
REVIEW ANSWERS TEST-TAKING TIP: The nurse could actually cause an eye
infection if he or she administered an ophthalmic
1. ANSWER: 4 medication that had been contaminated during a
Rationale: previous administration.
1. Although the medication would safely be administered, Content Area: Pediatrics
this does not meet the toddler’s need for autonomy. Integrated Processes: Nursing Process: Implementation
2. Although the medication would safely be administered, Client Need: Physiological Integrity: Pharmacological and
this does not meet the toddler’s need for autonomy. Parenteral Therapies: Medication Administration
3. Although the nurse has met the toddler’s need for Cognitive Level: Application
autonomy, a teaspoon is not a reliable measurement
instrument.
4. ANSWER: 4
Rationale:
4. This method would meet the toddler’s need for
1. This statement is not appropriate. The child has
autonomy, and the measurement tool is reliable.
indicated that he or she is unable to swallow tablets.
TEST-TAKING TIP: When administering medications, it is
2. This statement is not appropriate. Not only has the
essential that the nurse use a reliable measurement
child indicated that he or she is unable to swallow tablets,
instrument in order to provide the correct dosage. In
but also the nurse is intimating that the child is not
addition, the nurse should consider the child’s level of
performing at his or her level of growth and development.
growth and development.
3. This action is not appropriate. Medications should not
Content Area: Pediatrics—Toddler
be mixed with large quantities of juice or other
Integrated Processes: Nursing Process: Implementation
substances. The child will likely not finish all of the juice
Client Need: Physiological Integrity: Pharmacological and
and, therefore, not receive the full dose of the medication.
Parenteral Therapies: Medication Administration
4. This action is appropriate. School-age children who
Cognitive Level: Application
are unable to swallow medications would be able to
2. ANSWER: 2 consume a chewable tablet.
Rationale: TEST-TAKING TIP: When administering medications to
1. The medication should be warmed to room children, nurses should employ the procedure that will
temperature, but it would be unsafe to warm it in the result in the safe administration of the medication while
microwave. meeting the child’s needs. Chewable medications enable
2. This statement is correct. The nurse should pull the children who are unable to swallow pills safely to take
pinna of the ear up and back. oral medications.
3. The nurse should rub the area in front of the ear after Content Area: Pediatrics—School Age
administering the medication. Integrated Processes: Nursing Process: Implementation
4. The child should lie on the unaffected side for a few Client Need: Physiological Integrity: Pharmacological and
minutes after administering the medication. Parenteral Therapies: Medication Administration
TEST-TAKING TIP: Because the anatomy of the ear Cognitive Level: Application
changes as the child grows the nurse should pull the
5. ANSWER: 1, 2, and 4
pinna of the ear down and back until the child reaches 3
Rationale:
years of age. When the child is over 3 years, the pinna of
1. Filtered tubing must be used when infusing a blood
the ear should be pulled up and back.
product.
Content Area: Pediatrics—School Age
2. A full set of vital signs should be taken every 15 min
Integrated Processes: Nursing Process: Implementation
for 2 hr.
Client Need: Physiological Integrity: Pharmacological and
3. A blood infusion should be stopped after it has been
Parenteral Therapies: Medication Administration
hanging for 4 hr.
Cognitive Level: Application
4. This statement is correct. The nurse should identify
3. ANSWER: 2 the child and verify the blood data either with another
Rationale: nurse or with a physician.
1. An ophthalmic medication container should never 5. The main IV line should be normal saline with no
touch the patient. If it does, it is considered contaminated. dextrose.
2. This is a correct statement. Eye drop medication TEST-TAKING TIP: It is critical that nurses follow all
should be inserted before ophthalmic ointments. safety precautions when administering blood products.
3. The medications should be administered into the To ensure that the patient is receiving blood that is
conjunctival pocket formed when the lower lid is compatible to his or her blood type, protocols require
depressed. that two professionals check all identifying indicators.
4. The medications should be administered into the Filtered tubing must be used to make sure that no
conjunctival pocket formed when the lower lid is thrombi enter into the patient’s bloodstream. Vital signs
depressed. are monitored carefully in order to detect a transfusion
reaction as quickly as possible. Blood hemolyzes when
exposed to a dextrose solution. Only normal saline
should be used when hanging blood.
Convert 26 lb to kg: 26/2.2 = 11.82 Calculate the maximum safe amount per dose.
Calculate the maximum safe dose per day. 13.6/2 (2 doses per day) = 6.8 mg
709.2/4 (4 doses per day) = 177.3 mg Calculate the minimum safe amount per dose.
Calculate the minimum safe dose per day. 6.8/2 (2 doses per day) = 3.4 mg
20 mg/1 m2 = x mg/0.68 m2
x = 13.6 mg
Each time the medication is administered, the nurse Each time the medication is administered, the nurse
should give the child two tablets. should give the child 2.5 mL of the medicine.
Note: Although the last statement in the question is “If Content Area: Pediatrics
rounding is needed, please round to the nearest tenth” Integrated Processes: Nursing Process: Dosage Calculation
the answers do not include a trailing zero, or 2.0 tablets. Client Need: Physiological Integrity: Pharmacological and
The Joint Commission has noted, to prevent errors, Parenteral Therapies: Medication Administration
trailing zeroes should not be included in medication Cognitive Level: Synthesis
orders or calculations.
Content Area: Pediatrics
Integrated Processes: Nursing Process: Dosage Calculation
Client Need: Physiological Integrity: Pharmacological and
Parenteral Therapies: Medication Administration
Cognitive Level: Synthesis
500x = 250 × 5
500x = 1250
x = 2.5 mL
Pediatric Emergencies
KEY TERMS
Automated external defibrillator (AED)—A portable Hypovolemic shock—A condition resulting from
device used to diagnose arrhythmias and treat the excessive blood or fluid loss, in which the heart is
patient with electrical therapy. unable to pump enough blood to the body.
CAB—The acronym for CPR intervention, which Pica—The ingestion of nonfood substances, such as
stands for chest compression, airway, breathing. dirt.
Chelation therapy—The administration of a Trauma—A major, potentially life-threatening injury to
medication to remove heavy metals from the body. the body.
Distributive shock—Reduced circulatory perfusion to Waddell’s triad—Three distinct traumatic injuries
the vital organs and the periphery, commonly sustained by pedestrian children who are hit by a
caused by a massive infection, anaphylaxis, or drug car, consisting of abdominal injuries from the
overdose. initial strike, injuries to the extremities from
Extracorporeal membrane oxygenation (ECMO)— contact with the ground after being thrown into the
Treatment similar to cardiopulmonary bypass, air, and head injuries that occur when the child
usually only used as treatment for infants and lands on his or her head after being thrown.
young children.
157
i. The nurse should pat the child and ask the b. If no one is available to assist, the nurse should
child if he or she is okay. Adding the child’s care for the child for 2 full minutes, then leave
name, if it is known, may improve the the child and go to call for emergency
possibility of the child responding. personnel (e.g., call 911).
ii. When attempting to arouse the child, the 4. Assess for breathing.
nurse should be careful not to cause a. The nurse must next determine whether the
additional injury. In the case of a fall, for child is breathing. A head tilt may need to be
example, the neck should not be moved, if performed in order to open the child’s airway.
possible, to prevent injury to the spinal i. If the child is not breathing at all or is only
cord. gasping for breath, the nurse should assume
3. Get help. that the child is in need of resuscitation.
a. If the child fails to respond, the nurse should 5. Assess for a pulse: this procedure should take
assume the worst and should shout “Help!” to no longer than 10 sec.
attract the attention of others who can assist in a. This procedure differs depending on the age of
the care of the child. the child.
(b) Only if the item is seen in the thrust upward in sets of five
mouth should the nurse attempt thrusts until the object is
to remove the item by inserting a expelled or until the child
pinky finger and using it to clear becomes unresponsiveness
the object. and CPR is needed.
(c) Once the item appears to be B. Secondary assessment: when the child is breathing
dislodged, rescue breaths should and his or her heart is beating normally, the nurse
be performed. should take a full history and perform a head-to-toe
(d) If the infant should become assessment, as needed.
unresponsive, CPR should be 1. To remember all items that should be covered in
started. the secondary assessment, the acronym SAMPLE
(2) In all children over the age of 1, the should be used (Box 10.1).
Heimlich maneuver, or abdominal
thrusts, should be performed III. Obstructed Airway
(Fig. 10.3).
(a) The nurse should: It is not uncommon for children to experience an
(i) Stand (or kneel) behind the obstructed airway. Children, who already have narrow
child. tracheas, frequently move and play while eating snacks
(ii) Make a fist with one hand. and insert objects into their mouths that should not be
(iii) Wrap his or her arms around placed there. Because it is essential that the airway be
the child and place the fist on patent for gas exchange to take place, immediate interven-
the child’s abdomen just tion is needed.
below the rib cage. A. Incidence.
(iv) Cover the fist with the 1. Most commonly seen in children under 5 years of
second hand and repeatedly age (greater than 90% of cases).
2. Risk for Injury related to chelation therapy. they delay the administration of rescue breaths
a. Monitor laboratory values carefully, including and, if needed, cardiac compressions.
BLLs and renal function tests. F. Nursing considerations.
b. Monitor for central nervous system changes, 1. At the time of the drowning.
including Glasgow assessments. a. Impaired Gas Exchange/Impaired Breathing
c. Monitor strict intake and output. Pattern.
3. Risk for Impaired Coping/Anxiety/Guilt. i. Rescue breathing and CPR should be
a. Allow the parents and child to express performed, as needed.
concerns and fears. ii. When appropriate, parents should be
b. Allow the parents to ask important questions allowed to be present during resuscitation.
regarding prevention and treatment strategies. 2. Following resuscitation.
c. Educate the parents regarding the reason for a. Risk for Hypothermia.
administering chelating agents, if needed. i. Core temperature should be monitored
carefully.
VIII. Drowning ii. Wet clothing should be removed and warm
blankets provided.
A. Incidence. iii. Warmed IV fluid should be administered,
1. Drowning is the number one cause of death by as needed.
injury for children aged 1 to 4. b. Risk for Deficient Fluid Volume.
B. Etiology. i. Vital signs and fluid and electrolyte
1. Children can drown in any large body of water, balance should be monitored carefully.
including pools, lakes, and creeks, or in relatively ii. IV fluids should be administered, per
small bodies of water, including bath tubs, toilets, order.
and mop buckets. iii. Intake and output should be monitored
C. Pathophysiology. carefully.
1. When children are submerged, they try to hold c. Risk for Injury/Altered Growth and
their breath. Development.
2. Eventually, they swallow the water, which results i. Cardiac and oxygenation status should be
in a choking bronchospasm. monitored carefully.
3. The bronchospasm results either in: ii. Oxygen should be administered, per
a. Inhalation of water or order.
b. Laryngospasm leading to “dry drowning.” iii. Level of consciousness should be assessed,
4. Signs and symptoms. using the Glasgow scale.
a. Dependent on the age of the child, iv. The child should be carefully monitored
temperature of the liquid, and the length of for signs of increased intracranial pressure
time submerged. (see Chapter 22, “Nursing Care of the
b. Signs and symptoms range from mild Child With Neurological Problems”).
hypothermia and slight dyspnea to full v. Head of bed should be elevated 20 to 30
cardiopulmonary collapse. degrees.
D. Diagnosis. vi. The child should be monitored for altered
1. Clinical picture. cognitive function.
E. Treatment. 3. Following resuscitation and/or if the child dies.
1. Prevention. a. Risk for Altered Coping/Anxiety/Guilt.
a. Water safety education is essential! All i. Parents should be provided opportunities
children, ideally beginning in the preschool to express fears and guilt.
period, should complete swim lessons. ii. Parents should be given clear, accurate
b. Young children should never be left explanations of the interventions, including
unattended in bath water, near water buckets, the rationales for treatments.
near toilets, near any outdoor body of water, or iii. Health-care practitioners should provide
any other potential drowning hazard. the parents with honest information
2. Emergency intervention (see earlier). regarding the child’s status.
a. Airway obstruction protocols should not be b. Grieving/Risk for Complicated Grieving
performed with drowning victims because (Box 10.2).
1.
2.
3.
4.
1.
2.
3.
4.
C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse assign to this client?
1.
D. What interventions should the nurse plan and/or implement to meet this child’s and his family’s needs?
1.
2.
3.
4.
5.
6.
7.
8.
9.
Continued
1.
2.
3.
4.
5.
6.
7.
8.
F. What physiological characteristics should the child exhibit before being discharged home?
1.
2.
3.
10. A nurse working in a preschool discovers that a 13. A child is receiving IV calcium disodium versenate
2½-year-old child has drunk a bottle of red paint. (CaNa2EDTA). For which of the following serious
Place the following nursing actions in the correct side effects should the child be monitored? Select
order of priority. all that apply.
1. Notify the child’s parents. 1. Seizures
2. Question the child’s teacher regarding the 2. Hypertension
incident. 3. Hyperglycemia
3. Call the poison control center. 4. Hypercalcemia
4. Assess the child for adverse effects from the 5. Elevated serum creatinine
ingestion.
14. A 3-year-old child’s blood lead level measures
11. A 2-year-old child’s blood lead level is 4 micrograms 12 micrograms/dL. The nurse would expect the child
per dL. Based on the data, which of the following to exhibit which of the following signs/symptoms?
actions should the nurse take? 1. Hyponatremia
1. Notify the department of health regarding the 2. Polycythemia
value. 3. Aggression
2. Recommend to the primary health-care provider 4. Polyphagia
that the child receive chelation therapy.
15. A nurse discovers an 8-month-old child face down
3. Educate the child’s teacher regarding ways to
in a puddle of water. The child is not breathing and
prevent another incident.
has no pulse. Which of the following actions should
4. Remind the parents of the importance of
the nurse perform at this time?
frequently washing their child’s hands, especially
1. 5 back slaps followed by 5 cardiac compressions
prior to eating.
2. 30 cardiac compressions followed by 2 rescue
12. A child is receiving oral Chemet (succimer) for a breaths
BLL of 48 micrograms/dL. For which of the 3. A series of rescue breaths every 3 to 5 seconds
following side effects should the child be 4. Call 911 to activate the emergency response
monitored? team.
1. White blood cell count below 5,000 cells/mm3
2. Platelet count below 400,000 cells/mm3
3. Serum potassium above 3.5 mEq/L
4. Serum sodium above 135 mEq/L
TEST-TAKING TIP: To determine whether an injured child TEST-TAKING TIP: Activated charcoal is administered to
needs immediate medical attention, it is important for a absorb an ingested poison from the gastrointestinal tract.
nurse to ask a number of important questions. The The charcoal also, however, absorbs large quantities of
acronym SAMPLE will help the nurse to remember which fluid from the tract. As a result, constipation is a
questions should be asked. common side effect of the therapy.
Content Area: Pediatrics Content Area: Poisoning
Integrated Processes: Nursing Process: Implementation Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Physiological Client Need: Physiological Integrity: Physiological
Adaptation: Medical Emergencies Adaptation: Medical Emergencies
Cognitive Level: Application Cognitive Level: Application
Active immunity—The body’s production of memory Systemic lupus erythematosus (SLE)—A chronic,
B cells to prevent illness caused by an antigen. autoimmune disease affecting multiple bodily
Anaphylactic response—A severe, potentially life- systems in which the immune system mistakenly
threatening response to an allergen. attacks healthy tissues in the body rather than
Antibody—A protein produced by B cells that is foreign invaders.
encoded to seek and destroy one particular type of T cell—A type of lymphocyte that protects the body
antigen. either by attacking body cells that have been
Antigen—A foreign element in the body. infected by antigens or by coordinating B-cell
Atopy—A hypersensitivity reaction to an antigen. production.
B cell—A type of lymphocyte that produces antibodies Vertically acquired passive immunity—Antibodies
in an attempt to eradicate antigens from the body. received from the mother across the placenta and
Passive immunity—Antibodies produced by a source through breast milk.
other than the patient and usually received via the
intramuscular or intravenous route.
179
interferon, and enzymes) are produced by the producing antigen-specific antibodies against
body and sent to the site of invasion. An the disease. These antibodies protect the
inflammatory response—warmth, redness, and individual, preventing the person from again
swelling—is noted, and the antigens often are becoming ill from the disease. Some natural
stopped at this point. If, however, the nonspecific immunity (e.g., to mumps or rubella) is
response is not completely effective, a targeted lifelong, while other natural immunity (e.g., to
response is mounted. influenza) lasts for a short period of time.
3. During the targeted response, T cell and B cell b. Acquired active immunity (see also Chapter
lymphocytes as well as other substances (e.g., 12, “Nursing Care of the Child With Infectious
cytokines and complement) are produced. B cells Diseases”): when injected with an altered form
are programed to produce and secrete antigen- of a virus or bacterium (i.e., when immunized
specific antibodies. Each antigen-specific against a disease) the body develops memory
antibody is encoded to seek and destroy one B cells against the original organism. If
particular type of antigen. Antibodies, named exposed to the disease (e.g., varicella
IgA, IgG, and IgM, are primarily responsible for [chickenpox] or rubeola [measles]) the
fighting bacteria and viruses. IgE is most antibodies produced by the memory B cells
responsible for allergic responses in the body. prevent the person from contracting the
4. Once an antigen has infected a body cell, disease. In a similar fashion as in natural active
however, B cells are unable to fight the infection. immunity, some vaccines (e.g., inactivated
Rather, T cells protect the body either by poliovirus [IPV] and human papillomavirus
attacking body cells that have been infected by [HPV]), although given as a series, must be
antigens or by coordinating B-cell production. In administered only once, while other vaccines
addition, some T cells seek and destroy cancerous must be administered repeatedly in order for
body cells. individuals to maintain immunity (e.g.,
B. Immunity. tetanus).
1. Passive immunity.
a. While in utero, babies receive passive III. Human Immunodeficiency Virus (HIV)
immunity, also called vertically acquired
passive immunity, from their mother via the HIV infection is exhibited in a variety of ways, from mild
placenta. Antibodies in the maternal to severe, with the most severe form referred to as acquired
bloodstream pass through the placenta into the immunodeficiency syndrome, or AIDS.
fetal system and remain in the baby’s system A. Incidence.
during the first few weeks to approximately 1. “In 2010, an estimated 217 children younger than
6 months after birth. the age of 13 years were diagnosed with HIV in
b. Breast milk also contains antibodies, the 46 states with long-term, confidential name-
protecting the baby for the duration of time based HIV infection reporting since at least 2007;
that the baby is breastfed. 162 (75%) of those children were perinatally
c. Passive immunity may also be conveyed via infected” (CDC, 2014).
injection or intravenous (IV) administration of 2. In 2010, “26% of all new infections were among
immunoglobulins. If exposed to a dangerous young people ages 13–24 [and] 19% [of that
disease, individuals often are administered an number] were among young men who have sex
organism-specific serum containing antibodies with men” (CDC, 2010).
against the disease. Similar to the immunity 3. African American and Hispanic children are
transferred to babies from their mothers, the infected in much higher numbers than are
injections protect the individuals for a short children from other ethnic and racial groups.
period of time. B. Etiology.
2. Active immunity: conferred in one of two ways. 1. HIV resides in many fluids in the body, most
a. Natural active immunity: when an individual notably blood, semen, vaginal secretions,
becomes ill with a virus or bacterium, the cerebral spinal fluid, breast milk, and amniotic
body develops antibodies against that fluid.
organism. The antibodies work to eradicate the 2. The virus is transmitted when an infected bodily
body of the offending antigen. In addition, fluid penetrates the mucous membranes of a
memory B cells may also be produced. In the susceptible individual.
future, when the individual is exposed again to 3. The most common means of transmission of HIV
the same disease, the body responds by are:
1.
2.
3.
4.
B. What objective assessments indicate that this client is experiencing a health alteration?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse assign to this client?
1.
D. What interventions should the nurse plan and/or implement to meet this child’s and his family’s needs?
1.
2.
3.
4.
5.
E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing interventions?
1.
2.
F. What physiological characteristics should the child exhibit before leaving the clinic?
1.
G. What subjective characteristics should the child exhibit before leaving the clinic?
1.
8. A nurse is providing a teaching session for 11. The nurse is providing education to pregnant
adolescents and their parents regarding HIV. Which women who have a family history of severe
of the following information should the nurse allergies. Which of the following information should
include in the teaching session? Select all that the nurse convey regarding actions the women
apply. should take to minimize their children’s potential
1. It is recommended that all individuals aged 18 for developing allergies?
and older be tested for HIV. 1. Remove high-allergy foods from their diet
2. The potential for contracting HIV increases during their pregnancy and while breastfeeding.
when a person has intercourse with multiple 2. If they decide not to breastfeed their baby, to
partners. feed the baby a soy-based rather than a cow’s
3. A person can contract more than one strain of milk–based formula.
HIV, increasing the likelihood of the disease 3. Delay feeding their infant any solid foods until
progressing to AIDS. the infant is seven to eight months of age.
4. Although HAART helps to delay the onset of 4. When they begin to feed their infant solid foods,
AIDS, all patients with HIV will die within to begin serving high-allergy foods shortly after
approximately 20 years of the time of the initial low-allergy foods have been introduced.
infection.
12. A child, weighing 80 lb, has been prescribed an
5. Anyone who is diagnosed with hepatitis B or
EpiPen. Which of the following information should
hepatitis C is at high risk for also being infected
the nurse include in the medication teaching for the
with HIV.
parents and the child?
9. A 12-year-old girl has just been diagnosed with 1. To keep the medication in a refrigerator at all
systemic lupus erythematosus (SLE). Which of the times.
following information should the nurse include 2. Inject the medication at a 45 degree angle to the
when educating her and her parents regarding the body surface.
disease? 3. Administer the medication into the dorsogluteal
1. The cure rate for SLE is between 90% and 95%. muscle.
2. SLE is caused by a virus that permeates 100% of 4. Continue to inject the medication for at least 10
the cells of the kidneys and liver. seconds duration.
3. The pain of SLE arthritis will likely be controlled
13. A school nurse is called to a third grade classroom
with nonsteroidal anti-inflammatories.
because a child, with no previous history, is in
4. SLE antibodies were triggered by pubertal
anaphylaxis. Which of the following actions should
changes.
the nurse perform?
10. A nurse is providing education to parents of young 1. Notify the parents to pick up their child as soon
children regarding the children’s potential for as possible.
developing allergies. The nurse informs the parents 2. Take the AED to the classroom, and begin
that which are the most common allergies of emergency intervention.
childhood? 3. Have the child lie quietly in the nurse’s office for
1. Medicines the next 30 minutes.
2. Foods 4. Inform the health department that the child has
3. Pets a reportable illness.
4. Plants
11. ANSWER: 4 TEST-TAKING TIP: EpiPens are prescribed for anyone over
Rationale: 33 lb who experiences anaphylaxis after ingesting or
1. It is no longer recommended that women remove coming in contact with a specific allergen. It is essential
high-allergy foods from their diets during their pregnancy that the nurse educate the child and parents regarding
and while breastfeeding. the proper use of the EpiPen.
2. It is recommended that babies who are not breastfed be Content Area: Pediatrics—Medication
fed hydrolyzed formula, not soy formula, during their Integrated Processes: Nursing Process: Implementation;
infancy. Teaching/Learning
3. It is recommended that babies start to be fed solid Client Need: Physiological Integrity: Pharmacological and
foods between 4 and 6 months of age. Parental Therapies: Medication Administration
4. It is recommended that when solid foods are Cognitive Level: Application
introduced into infants’ diets, that high-allergy foods be
introduced shortly after low-allergy foods have been
13. ANSWER: 2
Rationale:
introduced.
1. Anaphylaxis is an emergent situation. The nurse should
TEST-TAKING TIP: For a number of years, it was
begin emergency intervention.
recommended that pregnant women, lactating women,
2. The nurse should take the AED to the classroom and
and infants refrain from consuming high-allergy foods.
begin emergency intervention.
That is no longer the recommendation. Pregnant and
3. Anaphylaxis is an emergent situation. The nurse should
lactating women may consume high-allergy foods with
begin emergency intervention.
no restrictions, and when solid foods are introduced into
4. Anaphylaxis is an emergent situation. The nurse should
infants’ diets, high-allergy foods should be introduced
begin emergency intervention. Anaphylaxis is not a
shortly after low-allergy foods have been introduced.
reportable illness.
The only exception to this recommendation is in relation
TEST-TAKING TIP: After ingesting or coming in direct
to peanuts. It is still recommended that pregnant and
contact with specific allergens, highly allergic individuals
lactating women whose family histories are high risk for
go into anaphylactic shock. Massive production of
allergies and their infants refrain from eating peanuts.
histamine results in a systemic inflammatory response.
Content Area: Maternity; Newborn; Pediatric—Infant
Emergency intervention is required to resuscitate and
Integrated Processes: Nursing Process: Implementation;
maintain physiological function.
Teaching/Learning
Content Area: Pediatrics
Client Need: Health Promotion and Maintenance: Health
Integrated Processes: Nursing Process: Implementation
Promotion/Disease Prevention
Client Need: Physiological Integrity: Physiological
Cognitive Level: Application
Adaptation: Medical Emergencies
12. ANSWER: 4 Cognitive Level: Application
Rationale:
1. It is recommended that the EpiPen be kept with the
person with the severe allergy at all times. It need not be
refrigerated.
2. The medication should be injected at a 90-degree angle.
3. The medication should be administered into the outer
thigh (i.e., vastus lateralis).
4. The medication should continue to be injected for at
least a 10-sec duration.
I. Description [see Chapter 16] and rotavirus [see Chapter 14]) are dis-
cussed elsewhere in the text. This chapter primarily
Historically, many children suffered from and succumbed focuses on viral illnesses that result either in significant
to communicable diseases. Because of immunizations, rashes or in bacterial illnesses that cause severe, life-
the vast majority of the diseases are seen infrequently threatening manifestations. Table 12.1 provides an easy
today. Indeed, smallpox has been eradicated from the format for accessing information about the diseases. It
world, and the wild form of polio has been eradicated references the pathogen causing the disease, the classic
from the United States as well as the rest of the Americas, manifestations of the disease, the site of the infection, the
Europe, and Eastern Pacific regions. Even though the incubation period of the illness, the communicability
incidence of the rest of the diseases is relatively small as of the illness, major complications that may develop, and
compared to the incidence in the early half of the 20th the medical management and the nursing management.
century and before, it is important for nurses to be famil- In some cases, a picture of a patient with the rash is
iar with them. Even more essential, however, is the impor- included.
tance for nurses to be aware of the many vaccines available A. Isolation: isolation practices as developed by the
for children and the immunization schedule as recom- Centers for Disease Control and Prevention (CDC)
mended by the Advisory Committee on Immunization are required when caring for children with many of
Practices (ACIP) (CDC, 2014), which was established as the diseases.
a result of an act by the U.S. Public Health Service. 1. Standard Precautions: at all times, health-care
providers are expected to perform basic infection
II. Diseases control measures that prevent the transmission of
infectious organisms between patients and
There are many communicable illnesses that children may themselves. The cornerstone of standard
acquire. Some (e.g., Streptococcus pyogenes pharyngitis precautions is hand hygiene. Wearing gloves,
195
gowns, masks, and eye protection and engaging in immunization schedule should be altered,
needle safety are aspects of the precautions. For a including changing the ages when the vaccines
full discussion of the guidelines see www.cdc.gov/ should be administered, adding new vaccines to
hicpac/2007ip/2007ip_table4.html. the schedule, and/or other recommendations (e.g.,
2. Contact isolation: to prevent the transmission of combining vaccines into one injection).
diseases that are communicable by direct contact a. The most up-to-date schedule is available for
with the pathogen. easy download from the CDC Web site, www
a. The child must be placed in a single-patient .cdc.gov/vaccines/schedules/hcp/child-
room or, only if a private room is not available, adolescent.html.
cohorted with other children with the same b. Also available on the CDC Web site is a list of
disease. contraindications and precautions for the
b. Health-care practitioners must wear gown and administration of some of the vaccines (www
gloves when providing care to the child. .cdc.gov/vaccines/recs/vac-admin/
c. Special ventilation in the room is not required. contraindications-vacc.htm).
3. Droplet isolation: to prevent the transmission 2. Immunizations in the ACIP-recommended
of diseases that are communicable when schedule for 2014 are:
contaminated respiratory secretions come in a. Hepatitis B (HepB)—administered in a
contact with the respiratory tract or mucous three-dose series.
membranes. i. Minimum age for first injection: birth.
a. The child must be placed in a single-patient b. Rotavirus (RV).
room or, only if a private room is not available, i. Available in two oral forms.
cohorted with other children with the same (1) RV1: trade name Rotarix, which is
disease. administered in a two-dose series.
b. Health-care practitioners must wear a standard (2) RV5: trade name RotaTeq, which is
operating room mask when entering the administered in a three-dose series.
patient’s room. ii. Minimum age for first administration:
c. If the child must be transported out of the 6 weeks.
room, he or she must wear a standard c. Diphtheria, tetanus, and acellular pertussis
operating room mask. (DTaP)—administered in a five-dose series.
d. Special ventilation in the room is not required. i. A combination vaccine containing
4. Airborne isolation: to prevent the transmission of diphtheria, tetanus, and acellular pertussis
communicable disease particles that remain in the vaccines.
air for long periods of time and over wide ii. Minimum age for first injection: 6 weeks.
distances. iii. This form of the vaccine is recommended
a. The child must be placed in a single-patient for children under 7 years of age.
room with the door closed. d. Tetanus, diphtheria, and acellular pertussis
b. Health-care practitioners must wear a special (Tdap).
N95 mask or respirator. This type of mask i. Same vaccines as DTaP, but this form of
filters at least 95% of the contagious particles the immunization is administered to
of the air breathed in by the practitioner. children (and adults) 10 years of age and
Special education is required to learn how to older.
don the masks. (1) Once the Tdap has been administered,
c. If the child must be transported out of the adults should receive booster vaccines
room, he or she must wear a standard of tetanus and diphtheria toxoids
operating room mask. every 10 years.
d. Special ventilation, with multiple air exchanges ii. Available in two forms: trade names
per hour, is required. Boostrix and Adacel.
5. For additional information, see CDC Isolation iii. Minimum age for first injections: 10 years
Guidelines at www.cdc.gov/hicpac/pdf/isolation/ for Boostrix, 11 years for Adacel.
Isolation2007.pdf.
B. Immunizations (vaccines): a number of vaccines are DID YOU KNOW?
available to prevent childhood communicable Because infants under 6 months of age are not fully
diseases. immunized against pertussis (whooping cough),
1. ACIP: each year, the members of ACIP consult until they receive the third injection, the CDC
with each other to determine whether the recommends that all pregnant women, irrespective
Diseases Listed in the Same Order as They Appear on the ACIP Immunization Schedule
Disease (Common Name)/Pathogen Classic Signs and Symptoms Site of Transmission of
the Infection
Hepatitis B Signs and symptoms can Introduction of the virus
Hepatitis B virus (HBV) range from complete into the body via
Blood-borne and sexually transmitted infection absence of symptoms to mucous membranes or
marked response, including skin wound, e.g., via
flu-like symptoms, severe contaminated needles,
jaundice, clay-colored during sexual
stools, and dark-colored intercourse, and via
urine. vertical transmission.
Virus is in its highest
concentration in the
blood of an affected
individual, but the virus
can be found in all
bodily fluids.
Some individuals who have
recovered from the
acute illness will
continue to carry the
antigen (HBsAg+) in their
blood and be able to
transmit the disease.
Virus can live on inanimate
surfaces for up to
7 days.
Diphtheria Initially, sore throat, fever, Discharge from respiratory
Corynebacterium diphtheria (gram positive bacillus) and chills. tract of infected
Eventually, a toxin is persons.
produced by the bacteria
that results in a grayish-
blue membrane at the back
of the throat that may
cover the trachea, resulting
in respiratory compromise,
including stridor and bull
neck (markedly edematous
neck).
2–5 days, with Until bacilli are Toxin may also result in Prevention: D portion of Droplet Isolation
a range of absent from cardiac and the DTaP and Tdap Administer IV DAT and
1–10 days. cultures on three neurological immunizations. antibiotics, per order.
separate complications, Treatment: diphtheria Monitor respiratory
occasions (usually including heart failure antitoxin (DAT), which function.
over 2–4 weeks). and paralysis. can be obtained only Provide humidified oxygen,
Death occurs in from CDC. per order.
10%–20% of cases. Antibiotics: patients are Suction, as needed.
usually no longer Maintain bedrest.
contagious once on Have emergency equipment
antibiotics for 2 full available.
days.
Continued
Pertussis (Whooping Cough) Bacteria attach to the cilia of Discharge from respiratory
Bordetella pertussis (gram negative bacterium) the respiratory tract and tract of infected
produce a paralyzing toxin, persons.
resulting in marked
inflammation of the tissues.
Pertussis is a three-stage
illness:
Catarrhal stage
Begins like an upper
respiratory infection (e.g.,
coryza, sneezing, tearing,
cough, and slight fever)
that usually lasts for 1 to
1½ weeks.
Paroxysmal stage
Cough (usually at night) that
starts short and rapid and
culminates with
inspirations that sound like
“whoops.”
During coughs, child becomes
flushed or cyanotic, eyes
bulge, and tongue
protrudes. Coughs often
end when the patient
vomits. The stage usually
lasts for 1–6 weeks, with
the shorter length usually
seen in those having
previously been vaccinated.
Convalescent stage
The patient slowly recovers,
with coughing and
paroxysms eventually
fading. The stage lasts for
1 to 1½ weeks.
5–21 days Greatest during Pneumothorax, Prevention: aP portion of Maintain droplet isolation
(usually catarrhal stage, pneumonia, otitis the DTaP and Tdap during catarrhal stage.
10 days). but, unless on media, convulsions, immunizations. All Observe for signs of airway
antibiotics, hemorrhages pregnant women obstruction.
communicability (subarachnoid, between 27 and Maintain bedrest, as
may last for subconjunctival, 37 weeks’ gestation and needed.
4 weeks from epistaxis), weight loss, anyone who is to be in Decrease exposure to
the onset of dehydration, hernias, close contact with an respiratory irritants (e.g.,
paroxysms. encephalopathy, infant should be dust and smoke).
fractured ribs, and immunized at least Provide fluids, as ordered
prolapsed rectum. 2 weeks prior to the (e.g., IV and/or frequent,
Death may occur, contact. small amounts of oral
especially in children Treatment: aggressive fluids).
under 1 year of age. antibiotic therapy. CDC Provide humidified oxygen,
recommends that those, as ordered.
especially infants, who Suction, as needed, to
have been exposed to a prevent choking.
known case of pertussis After discharge, visiting
should receive nurse service should
prophylactic antibiotic monitor the child’s
therapy. progress.
Monitor for signs of
complications.
Have emergency equipment
available.
Continued
On average, the One day before Ear infections, sinus Prevention: yearly, Maintain droplet isolation.
incubation symptoms infections, bronchitis, DNA-specific Administer antiviral agents,
period is develop to about and pneumonia. vaccinations. antipyretics, and/or
2 days long. 5 days after the On average, Treatment: once an analgesics, as ordered
onset of approximately accurate diagnosis is and needed.
symptoms. 35,000 individuals in made, antiviral therapy Maintain bedrest, as
the United States die may be administered. needed.
from the flu each If a bacterial infection is Encourage fluid intake, and
year. suspected, the child may monitor for signs of
initially be prescribed dehydration and
antibiotics. imbalanced electrolytes.
Monitor for signs of
complications.
Because of the potential
for Reye syndrome,
parents should be
reminded never to
administer aspirin to a
child with the flu.
Continued
16–18 days but 5 days before to Orchitis in males (most Prevention: second M Maintain droplet isolation.
may be as 5 days after the commonly portion of the MMR Provide child with
long as appearance of postpuberty— vaccine. nonirritating fluids (i.e.,
25 days. swelling. infertility is Treatment: palliative care. nonacidic liquids) and
uncommon), If CNS involvement, soft foods.
inflammation of the hospitalization is often Place ice or warming collar
ovaries or breasts, required. around the child’s neck,
septic meningitis, whichever is more
encephalitis, deafness. soothing.
Maintain bedrest, especially
if orchitis is present.
Administer analgesics, as
ordered and needed.
Monitor carefully for signs
of CNS involvement.
14 days with a 7 days before to Most benign of all Prevention: R portion of Practice droplet isolation.
range of about 5 days preventable childhood the MMR vaccine. Reassure parents of
12–23 days. after appearance illnesses, with rare Treatment: palliative care. benign nature of illness
of rash. complications of in child.
arthritis, encephalitis, Provide comfort measures,
and purpura. as necessary and
Highly injurious to the ordered, including
unborn fetus, antipyretics and
including cardiac analgesics.
defects, deafness, and Advise parents to inform
congenital cataracts. any pregnant women
with whom the child has
had contact.
Continued
Continued
Continued
4–14 days but Unclear but likely Joint pain in older Prevention: none. No isolation required.
may be as during prodrome. children and adults, Treatment: palliative care. Administer analgesics,
long as Not and chronic anemia in antipyretics, and
21 days. communicable immune-compromised antihistamines, as
once the rash individuals. needed and ordered.
appears. If a woman is pregnant, Maintain bedrest, as
a small percentage of needed.
fetuses will become Trim fingernails and cover
severely anemic, and hands with white mittens
fetal loss may result. to reduce itching and to
prevent secondary
infection.
Provide oatmeal baths/
lotions, as needed.
Educate parents to notify
any pregnant women
with whom the child has
had contact.
Within 3 weeks Up to 85% of HCV Persons are Prevention: refrain from Administer antiviral
the virus is positive patients communicable once engaging in high-risk medication, as ordered.
detectable will develop liver the virus is active in behaviors, especially Educate parents and child,
seriologically. infections and the blood. intravenous drug use. if appropriate, regarding
after many years Treatement: antiviral communicability,
up to 70% will medications. (For including possible
develop liver the most recent vertical transmission.
disease, e.g., recommendations see: Monitor liver function
cirrhosis and http://hcvguidelines tests.
hepatocarcinoma. .org/.)
Up to 5% of
infected persons
will die of their
disease.
Approximately Children usually Severe complications Palliative care with activity Maintain bedrest and
1 to 2 become infected are rare, but include: restriction, until frequent rest periods, as
months. while drinking ruptured spleen and splenomegaly resolves. needed.
from the same respiratory Provide antipyretics and
bottle, while compromise, if analgesics for symptom
kissing, or markedly enlarged relief.
engaging in other tonsils. Maintain adequate
activities that hydration.
result in a sharing Reinforce importance of
of oral secretions. activity restrictions for
Children may duration of the illness.
shed the virus for Monitor liver function
many months tests.
after resolution Educate parents and child,
of the illness. if appropriate, regarding
possible communicability
of the virus.
Continued
1–7 days. Communicable Rheumatic fever (see Prevention: none. Maintain droplet isolation
during the acute Chapter 16, “Nursing Treatment: once the until the child has been
infection until the Care of Child with bacteria have been on antibiotics for a full
child has been on Respiratory Illnesses”) identified, antibiotics are 24 hours.
antibiotics for a or acute administered. Administer antibiotics and
full 24 hours. glomerulonephritis educate parents to
(see Chapter 22, complete the full
“Nursing Care of antibiotic course.
Child with Administer antipyretics and
Neurological analgesics, as ordered
Problems”) may and needed.
develop if the child is Provide fluids and monitor
not treated with a for signs of dehydration.
full course of Maintain bedrest, as
antibiotics.. needed.
*Unless otherwise noted, the nurse should follow Standard Precautions when caring for a child with the disease. When specific isolation precautions are cited,
the nurse should follow both Standard Precautions and the isolation precautions.
1.
B. What objective assessments indicate that this client is experiencing a potential health alteration?
1.
C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse assign to this client?
1.
D. What interventions should the nurse plan and/or implement to meet this child’s and his or her family’s needs?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing interventions?
1.
2.
F. What physiological characteristics should the child exhibit before leaving for home?
1.
8. A 10-year-old child, who has been positively 12. A nurse is educating a group of parents regarding
diagnosed with influenza, is to be cared for at home ways to prevent disease in their home. Which of
by the child’s parents. Which of the following the following information should the nurse
client-care information should the nurse include in include regarding preventing the transmission of
the teaching? hepatitis A?
1. The child should be isolated from all susceptible 1. Cover mouths and noses when coughing or
contacts for 2 full weeks. sneezing.
2. The entire 10-day course of antibiotics must be 2. Protect family members from blood of affected
administered to the child. individuals.
3. If the child complains of a sore throat, the child 3. Wash all clothing and bedding and dry in a hot
should be seen in an emergency department. dryer.
4. Only acetaminophen should be administered to 4. Carefully wash all fresh fruits and vegetables
the child for pain or for febrile episodes. before eating.
9. A child, who has been diagnosed with rubeola, is 13. A parent asks the nurse, “Why should I have my
being cared for at home. Which of the following child immunized for human papillomavirus (HPV)
actions should the nurse educate the parents to when my child is only 11 years old? Isn’t it a
perform? sexually transmitted infection?” Which of the
1. Keep the lights in the child’s room dimmed. following responses by the nurse is appropriate?
2. Give the child oatmeal baths every 3 to 4 hours. 1. “I agree with you. I will ask your child’s
3. Administer calcium supplements every 12 hours. pediatrician if the HPV vaccine could be delayed
4. Maintain the child on contact isolation for one until she becomes sexually active.”
week. 2. “It is recommended that children begin the
vaccine series when they are preteen so that they
10. The parents of a boy who is diagnosed with mumps
have time to develop full immunity.”
ask the nurse whether there is any special care that
3. “Although HPV is defined as a sexually
they should provide their child. Which of the
transmitted disease, it can also be transmitted if
following responses would be appropriate for the
a person with upper respiratory warts coughs or
nurse to provide? Select all that apply.
sneezes.”
1. Offer soft foods for the child to eat.
4. “I understand. It is important to realize though
2. Encourage the child to drink citrus fruit juices
that the majority of people in this country are
each day.
infected with the virus by the time they are in
3. Monitor the child carefully for signs of testicular
high school.”
discomfort.
4. Place an ice collar or warm compresses around 14. The mother of a child who has been prescribed
the child’s neck. antibiotics for a diagnosis of scarlet fever telephones
5. Administer ordered antihistamines for the full the pediatrician’s office and states, “My child’s
course of the disease. temperature is normal, and the rash is disappearing,
but my child has enough antibiotics for another
11. The nurse reviewing the record of a woman who is
5 days. Do I really have to give my child all of the
planning to become pregnant notes that the woman
antibiotics?” Which of the following responses by
is not immune to rubella. In addition to
the nurse is appropriate?
recommending that the client have the MMR
1. “I will ask the doctor if you can stop because we
(measles, mumps, rubella) vaccine, which of the
are trying to keep from giving children too many
following actions should the nurse take?
antibiotics.”
1. Educate the client that she will be fully immune
2. “Scarlet fever is actually caused by a virus, so you
to rubella one year after receiving the injection.
can stop administering your child’s antibiotics
2. Advise the client that she should use birth
right away.”
control for 4 weeks after receiving the vaccine.
3. “As long as your child’s temperature remains
3. Inform the client that a baby born after she
normal for a full day, you can stop administering
receives the vaccine will be immune to rubella.
the antibiotics.”
4. Remind the client that she will need to receive
4. “It is important that you finish giving your child
2 more injections of the vaccine during the next
the antibiotics in order to prevent your child
few months.
from developing a serious complication.”
6. ANSWER: 3 9. ANSWER: 1
Rationale: Rationale:
1. This statement is untrue. The oral vaccine actually is 1. This statement is correct. The lights in the child’s
more effective than the injectable form. room should be kept dimmed.
2. This statement is untrue. 2. Rubeola is not markedly pruritic. Oatmeal baths are
3. This statement is correct. The oral form is no longer not indicated.
being administered in the United States. 3. This is incorrect. Vitamin A supplements are
4. This statement is untrue. administered to those with rubeola.
TEST-TAKING TIP: The wild form of polio has been 4. This statement is incorrect. Airborne isolation is
eradicated from the Americas, Europe, and other parts of required for those with rubeola.
the world. It is, however, still found in some developing TEST-TAKING TIP: Conjunctivitis and photophobia are
countries. To protect children who could come in associated with a diagnosis of rubeola. Children are much
contact with an individual from another country who more comfortable when they convalesce in a darkened
may be traveling in the United States and who may have room.
polio, the CDC has recommended that children still Content Area: Infectious Disease
receive the vaccine but no longer receive the live Integrated Processes: Nursing Process: Implementation;
attenuated, or oral, form of the vaccine. Teaching/Learning
Content Area: Child Health, Immunizations Client Need: Physiological Integrity: Physiological
Integrated Processes: Nursing Process: Implementation Adaptation: Illness Management
Client Need: Health Promotion and Maintenance: Health Cognitive Level: Application
Promotion/Disease Prevention
Cognitive Level: Application 10. ANSWER: 1, 3, and 4
Rationale:
7. ANSWER: 4 1. The child should be offered soft foods to eat.
Rationale: 2. The child should not be encouraged to drink citrus
1. Tinnitus is not associated with a diagnosis of polio. fruit juices each day.
2. Petechial rash is not associated with a diagnosis of 3. The child should be monitored carefully for signs of
polio. testicular discomfort.
3. Flank pain is not associated with a diagnosis of polio. 4. An ice collar or warm compress should be placed
4. Bradypnea may be evident in a child with polio. around the child’s neck.
TEST-TAKING TIP: The paralytic form of the poliovirus 5. Antihistamines are not administered to children
can lead to paralysis of the respiratory tract and/or diagnosed with the mumps.
paralysis of other muscle systems of the body. A drop in TEST-TAKING TIP: Mumps, also called parotitis, is
the respiratory rate of a child could indicate that the characterized by inflammation of the parotid gland. It can
child is developing respiratory paralysis. be quite painful for children with mumps to eat coarse
Content Area: Infectious Disease foods or to drink acidic juices. Ice or warm compresses
Integrated Processes: Nursing Process: Implementation to the neck can be comforting. The child should
Client Need: Physiological Integrity: Physiological determine which is more comforting.
Adaptation: Alteration in Body Systems Content Area: Infectious Disease
Cognitive Level: Application Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Physiological
8. ANSWER: 4 Adaptation: Illness Management
Rationale: Cognitive Level: Application
1. This statement is not true. Communicability drops after
a child has had symptoms for 5 days. 11. ANSWER: 2
2. The flu is caused by a virus. Antibiotics are not effective Rationale:
against viral illnesses. 1. The woman will become immune to the disease in a
3. This statement is incorrect. Sore throat is an expected shorter period of time
symptom of the flu. 2. This statement is correct. The client must be advised
4. This statement is correct. Only acetaminophen should that she should use birth control for 4 full weeks after
be administered as an antipyretic or as an analgesic. receiving the vaccine.
TEST-TAKING TIP: The two illnesses most associated with 3. This statement is not correct. The baby will receive
the development of Reye syndrome after being passive antibodies from the mother via the placenta, but
administered aspirin are the flu and chickenpox. to become fully immunized, the baby will receive the
Content Area: Infectious Disease MMR vaccines.
Integrated Processes: Nursing Process: Implementation; 4. This statement is incorrect. The woman will receive up
Teaching/Learning to two doses of the MMR vaccine.
Client Need: Physiological Integrity: Physiological TEST-TAKING TIP: Because the MMR vaccine is a live,
Adaptation: Illness Management attenuated vaccine, it is possible that a fetus can become
Cognitive Level: Application ill from the virus via vertical transmission. The woman
may become pregnant, with no danger to the fetus, once
4 weeks have passed from the date of the immunization.
Content Area: Child Health, Immunizations 4. This statement is not true. It is true, however, that 80%
Integrated Processes: Nursing Process: Implementation of women will be exposed to HPV by the time they are 50
Client Need: Health Promotion and Maintenance: Health years of age.
Promotion/Disease Prevention TEST-TAKING TIP: Three HPV vaccines must be
Cognitive Level: Application administered over time in order for full immunity to be
developed. In order for clients to become fully
12. ANSWER: 4 immunized before engaging in sexual relationships, it is
Rationale:
recommended that boys and girls begin to receive the
1. Although it is important for people to cover their
vaccine series at either 11 or 12 years of age.
mouths and noses when they cough or sneeze, hepatitis A
Content Area: Child Health, Immunizations
is not transmitted via coughing or sneezing.
Integrated Processes: Nursing Process: Implementation
2. Although the blood of hepatitis B is highly infectious,
Client Need: Health Promotion and Maintenance: Health
protecting family members from the blood of individuals
Promotion/Disease Prevention
with hepatitis A will not protect them from the disease.
Cognitive Level: Application
3. Washing all clothing and bedding and drying the items
in a hot dryer will not protect susceptible individuals 14. ANSWER: 4
from contracting hepatitis A. Rationale:
4. Carefully washing all fresh fruits and vegetables is one 1. It would be inappropriate for the nurse to make this
important action to protect susceptible individuals from statement. The child must complete the full course of
contracting hepatitis A. antibiotics.
TEST-TAKING TIP: Hepatitis A is contracted via the 2. This statement is incorrect. Scarlet fever is caused by
oral-fecal route (i.e., ingesting foods or fluids that have S. pyogenes.
been contaminated with the feces of an infected 3. This statement is incorrect. The child must complete
individual). Carefully washing fresh fruits and vegetables the full course of antibiotics.
before eating is a means of preventing the virus from 4. This statement is correct. It is important that the child
being ingested. finish the entire course of antibiotics in order to prevent
Content Area: Infectious Disease a serious complication.
Integrated Processes: Nursing Process: Implementation; TEST-TAKING TIP: If untreated or undertreated, patients
Teaching/Learning with infections from S. pyogenes can develop one of
Client Need: Health Promotion and Maintenance: Health two serious complications: rheumatic fever or acute
Promotion/Disease Prevention glomerulonephritis. Parents should be counseled to make
Cognitive Level: Application sure that their children complete the full course of
prescribed antibiotics.
13. ANSWER: 2 Content Area: Infectious Disease
Rationale:
Integrated Processes: Nursing Process: Implementation;
1. It is inappropriate for the nurse to make this statement.
Teaching/Learning
2. This statement is correct. It is recommended that
Client Need: Physiological Integrity: Physiological
children begin the vaccine series when they are preteens
Adaptation: Illness Management
so that they have time to develop full immunity.
Cognitive Level: Application
3. This statement is not true. HPV is transmitted only via
direct contact.
Aldosterone—A hormone that helps maintain fluid Hypokalemia—Potassium depletion less than
balance by stimulating the kidneys to retain 3.5 mEq/L.
sodium, decreasing urinary output. Hyponatremia—Sodium depletion less than
Ascites—Excess fluid in the peritoneal cavity. 135 mEq/L.
Hypercalcemia—Calcium excess greater than Hyporeflexia—Reduced response of the reflexes.
10.2 mg/dL. Hypotonic dehydration—Also called hyponatremic
Hyperkalemia—Potassium excess greater than dehydration. When sodium loss exceeds water loss.
5.0 mEq/L. Isotonic dehydration—Also called isonatremic
Hypernatremia—Sodium excess greater than dehydration. An equal loss of both fluid and
145 mEq/L. sodium.
Hyperreflexia—Overactive reflexes. Oliguria—Low urinary excretion.
Hypertonic dehydration—Also called hypernatremic Renin-angiotensin system (RAS)—The production of
dehydration. When water loss exceeds sodium loss. the hormones aldosterone and angiotensin to
Hypocalcemia—Calcium depletion less than regulate blood pressure and fluid balance.
8.5 mg/dL. Tetany—Sudden, painful muscle contractions.
221
place children at highest risk for imbalance are discussed D. Daily fluid exchange.
in other chapters. For example, diarrhea and vomiting 1. Each day there is an exchange of fluid in and out
that result in dehydration and electrolyte and acid-base of the body.
imbalances are discussed in Chapter 14, “Nursing Care of a. Fluid is lost via three main routes.
the Child With Gastrointestinal Problems,” while conges- i. Insensible loss via the lungs and skin.
tive heart failure that results in fluid volume overload is ii. Excreted loss via the kidneys.
discussed in Chapter 17, “Nursing Care of the Child With iii. Excreted loss via stool.
Cardiovascular Illnesses.”
DID YOU KNOW?
Water is lost in the form of water vapor when it
II. Essentials of Water and Fluid passes through the skin, called transepidermal
Compartments in the Body (Table 13.1) diffusion, and during respiration. This type of loss is
called insensible loss because it cannot be seen,
A. Total composition of the body that is water. felt, or easily measured. Insensible loss increases
1. 75% of the weight of infants/young children is whenever the respiratory rate increases and when
fluid. one perspires.
2. 60% to 65% of the weight of preschool children is
fluid. 2. Each day, the percentage of fluid that is
3. 55% to 60% of the weight of older children exchanged in the body is markedly different
through adulthood is fluid. between young children as it is in older children
B. ICF compartment. through adulthood.
1. Percentage of fluid. a. 50% of infants’ and young children’s fluid is
a. Approximately the same in infants and young exchanged per day.
children as it is in older children through to b. 16% to 17% of older children’s through adults’
adulthood. fluid is exchanged per day.
b. 35% of the weight of children and adults. 3. There is fluid movement between and among the
C. ECF compartment. ICF and ECF compartments.
1. Percentage of fluid. E. Mechanisms in the body that help to maintain fluid
a. The percentage of fluid that resides in balance in response to decreased fluid levels in the
extracellular spaces is markedly different in body.
young children than it is in older children 1. Thirst.
through adulthood. a. Triggers an increase in fluid intake.
b. 40% of infants’ and young children’s weight. 2. Antidiuretic hormone (ADH).
c. 30% of preschool children’s weight. a. Produced by the posterior pituitary.
d. 20% of older children’s, adolescents’, and b. Kidneys respond by decreasing urinary
adults’ weight. output.
Table 13.1 Fluid Composition Differences Between Infant/Young Child to Older Child/Adolescent
3. Aldosterone.
Table 13.2 Concentration of Electrolytes in Fluid
a. Produced by the adrenal cortex.
Compartments in the Body
b. Kidneys respond by retaining sodium and, as a
result, decreasing urinary output. Electrolyte Extracellular Fluid Intracellular
4. Renin-angiotensin system (RAS). (ECF)—Vascular Tree, Fluid (ICF)
a. Produced by the kidneys. Interstitial Space,
b. Results in the production of aldosterone as Spinal Column
well as angiotensin, a vasoconstrictor. Na+ High Low
F. Factors that impact fluid balance.
Cl− High Low
1. Factors that place infants and young children at
higher risk for fluid imbalance as compared to K+ Low High
older children and adolescents. Ca++ Low Moderate
a. Body surface area (BSA)
i. The BSA of infants and young children is
two to three times the area of older
children and adolescents. b. Increased intracranial pressure (ICP) (see
ii. BSA is composed of the surface of the Chapter 22, “Nursing Care of the Child with
gastrointestinal tract as well as the surface Neurological Problems”).
of the skin.
b. Metabolic rate. III. Essentials of Electrolyte Composition
i. An increased rate in infants and
children is needed to support their rapid A. Sodium, chloride, potassium, and calcium.
growth. 1. Concentration of the electrolytes varies in the
ii. The increased metabolic rate is evidenced fluid compartments of the body (Table 13.2).
by the pulse and respiratory rates of 2. Because fluids of the body are comprised of water
infants and young children that are and electrolytes, any shift in water balance results
markedly faster than those of older in a shift in electrolyte balance.
children and adolescents. 3. Sodium: Na+.
c. Immature renal system. a. High concentrations in ECF spaces.
i. Because of their inability to concentrate b. Low concentrations in ICF spaces.
and dilute urine efficiently, the immature c. Normal serum (extracellular) level is 135 to
kidneys of infants and young children 145 mEq/L.
retain or excrete urine poorly in response 4. Chloride: Cl−.
to reduced or elevated fluid volumes. a. High concentrations in ECF spaces.
d. Fluid needs. b. Low concentrations in ICF spaces.
i. Compared to older children and c. Normal serum (extracellular) level: 98 to
adolescents, infants and young children 106 mEq/L.
proportionately must consume larger
quantities of fluids each day in order to
DID YOU KNOW?
Sodium (Na) and chloride (Cl) combine to form the
maintain optimal fluid balance.
salt compound (i.e., NaCl). The concentrations of
2. Important factors that increase fluid requirements
sodium and chloride, therefore, are similar in the
and place children at high risk for dehydration.
fluid compartments of the body. In addition,
a. From insensible loss.
whenever a fluid shift occurs, patients usually will
i. Fever.
experience a shift in both sodium and chloride.
ii. Tachypnea.
iii. Phototherapy in neonates. 5. Potassium: K+.
b. From excretion. a. Low concentrations in ECF spaces.
i. Vomiting. b. High concentrations in ICF spaces.
ii. Diarrhea. c. Normal serum (extracellular) level is 3.5 to
iii. Burns. 5 mEq/L.
3. Important factors that may reduce children’s daily 6. Calcium: Ca++
fluid needs. a. Low concentrations in ECF spaces.
a. Congestive heart failure (CHF) (see Chapter b. Moderate concentrations in ICF spaces.
17, “Nursing Care of the Child with c. Normal serum (extracellular) level is 8.5 to
Cardiovascular Illnesses”). 10.2 mg/dL.
The large percentage of body weight that is fluid puts To calculate percentage of weight loss, the nurse must
infants and young children at very high risk for fluid loss subtract the child’s current weight from the last recorded
(i.e., for deficient fluid volume or dehydration). weight of the child. The remainder is then divided by the last
recorded weight of the child and multiplied by 100.
A. Incidence.
1. Dehydration is a common acute problem in % of weight loss
pediatrics. last recorded weight − current weight
= × 100
B. Etiology and pathophysiology of types of last recorded weight
dehydration. Example 1
1. Isotonic dehydration (also called isonatremic A child is admitted to the hospital with a diagnosis of
dehydration). dehydration. The child’s last recorded weight was 37¼ lb. The
a. When fluid loss and sodium loss are child’s current weight is 34½ lb. What is the child’s
proportionate. percentage of weight loss?
i. No shift seen between contents of the ICF 37.25 lb − 34.5 lb
% of weight loss = × 100
and ECF compartments. 37.25 lb
b. Commonly seen with minor vomiting and = (2.75 ÷ 37.25) × 100
diarrheal illnesses. = 0.074 × 100
= 7.4% weight loss
2. Hypotonic dehydration (also called hyponatremic
dehydration). Example 2
a. When sodium loss exceeds the water loss. A baby is admitted to the hospital with dehydration. The
i. Shift of fluid seen from the ECF child’s last recorded weight was 4,572 g. The child’s current
compartments to the ICF spaces, weight is 4,112 g. What is the child’s percentage of weight
loss?
increasing the severity of the dehydration.
b. Commonly seen with: 4, 572 g − 4, 112 g
% of weight loss = × 100
i. Burns. 4, 572 g
ii. Renal disease. = (460 g ÷ 4,572 g) × 100
= 0.101 × 100
iii. Excessive vomiting and diarrhea. = 10.1% weight loss
iv. Intravenous (IV) therapy when no
electrolytes are added to the solution.
v. Plain water given to children under
6 months of age. c. Severe: 10% or more weight loss in infants and
3. Hypertonic dehydration (also called young children, 9% or more weight loss in
hypernatremic dehydration). older children and adolescents.
a. When water loss exceeds sodium loss: 2. Dehydration is also determined by changes in
i. Shift of fluid is seen from the ICF physiological characteristics. The severity of the
compartments to the ECF compartments. changes increases in relation to the severity of the
ii. Often, symptoms are delayed, but when dehydration (Table 13.3).
they appear, they are very serious, with a. Poor skin color.
neurological symptoms usually being b. Reduced skin turgor.
noted. c. Drying of mucous membranes.
b. Commonly seen with: d. Change in vital signs.
i. IV therapy when concentrations of e. Decrease in urinary output.
electrolytes are too high. i. But the volume of urinary output changes
ii. Tube feedings (or formula feedings) when little in infants and young children.
concentrations of electrolytes are too high. f. Increase in urine specific gravity.
C. Diagnosis of severity of dehydration. i. But the specific gravity changes little in
1. Best determined by calculating the percentage of infants and young children.
weight loss (Box 13.2). g. Soft eyeballs.
a. Mild: 5% weight loss in infants and young h. In infants, depressed anterior fontanels.
children, 3% to 5% weight loss in older D. Treatment.
children and adolescents. 1. Oral rehydration therapy (ORT) (e.g., Pedialyte,
b. Moderate: 5% to 9% weight loss in infants and Infalyte, and Rehydralyte).
young children, 6% to 8% weight loss in older a. Contains water, sugar, sodium, potassium,
children and adolescents. chloride, and lactate.
hypernatremia. Combinations D5NS, D5 ½ NS, D5 1/3 NS, and D5 ¼ NS provide both calories and electrolytes.
b. Replaces fluids and electrolytes and provides c. Administer oral rehydration therapy and/or IV
some calories. fluids, per orders.
2. IV therapy. d. Monitor intake and output.
a. Specific fluid required is dependent on the e. Carefully monitor vital signs.
type of dehydration, severity of the f. Assess laboratory values.
dehydration, and/or fluid and electrolyte needs
(Table 13.4). V. Edema
! The primary health-care provider may order potassium A. Incidence.
chloride (KCl) to be added to a child’s IV fluid. In 1999, the
1. Is seen as a symptom of some illnesses (e.g.,
Joint Commission declared that KCl is a high-alert medication
CHF).
because of the serious complications that can arise from an
B. Etiology.
overdose of the electrolyte. All IV solutions with potassium
1. Related to the inability of the body to excrete
added, therefore, should be administered only if they have
excess fluids.
been premixed in the pharmacy. In addition, the nurse must
C. Pathophysiology.
always double check to make sure that the solution is labeled
1. Problems usually are present in the cardiovascular
with the right percentage of potassium.
system, such as:
E. Nursing considerations. a. Decrease in circulating protein, resulting in
3. Deficient Fluid Volume. fluid movement from within the vascular tree
a. Weigh child on admission and daily thereafter. to the interstitial spaces.
b. Assess for signs of dehydration, including skin b. Failure of the heart to pump efficiently,
turgor, condition of mucous membranes, and resulting in:
presence of tears. i. Pulmonary edema from left-sided failure.
1.
2.
B. What objective assessments indicate that this client is experiencing a health alteration?
1.
2.
3.
4.
5.
6.
7.
8.
C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse assign to this client?
1.
D. What interventions should the nurse plan and/or implement to meet this child’s and her family’s needs?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
1.
2.
3.
4.
5.
6.
7.
F. What physiological characteristics should the child exhibit before being discharged home?
1.
2.
G. What subjective characteristics should the child exhibit before being discharged home?
1.
12. The nurse assesses the following blood gas results 14. A child, who is frightened, is hyperventilating.
on an infant in the emergency department. Which Which of the following blood gas values would the
of the following conclusions is consistent with the nurse expect to see? Select all that apply.
data? 1. Depressed Pco2
Po2: 90 mm Hg 2. Depressed Po2
Pco2: 34 mm Hg 3. Elevated pH
HCO3: 16 mEq/L 4. Elevated HCO3
Base excess: −4 5. Base excess of 0
pH: 7.28
15. The nurse, who is assessing the blood gas results of
1. Metabolic acidosis
a young child in the emergency department, notes
2. Metabolic alkalosis
that the Pco2 is elevated and that the pH is low.
3. Respiratory acidosis
The nurse will check to see if the child’s body has
4. Respiratory alkalosis
attempted to compensate for the disturbance by
13. The nurse assesses the following blood gas results doing which of the following?
on a child in the emergency department. Which of 1. Raising the serum bicarbonate levels
the following diagnoses is consistent with the data? 2. Raising the serum oxygen levels
Po2: 60 mm Hg 3. Raising the serum carbonic acid levels
Pco2: 50 mm Hg 4. Raising the serum potassium levels
HCO3: 30 mEq/L
Base excess: −4
pH: 7.28
1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
Content Area: Pediatrics nurse should assess the child’s lung sounds for the
Integrated Processes: Nursing Process: Implementation presence of rales and crackles.
Client Need: Physiological Integrity: Physiological Content Area: Pediatrics—Infant
Adaptation: Fluid and Electrolyte Imbalances Integrated Processes: Nursing Process: Assessment
Cognitive Level: Synthesis Client Need: Physiological Integrity: Physiological
Adaptation: Fluid and Electrolyte Imbalances
6. ANSWER: 6.5% Cognitive Level: Application
Rationale:
9. ANSWER: 1
34.5 lb
Rationale:
–32.25 lb 1. The nurse should monitor the child for dysrhythmias.
2. Thirst is noted when the sodium levels are very low.
2.25 lb difference 3. Seizures are seen when sodium levels are very high and
when calcium levels are low.
(2.25 ÷ 34.5) × 100 = 0.065 × 100 = 6.5%
4. Dry mucous membranes are indicative of dehydration.
TEST-TAKING TIP: It is possible to calculate the TEST-TAKING TIP: Dysrhythmias often are noted when a
percentage of weight loss using the English system. child is hypokalemic (i.e., when the child’s serum
The test taker simply must remember that there potassium level is below 3.5 mEq/L). Dysrhythmias also
are 16 oz in every pound. Fractions of a pound can are seen when potassium levels are elevated (i.e., above
then be determined (e.g., 8 oz = ½ or 0.5 lb; 4 oz = ¼ 5 mEq/L).
or 0.25 lb). Content Area: Pediatrics
Content Area: Pediatrics Integrated Processes: Nursing Process: Implementation
Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Physiological
Client Need: Physiological Integrity: Physiological Adaptation: Fluid and Electrolyte Imbalances
Adaptation: Fluid and Electrolyte Imbalances Cognitive Level: Application
Cognitive Level: Synthesis
10. ANSWER: 1
7. ANSWER: 3 Rationale:
Rationale: 1. The most likely etiology is that the child is consuming
1. There is no indication in the question that the intake of concentrated formula that has not been diluted with
dairy products would need to be restricted. water.
2. The child’s potassium level is normal. IV potassium is 2. A diagnosis of cardiac defect does not put a child at
not indicated. high risk for elevated electrolyte levels.
3. The nurse would expect the child to be fed ORT. 3. Gastroenteritis usually results in the loss of electrolytes.
4. Bouillon soup contains high levels of sodium. A 4. High water intake by babies can result in low serum
high-salt intake is not indicated. electrolyte levels.
TEST-TAKING TIP: As with the child in the question stem, TEST-TAKING TIP: Both the serum potassium and sodium
isotonic dehydration is characterized by fluid loss but levels are elevated. When babies are fed concentrated
with normal serum electrolyte levels. ORT is an oral formula, they can become very ill because they are
solution that provides both fluids and electrolytes, in consuming an undiluted fluid that contains a high
physiological proportions, to sick children. It is the concentration of electrolytes as well as a high
appropriate intervention for a child who is in mild concentration of fats, proteins, and carbohydrates.
isotonic dehydration. Content Area: Pediatrics—Infant
Content Area: Pediatrics—Toddler Integrated Processes: Nursing Process: Analysis
Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological
Client Need: Physiological Integrity: Physiological Adaptation: Fluid and Electrolyte Imbalances
Adaptation: Fluid and Electrolyte Imbalances Cognitive Level: Application
Cognitive Level: Application
11. ANSWER: 3
8. ANSWER: 2 Rationale:
Rationale: 1. The solution only contains dextrose and saline that is
1. A sunken fontanel is seen when a child is dehydrated. one-half the concentration of the blood.
2. Marked weight gain is noted when a child is in a state 2. Because this response is made using medical
of fluid volume excess. terminology, it will be difficult for the parent to
3. Soft eyeballs are seen when a child is dehydrated. understand. In addition, only sodium and chloride are
4. High urine specific gravity (i.e., concentrated urine) is being replaced.
seen when a child is dehydrated. 3. This is an appropriate response for the nurse to
TEST-TAKING TIP: When a child is in a state of excess provide.
fluid volume, he or she is edematous with marked weight 4. This statement is not accurate. The fluid is not the same
gain. Because pulmonary edema may be present, the as drinking water. It contains saline one-half the
concentration of the blood and 5 g of dextrose for every 3. Using ROME, the pH and the Pco2 are in opposite
100 mL of water. directions. The cause of the altered blood gases,
TEST-TAKING TIP: The solution, D5 ½ NS, is comprised of therefore, is respiratory.
77 mEq of both sodium and chloride for every 1,000 mL, 4. Check Pco2: high = cause of the problem.
and 5 g of dextrose for every 100 mL of water. It is 5. High HCO3 = compensatory response.
providing the child, therefore, with saline that is one-half 6. The child is in respiratory acidosis.
the concentration of saline of the blood as well as some
A possible medical diagnosis for the respiratory acidosis
dextrose for calories.
is a severe asthma attack. Please see Chapter 16, “Nursing
Content Area: Pediatrics Care of the Child With Respiratory Illnesses,” for a
Integrated Processes: Nursing Process: Implementation complete discussion of asthma.
Client Need: Physiological Integrity: Physiological Content Area: Pediatrics—Infant
Adaptation: Fluid and Electrolyte Imbalances
Integrated Processes: Nursing Process: Analysis
Cognitive Level: Application Client Need: Physiological Integrity: Physiological
12. ANSWER: 1 Adaptation: Fluid and Electrolyte Imbalances
Rationale: Cognitive Level: Application
1. The child is in metabolic acidosis. 14. ANSWERS: 1 and 3
2. The child is in metabolic acidosis.
Rationale:
3. The child is in metabolic acidosis.
1. The nurse would expect to see a low Pco2.
4. The child is in metabolic acidosis.
2. The nurse would expect to see a normal Po2.
TEST-TAKING TIP: Blood gases should be analyzed 3. The nurse would expect to see an elevated pH.
systematically. 4. The nurse would expect to see an depressed HCO3.
1. Check the pH: 7.28 is an acidic pH. 5. The nurse would expect the base excess to be elevated.
2. Check Pco2: low TEST-TAKING TIP: Because the child is exhaling large
3. Using ROME, the pH and the Pco2 are both low, i.e., quantities of carbon dioxide, the concentration of
they are altered in the same direction. The cause of the carbonic acid in the blood is reduced. The child,
altered blood gases, therefore, is metabolic. therefore, is in respiratory alkalosis.
4. Check HCO3: low = cause of the problem. Content Area: Pediatrics
5. Low Pco2 = compensatory response. Integrated Processes: Nursing Process: Assessment
6. The child is in metabolic acidosis. Client Need: Physiological Integrity: Physiological
Adaptation: Fluid and Electrolyte Imbalances
A possible medical diagnosis for the metabolic acidosis is
Cognitive Level: Application
diarrhea. Please see Chapter 14, “Nursing Care of the
Child With Gastrointestinal Problems” for a complete 15. ANSWER: 1
discussion of diarrhea. Rationale:
Content Area: Pediatrics—Infant 1. The nurse would assess to see if the serum
Integrated Processes: Nursing Process: Analysis bicarbonate levels are elevated.
Client Need: Physiological Integrity: Physiological 2. The nurse would not expect a rise in serum oxygen
Adaptation: Fluid and Electrolyte Imbalances levels.
Cognitive Level: Analysis 3. The child already has a high serum carbonic acid level.
4. The nurse would not expect the serum potassium levels
13. ANSWER: 3 to rise.
Rationale:
TEST-TAKING TIP: To compensate for respiratory
1. The child is in respiratory acidosis.
acidosis, the body should try to compensate by raising
2. The child is in respiratory acidosis.
the bicarbonate levels.
3. The child is in respiratory acidosis.
Content Area: Pediatrics—Toddler
4. The child is in respiratory acidosis.
Integrated Processes: Nursing Process: Assessment
TEST-TAKING TIP: Blood gases should be analyzed
Client Need: Physiological Integrity: Physiological
systematically. Adaptation: Fluid and Electrolyte Imbalances
1. Check the pH: 7.28 is an acidic pH. Cognitive Level: Application
2. Check Pco2: high
237
b. Rotavirus vaccine is recommended to be medications. Parents should be advised not to administer any
administered to infants at 2, 4, and 6 months over-the-counter antidiarrhea medications to their children.
of age.
c. Babies who are exclusively breastfed are much F. Nursing considerations.
less likely to develop gastroenteritis than are 1. Risk for Imbalanced Nutrition: Less than Body
formula fed babies. Requirements/Risk for Deficient Fluid Volume.
a. Take an excellent history of the child’s
DID YOU KNOW? activities preceding the diarrhea, including:
All mothers should be strongly encouraged to
i. Dietary intake, travel, day-care attendance,
breastfeed. Not only is breast milk comprised of
and play activities.
fats, proteins, and carbohydrates that are ideal for
b. Assess the frequency, consistency, appearance,
human babies, it also contains many protective
and smell of the child’s stools.
properties, including white blood cells, antibodies,
i. Stools may need to be weighed in order to
and lactobacilli, that help to protect babies from
estimate the extent of fluid loss via the
infectious diseases, including gastrointestinal
gastrointestinal tract.
illnesses. When breastfed babies do become ill, they
c. Assess the frequency, amount, and
should continue to receive breast milk. If
characteristics of any vomiting.
breastfeeding difficulties occur at any time, a
d. Carefully monitor the child’s hydration status
referral to a lactation consultant should be made to
(see Chapter 13, “Nursing Care of the Child
remedy the problem.
With Fluid and Electrolyte Imbalances”),
2. Treatment. including:
a. Fluid and electrolyte replacement. i. Calculating the percentage of weight loss.
i. The child with diarrhea may require as ii. Assessing for additional physiological
much as two and a half times his or her signs of dehydration, including low
daily maintenance volume (DMV) (see urinary output, poor skin turgor, absence
Chapter 3, “Nursing Care of the Child of tears, and altered vital signs and,
With Fluid and Electrolyte Alterations,” iii. If the child is an infant, assessing for a
for the formula to calculate DMV). sunken anterior fontanel.
ii. Oral rehydration therapy (ORT) is iv. Monitoring input and output (I & O).
usually prescribed if mild to moderate e. Carefully assess all pertinent laboratory data,
dehydration is diagnosed and the child including the complete blood count (CBC),
can tolerate oral fluids. electrolytes, blood gases, and, if performed,
(1) If the child is breastfeeding, ORT is stool culture reports.
offered as a supplement following each i. Metabolic acidosis may develop, secondary
feeding. to the loss of bicarbonate via the stools.
(2) If the child is formula feeding, ORT is ii. Hyponatremia and/or hypokalemia may
usually fed to the child as a be present.
replacement rather than as a f. Provide ORT and/or IV therapy, as needed,
supplement to the formula. per order.
(3) If the child is interested in eating solid i. Calculate the child’s DMV knowing that
foods, small frequent feedings of low the child will be prescribed up to 2½ times
fat meats, complex starches, and well- the DMV in order to replace needed
cooked vegetables may be offered with fluids.
the ORT. ii. If the child is to be managed at home,
iii. IV infusions are needed if the child is inform the parents and child, if
severely dehydrated and/or if the child is appropriate, regarding the importance of
unable to tolerate oral fluids. consuming the rehydration therapy.
b. Antibiotics: may be administered for some iii. Even if vomiting is present, ORT should
bacterial infections. be administered in small, frequent,
i. Antibiotics usually are not administered quantities.
for a diagnosis of diarrhea from E. coli or g. Weigh the child daily.
giardia. h. If the child has previously not tolerated
oral fluids, once he or she is able, the child
! Antidiarrhea medications are not recommended for should return to a normal diet in addition to
children because they often develop constipation from the the ORT.
Fig 14.1 Tape test for the presence of pinworms. V. Cleft Lip/Palate
A. Incidence.
1. Cleft palate alone.
F. Nursing considerations. a. Approximately 2,600 children each year, or 1
1. Risk for Infection. in every 1,500 live births.
a. Obtain a thorough history of the child’s signs 2. Cleft lip alone.
and symptoms as well as his or her activities a. Over 4,400 children each year, or almost 1 in
preceding the illness, e.g., play history and every 1,000 live births.
day-care attendance. 3. Children may also exhibit a combination of cleft
b. Educate the parents regarding how to perform lip and palate.
the tape test. B. Etiology.
i. To prevent startling the child, strongly 1. The cause of the majority of cleft birth defects is
encourage the parents to forewarn their unknown.
child before going to sleep that the tape 2. There is evidence that:
test will be performed early the next a. Women who smoke during pregnancy have a
morning. higher likelihood of delivering a baby with a
c. Educate the parents regarding medication cleft (Little, Cardy & Munger, 2004).
administration for the child as well as for all b. Women who are preexisting diabetics have a
members of the family, as prescribed. higher likelihood of delivering a baby with a
2. Deficient Knowledge. cleft (Spilson, Kim & Chung, 2001).
a. Educate the parents regarding the need to 3. There appears to be a multifactorial cause of
clean clothing and household surfaces well. orofacial clefts (i.e., a combination of genetic
i. Pinworm eggs can live for many weeks on predisposition and environmental factors).
inanimate objects in the child’s a. Clefts are associated with some chromosomal
environment. syndromes (e.g., Pierre Robin syndrome and
b. Remind the parents and child, if appropriate, Down syndrome).
regarding the need for frequent handwashing. b. Clefts are seen more frequently in children of
c. Educate the parents to keep their child’s Asian, Hispanic, and Native American descent.
fingernails short to prevent eggs from C. Pathophysiology (Fig. 14.2).
collecting underneath. 1. Orofacial clefts occur when the structures of the
d. Educate the parents to cover sandboxes when mouth fail to fuse during the organogenic period
not in use. of fetal development.
e. Educate the parents to keep pets from using 2. Cleft lips develop at approximately 6 to 8 weeks’
sandboxes and other play areas for toileting. gestation.
f. Educate the parents to wash fruits and a. Cleft lips can occur unilaterally or bilaterally.
vegetables well. b. They may appear as a slight notch in the lip or
g. Educate the parents to change young children’s extend deep into the nasal cavity.
diapers frequently. i. Cleft lips that extend into the nares usually
h. Advise the parents to dress their children in also adversely affect tooth and gum
clothing that will reduce the likelihood of the development.
child scratching his or her anal area (e.g., 3. Cleft palates occur at approximately 7 to 12 weeks’
“onesie” pajamas). gestation.
iv. Milk will exit via the nose when a cleft ecchymosis, discharge, and approximation
palate is present. of the tissue (REEDA).
b. Risk for Altered Family Process/Anxiety/ (1) Any surgical site, no matter the
Grieving. location, is a potential site of injury
i. Allow the parents to express grief and loss and/or infection. The REEDA
of the perfect child. assessment includes signs of infection
ii. Assess the parents’ responsiveness to the and/or injury.
baby. ii. Maintain elbow restraints to protect
(1) Encourage skin-to-skin contact to the site from injury because infants
promote bonding. put their hand to their mouths
(2) If poor bonding is noted, the nurse involuntarily.
should recommend the primary (1) Only one restraint should be removed
health-care provider to refer the at a time.
family for counseling. (2) The restraints should be removed
iii. Enable the parents to discuss their frequently and the skin under
concerns regarding their feelings of stress restraints should be assessed for signs
and their child’s need for surgery. of altered skin integrity.
c. Deficient Knowledge. iii. Place the infant supine in an infant seat or
i. Teach the parents regarding feeding with the crib head elevated to reduce the
techniques, pre- and postsurgery, as potential for injury, edema, and
needed. respiratory difficulties.
ii. Provide information regarding corrective iv. Cleanse the lip with sterile water after
surgeries. feedings and apply prescribed antibiotic
iii. Encourage the primary health-care ointments to the surgical site to prevent
provider to refer the family for genetic infections.
counseling. v. Apply protective devices (e.g., Logan bow),
iv. Refer the family to community resources if ordered, to maintain the integrity of the
(e.g., Cleft Palate Foundation and suture line.
Children’s Craniofacial Association). b. Pain
v. Educate the parents how to provide their i. Provide both pharmacological and
child with preoperative teaching prior to nonpharmacological pain interventions
surgery, for example: (see Chapter 8, “Nursing Care of the Child
(1) Loosely apply elbow restraints on the in the Health-Care Setting”), as needed
child for approximately 20 min at a and prescribed.
time for a few days prior to surgery. (1) Very important to reduce crying
This will accustom the child to the because stretching of the mouth can
restraints that will be used to prevent lead to suture dehiscence.
the child from injuring the repair. c. Risk for Altered Nutrition: Less than Body
(2) Elevate the head of the child’s crib for Requirements.
sleep, or place the child in an infant i. Infant feedings are usually reintroduced
seat for sleep. This will accustom the shortly after awaking from surgery.
child to the position that he or she (1) Care must be taken to prevent injury
will be placed to reduce inflammation to the suture line.
and aspiration and will prevent the (2) Cleansing of the suture line following
child from rubbing his or her face on feedings is important to prevent
a hard surface. infection (see above).
(3) Attach the Logan bow or other 3. Postoperative cleft palate repair.
protective device that the surgeon may a. Impaired Skin Integrity/Risk for Injury/Risk
use following surgery to accustom the for Infection.
child to its presence. i. Carefully perform REEDA assessments of
2. Postoperative cleft lip repair. the surgical site.
a. Impaired Skin Integrity/Risk for Injury/Risk ii. Keep all objects away from the baby’s
for Infection mouth for 7 to 10 days (e.g., straws,
i. The operative site should be assessed fingers, spoons, forks) to protect the palate
carefully for signs of redness, edema, repair from injury.
iii. Progress diet as indicated, and protect the VI. Esophageal Atresia With
site from injury.
(1) Soft solid foods are usually offered
Tracheoesophageal Fistula (EA/TEF)
from a spoon that is too large to fit
A. Incidence.
into the mouth. The child is taught to
1. About 1 in 4,000 live births in the United States.
slurp the food from the spoon.
B. Etiology.
(2) Similarly, liquids are usually cup fed,
1. Exact etiology is unknown.
spoon fed from a large spoon, or
2. The defect likely has a genetic component because
bottlefed through a short nipple.
about 50% of babies born with the defect have
iv. Following feedings, rinse mouth with
other anomalies, including babies with
water, per orders, to prevent infection.
chromosomal syndromes and with renal, cardiac,
b. Pain
and other gastrointestinal defects.
i. Provide both pharmacological and
C. Pathophysiology (see Fig. 14.3).
nonpharmacological pain interventions, as
1. Esophageal atresia is characterized by an
needed and as prescribed.
esophagus that ends in a blind pouch and, most
(1) Very important to reduce crying
commonly, is accompanied by a defect affecting
because stretching of the mouth can
the trachea.
lead to suture dehiscence.
a. The most common form—EA/TEF—is
4. Long term: Risk for Altered Health Maintenance.
characterized by an esophagus that ends in a
a. On-going speech, hearing assessments, and
blind pouch and with a fistula between the
dental assessments.
distal end of the esophagus and the trachea.
b. Referral to experts in other disciplines (e.g.,
i. Because both the esophagus and the
speech pathologist, orthodontist,
trachea are affected, both the
otolaryngologist), as needed.
iii. Educate the parents regarding corrective ii. Ultrasound visualization confirms the
surgeries. diagnosis.
iv. Enable the parents to discuss concerns 2. Newborn
regarding their stress and the need for a. Direct visualization of the defect is possible.
surgery. b. X-ray, ultrasound, MRI, and/or CT scan are
v. Refer the family to community/parental often performed to determine the severity of
group resources (e.g., Intermountain the defect.
Healthcare System, Salt Lake City, E. Treatment.
Utah). 1. Surgical closure, which may be performed either
(1) Because of the rarity of the defect, prenatally or after delivery.
local resources specific to a. If done as a newborn, the surgery is usually
Hirschsprung’s disease are unlikely. completed within 48 hr of delivery.
d. Pain b. Closure may be performed in stages if the
i. Provide both pharmacological and non- defect is large.
pharmacological pain interventions, as i. The defect is covered with sterile gauze and
needed and as prescribed. plastic covering.
3. Long-term care: ii. Once the skin is able to cover the gastric
a. Provide guidance to the parents and child contents, the surgical repair is completed.
regarding toilet training. F. Nursing considerations.
i. Toilet training usually takes much longer 1. Risk for Injury/Risk for Infection/Risk for Altered
than in children with normal anatomy at Thermoregulation.
birth. a. Maintain N/G tube, as needed.
b. Position the baby supine, taking care to
IX. Gastroschisis/Omphalocele prevent injury to the abdominal contents,
including kinking of intestines.
A. Incidence. c. Cover the site with moist, sterile gauze and
1. Combined incidence is approximately 1 in every plastic.
2,000 live births. d. Monitor for signs of infection.
B. Etiology. e. Monitor for hypothermia and hyperthermia
1. No specific etiology has been established, because infected neonates may exhibit either
however. temperature shift.
a. Higher incidence seen in women who smoke, f. Administer safe dosages of antibiotics, per
drink alcohol, and/or take drugs during their orders.
pregnancies. g. Provide exogenous warmth in Isolette or
b. There appears to be a lower incidence of warming crib to maintain normal temperature.
abdominal wall defects in women who take 2. Imbalanced Nutrition: Less than Body
folic acid supplements during their Requirements/Risk for Deficient Fluid Volume/
pregnancies. Risk for Dysfunctional Gastrointestinal Motility.
C. Pathophysiology. a. Maintain IV, as prescribed.
1. Gastroschisis is a congenital defect in b. Administer total parenteral nutrition (TPN)
which the abdominal wall fails to develop, through a central line, if prescribed.
resulting in the intestines protruding from the c. Monitor strict I & O.
body. d. Monitor weight daily.
a. The abdominal organs lie outside the body, e. Monitor bowel sounds.
with no skin or sac covering. i. The baby is at high risk for developing a
2. Omphalocele is a congenital defect resulting from paralytic ileus (i.e., absence of intestinal
poor abdominal muscle development in which peristalsis).
the intestines or abdominal organs herniate into 3. Risk for Altered Family Process/Anxiety/
the umbilicus. Grieving.
D. Diagnosis. a. Allow parents to express grief and loss of the
1. Prenatally. perfect child.
a. Screening test results indicate the possible b. Assess the parents’ responsiveness to the baby.
presence of a defect. i. Encourage frequent visitation to promote
i. Elevated alpha fetoprotein levels. bonding.
(1) May be obtained either via serum or ii. If poor bonding is noted, the nurse
amniotic fluid testing. should recommend the primary
ii. Advise the parents to report any vomiting. c. Drawing of knees toward the abdomen.
iii. Educate the parents regarding d. Vomiting.
postoperative incision assessment and e. Sausage-shaped mass in right upper quadrant.
care, and to report any deviations from f. “Currant jelly” stools, i.e., stools mixed with
normal. blood and mucus.
D. Diagnosis.
XI. Intussusception 1. Clinical picture is highly suggestive.
2. X-ray, often with barium contrast, and ultrasound
A. Incidence. are diagnostic.
1. Most commonly seen in children under 2 years of E. Treatment.
age, with peak age in middle of the first year of 1. If no signs of shock or sepsis, the bowel is usually
life. restored via air or barium enema.
2. Most common bowel obstruction problem in a. The force of the enema corrects the
children under 5 years of age. intussusception.
3. Higher incidence in boys than in girls.
4. Babies are high risk for recurrence.
DID YOU KNOW?
An intussusception of the bowel is similar to the
B. Etiology.
finger of a rubber glove that invaginates after it is
1. Majority of cases have an unknown cause.
taken off the hand. To correct the invagination, one
2. Gastrointestinal pathology of cystic fibrosis (see
blows into the glove, and the finger pops back to its
Chapter 16, “Nursing Care of the Child with
original position. Similarly, when the child is given
Respiratory Illnesses”) predisposes affected
an enema, the bowel is forced open.
children to intussusception.
C. Pathophysiology. b. Surgical repair, usually via laparoscope, is
1. Invagination of bowel, usually at the ileocecal performed if the clinical picture is poor or if
valve (see Fig. 14.4). an enema is ineffective.
2. Signs and symptoms. F. Nursing considerations.
a. Sudden onset of pain, which begins as periodic 1. Imbalanced Nutrition: Less than Body
and rapidly progresses to constant pain, Requirements/Deficient Fluid Volume.
characterized by intense, inconsolable crying. a. Assess vital signs for possible shock or sepsis.
b. Abdominal guarding. b. Monitor for vomiting and, if present,
document the frequency, amount, and
characteristics of the vomitus.
c. Assess hydration status, including.
i. Calculating the percentage of weight loss.
Ascending ii. Assessing for additional physiological
colon
signs of dehydration, including low
urinary output, poor skin turgor, absence
of tears, and altered vital signs and,
sunken anterior fontanel.
iii. Monitoring the I & O
d. Maintain the NPO until therapy is instituted,
then progress diet, as indicated, following
correction of the defect.
e. Maintain IV therapy, as prescribed.
f. Monitor serum electrolyte laboratory values.
Ileum g. Administer electrolytes, as prescribed.
h. Monitor for resumption of normal stooling
pattern.
i. The child should not be discharged until he
or she has had a normal stool.
2. Risk for Altered Family Process/Anxiety/Deficient
Knowledge.
a. Enable the parents to discuss their concerns
regarding their stress as well as the child’s
Fig 14.4 Intussusception. painful episodes and need for surgery.
1.
2.
3.
B. What objective assessments indicate that this client is experiencing a health alteration?
1.
2.
3.
4.
5.
6.
C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse assign to this client?
1.
D. What interventions should the nurse plan and/or implement to meet this child’s and his family’s needs?
1.
2.
3.
4.
5.
6.
7.
E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing interventions?
1.
2.
3.
4.
F. What physiological and psychological characteristics should the child exhibit before being discharged home?
1.
2.
3.
4.
5.
6.
G. What subjective characteristics should the child exhibit before being discharged home?
1.
12. A child has been diagnosed with Hirschsprung’s 17. The parent of a 6-month-old calls the child’s
disease. Which of the following findings would the primary health-care provider and states, “My child
nurse expect the parents to report in the child’s has had 5 loose stools since she woke up this
history? Select all that apply. morning. What should I do?” The mother is
1. Ribbon-like stools exclusively breastfeeding her baby. Which of the
2. Chronic constipation following responses by the nurse is appropriate?
3. Black and tarry stools 1. “Let’s figure out what you may have eaten during
4. Distended abdomen the last day that could have caused the diarrhea.”
5. Delayed meconium passage 2. “Continue to feed the baby breast milk and give
oral rehydration therapy after each feeding.”
13. A school nurse is monitoring the eating patterns of
3. “That’s not that unusual for babies who are
a child with celiac disease. The nurse counsels the
breastfed but do call again if the stools turn a
child to choose an alternate lunch when the child
green color.”
picks which of the following foods to put on the
4. “Bring the baby in for an appointment with the
lunch tray?
doctor so that we can weigh and check over the
1. Corn taco with refried beans
baby.”
2. Rice noodles with beef and broccoli
3. Turkey meatloaf with baked potato 18. A child is severely dehydrated from a diarrheal
4. Roast pork with applesauce illness. The nurse assesses the child’s laboratory
results. Which of the following results would the
14. A child has just been diagnosed with celiac disease.
nurse expect to find?
Which of the following signs and symptoms would
1. Hematocrit (Hct) 30%
the nurse expect the parents to report in the child’s
2. Partial pressure of oxygen (Po2) 60 mm Hg
history? Select all that apply.
3. Potassium (K) 3.0 mEq/L
1. Irritability
4. Platelet (Plt) count 100,000 cells/mm3
2. Failure to thrive
3. Abdominal pain 19. A 4-year-old child is seen at the primary health-care
4. Excessive hunger provider’s office with vomiting and diarrhea for the
5. Recurring diarrhea past 24 hours. The primary health-care provider
orders a number of interventions. If ordered, the
15. A 10-year-old child is diagnosed with enterobiasis
nurse should question the administration of which
(pinworm). Which of the following signs/symptoms
of the following medications for the child?
would the nurse expect to see?
1. Lomotil (diphenoxylate/atropine)
1. Recurrent vomiting
2. Zofran (ondansetron)
2. Enuresis
3. Reglan (metoclopramide)
3. Bloody diarrhea
4. Dramamine (dimenhydrinate)
4. Pain
20. A child is admitted to the pediatric unit. While the
16. The nurse is educating the parents of a 2-month-old
nurse was taking the nursing history, the child
infant regarding the immunizations that the child
regurgitated vomitus that looked like coffee grounds
will receive that day. The nurse should educate the
and smelled like feces. Which of the following
parents that which of the following immunizations
communications would it be appropriate for the
will protect the child from a serious gastrointestinal
nurse to report to the primary health-care provider?
infection?
“After assessing the vomitus, it appears that the
1. Rotavirus vaccine (RV)
child:
2. Diphtheria, tetanus, and acellular pertussis
1. has an obstruction proximal to the stomach.”
(DTaP)
2. has a perforated duodenal ulcer.”
3. Haemophilus influenzae type b (Hib)
3. is vomiting blood from the lower bowel.”
4. Pneumococcal conjugate (PCV13)
4. is exhibiting signs of ruptured esophageal
varices.”
Content Area: Pediatrics TEST-TAKING TIP: Pinworm eggs hatch in the small
Integrated Processes: Nursing Process: Assessment intestines. They then migrate through the remainder of
Client Need: Physiological Integrity: Physiological the bowel and exit via the anus during the nighttime
Adaptation: Alterations in Body Systems hours. The activity of the worms on the perineum and
Cognitive Level: Application around the anus often results in the child urinating in his
or her sleep.
13. ANSWER: 3 Content Area: Pediatrics
Rationale: Integrated Processes: Nursing Process: Assessment
1. A meal of a corn taco with refried beans is compatible Client Need: Physiological Integrity: Physiological
with a celiac diet. Adaptation: Alteration in Body Systems
2. A meal of rice noodles with beef and broccoli is Cognitive Level: Application
compatible with a celiac diet.
3. The nurse should counsel a child with celiac disease 16. ANSWER: 1
who chooses meatloaf for lunch. Rationale:
4. A meal of roast pork with applesauce is compatible 1. Rotavirus vaccine (RV) is the correct response.
with a celiac diet. 2. Neither diphtheria, tetanus, nor acellular pertussis
TEST-TAKING TIP: Meatloaf is made with breadcrumbs, (DTaP) is a gastrointestinal illness.
and breadcrumbs contain gluten protein. Children and 3. Haemophilus influenzae type b (Hib) protects the baby
parents must be counseled that many foods may look from an organism that causes pneumonia, meningitis, and
like they are compatible with a celiac diet but are not sepsis.
(e.g., meatloaf that looks like it contains only meat but 4. Pneumococcal conjugate (PCV13) protects the baby
also contains breadcrumbs). from an organism that causes pneumonia, meningitis, and
Content Area: Pediatrics sepsis.
Integrated Processes: Nursing Process: Implementation TEST-TAKING TIP: At the 2-month well-baby visit, it is
Client Need: Physiological Integrity: Physiological recommended that infants receive a number of
Adaptation: Potential for Alterations in Body Systems vaccinations: rotavirus (RV); diphtheria, tetanus, and
Cognitive Level: Application acellular pertussis (DTaP); Haemophilus influenzae type b
(Hib); pneumococcal conjugate (PCV13); and inactivated
14. ANSWER: 1, 2, 3, and 5 poliovirus (IPV). Only one of the immunizations protects
Rationale: babies from gastrointestinal illness—the rotavirus vaccine.
1. The nurse would expect the parents to report that the Content Area: Pediatrics
child was irritable. Integrated Processes: Nursing Process: Implementation;
2. The nurse would expect the parents to report that the Teaching/Learning
child experienced failure to thrive. Client Need: Health Promotion and Maintenance: Health
3. The nurse would expect the parents to report that the Promotion/Disease Prevention
child had abdominal pain. Cognitive Level: Application
4. The nurse would not expect the parents to report that
the child had been excessively hungry. In fact, the child 17. ANSWER: 4
would likely have been anorexic. Rationale:
5. The nurse would expect the parents to report that the 1. It is unlikely that a change in the mother’s diet would
child had recurring diarrhea. result in a child developing acute diarrhea. In addition,
TEST-TAKING TIP: Those with celiac disease can exhibit a the child needs to be evaluated for signs of dehydration.
variety of signs and symptoms. Children usually exhibit 2. Although the mother may eventually be directed to
the most common of these: “failure to thrive, chronic continue to breastfeed and to supplement the feedings
diarrhea/constipation, recurring abdominal bloating and with ORT, the baby first needs to be assessed for signs of
pain, fatigue and irritability” (University of Chicago Celiac dehydration.
Disease Center [2014]). 3. Breastfeeding stools are relatively loose, but the baby is
Content Area: Pediatrics 6 months old. The mother, by that time, is clearly familiar
Integrated Processes: Nursing Process: Assessment with the child’s bowel habits.
Client Need: Physiological Integrity: Physiological 4. The baby does need to be weighed to determine
Adaptation: Alteration in Body Systems whether the baby is dehydrated.
Cognitive Level: Application TEST-TAKING TIP: Percentage of weight loss is the best
way to determine the severity of dehydration. The baby
15. ANSWER: 2 should be weighed and the percentage of weight loss
Rationale: calculated. If the baby has mild dehydration, the mother
1. The nurse would not expect to see recurrent vomiting. likely will be advised to continue to breastfeed and to
2. The nurse would expect the child to be wetting the give oral rehydration therapy after each feeding.
bed. However, if the child is severely dehydrated, the child
3. The nurse would not expect to see bloody diarrhea. likely will need IV therapy.
4. The nurse would not expect to see the child in pain.
261
A. Incidence.
1. The majority of male infants with cryptorchidism
are either preterm or lower birth weight babies.
B. Etiology.
1. Infants’ testes descend normally after the 32nd
week of gestation.
C. Pathophysiology.
1. Either one or both testes fail to descend into the
scrotal sac.
D. Diagnosis.
1. The scrotal sacs are gently palpated on admission
into the newborn nursery. If the testes are not felt
in the sac, ultrasonography is often performed to
assess their location.
Urethra Chordee pulls
E. Treatment. opens at penis down
1. The vast majority of infants’ testes will descend on base of
their own by the time they are 6 months of age. scrotum
2. If the testes do not descend naturally, surgery is Fig 15.1 Chordee penis with hypospadias.
performed. Undescended testes place the boy at
high risk for testicular cancer as well as infertility.
F. Nursing considerations. 2. Also higher incidence in sons of women over 35
1. Deficient Knowledge/Anxiety. years of age.
a. Educate the parents regarding the condition. C. Pathophysiology.
b. Advise the parents of the strong likelihood that 1. Hypospadias.
the testes will descend without intervention. a. The urethral opening is located on the
i. If surgery is required, advise the parents underside of the penile shaft.
that the procedure usually is performed b. A chordee penis (a penile shaft that curves
laparoscopically on an outpatient basis, and downward) is frequently seen with
enable parents to discuss their concerns hypospadias (Fig. 15.1).
regarding their stress and the need for 2. Epispadias.
surgery. a. The urethral opening lies on the top side of the
2. Risk for Infection/Risk for Deficient Fluid Volume penile shaft.
related to surgery. b. Bladder exstrophy (a bladder that lies outside
a. Parents must be advised to monitor the of the abdominal cavity) may also be present.
laparoscopic incision carefully for bleeding and D. Diagnosis.
for redness, edema, ecchymosis, discharge and 1. Physical examination and visualization of urine
approximation (REEDA) and to report any flowing from the opening.
deviations from normal. a. Monitoring by nurses of the neonate’s urinary
b. Educate the parents regarding any prescribed stream is important.
interventions to reduce the possibility of E. Treatment.
bleeding and infection of the surgical site. 1. Surgical intervention: to provide the child with as
normal urination and reproductive health as
possible.
III. Hypospadias/Epispadias: Congenital F. Nursing considerations.
Anomalies of the Penile Shaft 1. Deficient Knowledge/Anxiety/Grieving/Altered
Family Processes.
A. Incidence. a. Allow parents to express grief and loss of the
1. Hypospadias: occurs relatively frequently (in perfect child.
about 1 of every 250 male infants), while b. Assess the parents’ responsiveness to the baby.
epispadias is quite rare. i. Encourage skin-to-skin contact to
2. A small percentage of neonates with hypospadias promote bonding.
will also have undescended testes. ii. If poor bonding is noted, the nurse
B. Etiology. should recommend the primary
1. The incidence runs in families, indicating a health-care provider to refer the family
hereditary etiology. for counseling.
c. Educate the parents and child, using age- 2. Usually occurs about 1 to 2 weeks post strep
appropriate language, regarding appropriate infection.
interventions, for example: C. Pathophysiology.
i. Remind the child to void at regular 1. Inflammatory process that results from a toxin
intervals throughout the day. (antigen/antibody complex) produced by the strep
ii. Advise the parent and child to restrict the bacteria. The complex affects the ability of the
child’s fluid intake in the evening hours. glomerulus to filter the blood.
iii. Advise the parent and child to refrain 2. Sodium and water are retained by the body,
from consuming products containing resulting in oliguria and edema. (This rarely
caffeine that can cause bladder irritation. results in encephalopathy.)
iv. Advise the parents to praise the child for 3. Large molecules are able to be excreted through
periods of dryness. the injured capillary walls, most notably red blood
d. If prescribed, educate the parents and child, cells.
using age appropriate language, regarding the 4. Signs and symptoms (see Table 15.1).
safe administration of the nocturnal alarm a. Gross hematuria.
system and/or medications. i. Urine often turns dark brown (tea or coke
colored).
V. Acute Poststreptococcal b. Mild to moderate proteinuria.
c. Edema.
Glomerulonephritis (Acute
i. Especially of the face.
Poststreptococcal Glomerular Nephritis) ii. Most notably in the morning, and edema
subsides as the day progresses.
A. Incidence.
d. Slight weight gain.
1. Seen most frequently in children at high risk for
e. Hypertension: resulting from sodium and
strep throat (i.e., preschool- and school-age
water retention.
children).
f. Elevated ASO antibodies.
2. Acute poststreptococcal glomerulonephritis
(AGN) is may also occur following a case of DID YOU KNOW?
impetigo, scarlet fever, or any other illness caused Streptolysin-O is a toxin released by beta
by S. pyogenes. (See Chapter 11, “Nursing Care of hemolytic streptococcal bacteria that causes
the Child With Infectious Diseases,” and Chapter hemolysis (i.e., the destruction of red blood
19, “Nursing Care of Children With cells). In response, the body produces the
Integumentary System Disorders.”) antibody antistreptolysin-O (ASO), the presence
B. Etiology. of which indicates that an individual is infected
1. Sequela to a group A beta hemolytic strep with beta hemolytic streptococci (S. pyogenes)
infection (see Chapter 16, “Nursing Care of the or had been infected with the bacteria in the
Child With Respiratory Illnesses”). recent past.
D. Diagnosis: clinical history and picture. c. Place the child with a roommate who also
1. Gross hematuria with mild to moderate must comply with activity restrictions.
proteinuria. d. Educate the child, using age-appropriate
2. Elevated ASO antibodies. (If the infection language, and the parents regarding the need
presented as impetigo or other skin infection, the to avoid injury to the kidney until the
child may not have produced ASO antibodies.) inflammation is resolved.
3. Rarely, a culture that is positive for S. pyogenes. 3. Risk for Impaired Skin Integrity.
a. The child will culture positive only if the a. Encourage the child to change positions
infection is still present. frequently.
E. Treatment. b. Provide excellent, atraumatic skin care.
1. Antibiotics, only if the bacteria are still present. c. Place the child on a lamb skin mattress, if
2. Palliative care (there is no cure for AGN). needed.
a. Control of hypertension. d. Monitor skin for signs of dehydration,
i. Antihypertensive medications and/or including poor skin turgor and dry mucous
ii. No salt-added diet and membranes.
iii. Fluid restriction. 4. Anxiety/Fear/Risk for Altered Coping/Deficient
b. To protect the kidneys from further injury, the Knowledge.
child is restricted from engaging in any contact a. Allow the parents and child to express anxiety
sports or activities (e.g., rough housing). and fears.
F. Nursing considerations. b. Reassure everyone that the vast majority of
1. Imbalanced Fluid Volume (interstitial excess and children recover completely and that
intravascular deficit)/Risk for Impaired Gas recurrence is rare.
Exchange/Risk for Altered Breathing Pattern/Risk c. Provide the parents and child with age-
for Injury/Imbalanced Nutrition: Less than Body appropriate explanations of the disease process
Requirements. and of the interventions.
a. Strict intake and output (I & O). d. Educate the parents that whenever their child
i. Report output that is less than minimum has a prolonged sore throat or other possible
for the child. source of S. pyogenes in the future, that he or
(1) Infants and toddlers (although AGN she should be seen by a health-care provider in
rarely seen at this age): 2 to 4 mL/kg/ order to have the site cultured.
hr. e. On discharge, educate the parents and
(2) Preschoolers and young school-age child, using age-appropriate language,
children: 1 to 2 mL/kg/hr. regarding:
(3) Older children: 0.5 to 1 mL/kg/hr. i. Fluid restrictions,
b. Monitor weight daily. ii. Diet modification,
c. Monitor blood pressure every 4 hr, using an iii. The need for blood pressure management,
accurately sized cuff. including important information regarding
d. Auscultate lung fields and report adventitious antihypertensive medications,
sounds. iv. The need for activity restriction, and
i. Pulmonary edema may develop as a result v. The need to return to the primary
of marked fluid retention. health-care provider for frequent blood
e. Restrict fluids, as prescribed. pressure, urine, and serum assessments.
f. Restrict salt intake, as prescribed.
i. Consult with the family and a registered VI. Nephrotic Syndrome (nephrosis)
dietitian to develop a menu of low-salt
foods that are palatable to the child. A. Incidence.
g. Administer safe dosages of antihypertensive 1. Illness predominately of toddlers and preschool-
medications employing the five rights of age children.
medication administration. 2. May recur in the same child.
2. Fatigue/Activity Intolerance. B. Etiology.
a. Organize nursing care, allowing for periods of 1. The specific cause of nephrosis is usually
rest and sleep. unknown (i.e., it is usually an idiopathic
b. Provide interesting, quiet activities (e.g., disease).
television, video games, puzzles) to entertain 2. In rare instances, the disease occurs following
the child. another illness.
Vital Signs
Temperature: 98.8°F
Heart rate: 100 bpm
Respiratory rate: 26 rpm
Blood pressure: 106/66 mm Hg
1.
2.
B. What objective assessments indicate that this client is experiencing a health alteration?
1.
2.
3.
4.
5.
6.
7.
C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse assign to this client?
1.
D. What interventions should the nurse plan and/or implement to meet this child’s and her family’s needs?
1.
2.
3.
4.
5.
6.
7.
8.
9.
E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing interventions?
1.
2.
3.
4.
Continued
1.
2.
3.
4.
5.
6.
7.
G. What subjective characteristics should the child exhibit before being discharged home (from the hospital)?
1.
10. A child is admitted to the pediatric unit with 14. A young girl is being discharged from the pediatric
nephrotic syndrome. Which of the following unit after a left nephrectomy for Stage 1 Wilms’
laboratory results would the nurse expect to see? tumor of the left kidney and the first round of
1. Thrombocytopenia chemotherapy. The nurse is providing the parents
2. Hypoalbuminemia with discharge planning. Which of the following
3. Neutropenia statements should the nurse include?
4. Hypermagnesemia 1. Child will need to restrict fluids for the rest of
his or her life.
11. A child with nephrotic syndrome has been
2. Child will require dialysis until a kidney for
prescribed prednisone. The nurse should monitor
transplant is found.
the child for which of the following medication side
3. Child will be able to live a normal life after the
effects?
surgical site heals.
1. Gastric distress
4. Child will have to take antirejection medications
2. Bradycardia
after surgery.
3. Hypoglycemia
4. Weight loss 15. The parents of a Hispanic American child who has
been diagnosed with Wilms’ tumor ask the nurse
12. A 2-year-old child with nephrotic syndrome is
about the origin of the tumor. Which of the
admitted to the pediatric unit. The following orders
following information should the nurse provide the
have been written in the child’s medical record.
parents?
Which of the actions is highest priority for the
1. “Nephroblastoma is a cancer that originated in
nurse to perform?
another part of your child’s body.”
1. Place child on alternating pressure mattress.
2. “The tumor often starts growing in the kidney
2. Administer intravenous albumin.
while the baby is still in the uterus.”
3. Weigh all wet diapers.
3. “Wilms’ tumor is especially prevalent in the
4. Administer oral antibiotics.
Hispanic population.”
13. A 3-year-old child is admitted to the pediatric unit 4. “The cancer is often seen in children who live in
for surgery. The child has a tumor in his left kidney. areas near nuclear reactors.”
The child is to undergo surgery the next day. Which
16. The oncologist caring for a child immediately
of the following primary health-care practitioner
postsurgery for Wilms’ tumor reports: the child is in
prescriptions is most important for the nurse to
Stage III. The child will go through a series of
follow?
chemotherapy. Based on the proposed therapy,
1. Maintain the child NPO after midnight.
which of the following patient-care goals should be
2. Place a sign at the head of the bed stating, “Do
included in the child’s nursing care plan? Select all
not touch abdomen.”
that apply.
3. Send a urine specimen for a urinalysis.
1. The child will be free of infection.
4. Send a blood specimen for electrolyte analysis.
2. The child will experience no tissue damage.
3. The child will have regular bowel movements.
4. The child will not complain of nausea and will
not vomit.
5. The child will regress to the previous level of
growth and development.
4. This statement is correct. The child will require aspects of each child’s characteristics, including growth
frequent urinalyses and blood pressure assessments to and development, activity levels, and potential for
monitor the progression of the disease. transmission of infection.
5. Children with AGN rarely are placed on strict bedrest. Content Area: Pediatrics
In the early days of the disease, they usually modify their Integrated Processes: Nursing Process: Implementation
own activity level. Once they feel well enough, they are Client Need: Psychosocial Integrity: Therapeutic
allowed to ambulate. Environment
TEST-TAKING TIP: The nurse should educate both the Cognitive Level: Application
parents and the child and should evaluate the child’s as
well as the parents’ understanding. The large part of a
9. ANSWER: 3
Rationale:
child’s day is spent at school away from parents. It is
1. Push and pull toys are appropriate for active toddlers.
critically important that sick children be included in
2. Bean bags would be appropriate for an active child who
age-appropriate discussions about their illnesses as well
is angry at being confined to a bed.
as their plans of care.
3. It would be most appropriate to provide the child
Content Area: Pediatrics
with crayons and paper. The activity would not be too
Integrated Processes: Nursing Process: Implementation:
strenuous, and the child could express his or her feelings
Teaching/Learning
about being hospitalized in a drawing.
Client Need: Physiological Integrity: Reduction of Risk
4. A set of blocks would be appropriate for an active child
Potential: Therapeutic Procedures
who could get down onto the floor and build a tower.
Cognitive Level: Application
TEST-TAKING TIP: Toys and activities provided to sick
7. ANSWER: 4 children should be appropriate to the age without being
Rationale: overly challenging. Materials for drawing and painting are
1. The nurse would expect to see white blood cells in the especially appropriate for school-age children because
urine if the child had a UTI. the art supplies enable the child to express him or herself
2. Because of the hematuria and proteinuria, the nurse through the art. In addition, puppets and dolls enable
would expect to see an increase in the child’s urinary children to act out their frustrations through play.
specific gravity. Content Area: Pediatrics
3. Because the child’s kidney function is compromised, Integrated Processes: Nursing Process: Implementation
the nurse would expect to see reduced creatinine Client Need: Psychosocial Integrity: Therapeutic
clearance in the urine, but a concurrent rise in the serum Environment
creatinine. Cognitive Level: Application
4. The number of red blood cells in the urine increases
dramatically. 10. ANSWER: 2
Rationale:
TEST-TAKING TIP: Laboratory data often can provide the
1. The nurse would expect the platelet count to be within
nurse with important information regarding a patient’s
normal limits.
clinical course. It is essential that the nurse become
2. The child’s serum albumin levels would be markedly
familiar with normal laboratory results and expected
decreased.
changes in relation to disease states.
3. The nurse would expect the serum white blood cell
Content Area: Pediatrics
count to be within normal limits.
Integrated Processes: Nursing Process: Assessment
4. The nurse would expect the serum magnesium levels to
Client Need: Physiological Integrity: Physiological
be within normal limits.
Adaptation: Alterations in Body Systems
Cognitive Level: Application TEST-TAKING TIP: Children with nephrotic syndrome lose
large quantities of albumin into the urine. As a result, the
8. ANSWER: 3 child’s serum albumin levels are markedly decreased.
Rationale: Because antibodies are protein, children with
1. Isolation is not needed. The child has negative cultures. hypoalbuminemia are at high risk for infections.
2. Isolation is not needed. The child has negative cultures. Content Area: Pediatrics
3. This would be the most appropriate room to place the Integrated Processes: Nursing Process: Assessment
child. Children in the early stages of AGN often remain Client Need: Physiological Integrity: Physiological
in their beds because of marked fatigue. A child in Adaptation: Alterations in Body Systems
traction would also be confined to his or her bed. Cognitive Level: Application
4. A child in the hospital for insulin control is likely up
and about with no medically imposed or self-imposed 11. ANSWER: 1
activity restrictions. Although the children are the same Rationale:
age, their activity levels will be much different. 1. Gastric distress is a common side effect of prednisone.
2. Bradycardia is not a documented side effect of
TEST-TAKING TIP: One of the important actions of the
prednisone.
pediatric nurse is the assignment of children to patient
3. Hyperglycemia is seen in patients taking high doses of
rooms. The nurse should take into consideration all
prednisone.
4. Weight loss is not a documented side effect of 3. Child will be able to live a normal life after the
prednisone. surgical site heals. This statement is correct.
TEST-TAKING TIP: It is important for the test taker to 4. The child did not receive a transplant. The child will
read questions carefully. Hyperglycemia is a side effect of not need to take antirejection medications after surgery.
prednisone, while hypoglycemia is not. TEST-TAKING TIP: Stage 1 tumors are tumors that are
Content Area: Pediatrics completely encapsulated, are contained within one
Integrated Processes: Nursing Process: Implementation kidney, and completely removed during surgery. The
Client Need: Physiological Integrity: Pharmacological and prognosis is excellent following successful surgery.
Parenteral Therapies: Adverse Effects/Contraindications/ Content Area: Pediatrics
Side Effects/Interactions Integrated Processes: Nursing Process: Implementation
Cognitive Level: Application Client Need: Physiological Integrity: Reduction of Risk
Potential: Potential for Complications of Diagnostic Tests/
12. ANSWER: 2 Treatments/Procedures
Rationale: Cognitive Level: Application
1. It is important to place the child on an alternating
pressure mattress, but it is not the priority action. 15. ANSWER: 2
2. Administering IV albumin is the priority action. Rationale:
3. Weighing all wet diapers is important, but it is not the 1. Nephroblastomas arise from embryonic tissue and
priority action. develop over time.
4. Administering oral antibiotics is important, but it is not 2. This statement is correct.
the priority action. 3. Wilms’ tumor is slightly more prevalent in the African
TEST-TAKING TIP: To determine the priority action, the American population.
nurse should determine which action will reverse the 4. This statement is untrue.
problem. The only response that is a treatment that will TEST-TAKING TIP: Usually, the etiology of Wilms’ is
help to reverse the pathology of nephrotic syndrome is unknown. About 10% of patients who develop Wilms’
the administration of albumin. were also born with a birth defect, about 2% of children
Content Area: Pediatrics with Wilms’ have a family member who also was
Integrated Processes: Nursing Process: Implementation diagnosed with the tumor, and Wilms’ is seen slightly
Client Need: Safe and Effective Care Environment: more often in the African American population than in
Management of Care: Establishing Priorities other ethnic groups.
Cognitive Level: Analysis Content Area: Pediatrics
Integrated Processes: Nursing Process: Implementation;
13. ANSWER: 2 Teaching/Learning
Rationale: Cognitive Level: Application
1. Even if it were within the 12-hr window before surgery, Client Need: Physiological Integrity: Physiological
this is not the first order that the nurse should complete. Adaptation: Pathophysiology
2. The nurse should first place a sign at the head of the
child’s bed stating, “Do not touch abdomen.” 16. ANSWER: 1, 2, 3, and 4
3. The nurse can wait to send the urine specimen for Rationale:
urinalysis. 1. This is an appropriate patient-care goal.
4. The nurse can wait to send the blood specimen for 2. This is an appropriate patient-care goal.
protein and electrolytes. 3. This is an appropriate patient-care goal.
TEST-TAKING TIP: The prognosis of Wilms’ tumor is 4. This is an appropriate patient-care goal.
dependent on the tumor remaining encapsulated in the 5. Although the child may regress, the goal should be that
kidney. If it were to rupture, the likelihood of metastasis the child will regain or maintain his or her level of growth
markedly increases. The nurse must place the sign at the and development.
head of the child’s bed to make sure that no one TEST-TAKING TIP: Chemotherapy places children at high
entering the room palpates the child’s abdomen. risk for a number of complications. The goals of patient
Content Area: Pediatrics care should state that the child will not develop any of
Integrated Processes: Nursing Process: Implementation the complications, including infection, stomatitis, nausea,
Client Need: Safe and Effective Care Environment: vomiting, and constipation.
Management of Care: Establishing Priorities Content Area: Pediatrics
Cognitive Level: Analysis Integrated Processes: Nursing Process: Planning
Client Need: Physiological Integrity: Pharmacological and
14. ANSWER: 3 Parenteral Therapies: Adverse Effects/Contraindications/
Rationale: Side Effects/Interactions
1. The child will not need to restrict fluids for the rest of Cognitive Level: Application
his or her life.
2. The child still has one kidney. There will be no need for
dialysis.
Acute otitis media (AOM)—Acute inflammation of the high-pitched squeal on inhalation) are signs of the
middle ear. illness.
Asthma—Reversible airway disease characterized by Intercostal retractions—The pulling inward of the
inflammation of the bronchi and lower airway intercostal muscles (attached to the ribs) during
obstruction as a result of edema and mucus labored breathing.
production. Laryngotracheal bronchitis (LTB)—A viral croup illness
Bronchiolitis—Inflammation of the bronchioles seen affecting tissue both above and below the vocal
almost exclusively in infants, primarily caused by cords.
respiratory syncytial virus (RSV). Mucolytic—A class of drugs used to loosen and
Croup—A group of middle airway illnesses primarily liquefy mucus.
seen in infants and toddlers characterized by a Myringotomy—Surgical insertion of tympanostomy
barking cough. tubes to drain fluid from the middle ear related to
Cystic fibrosis (CF)—An autosomal recessive illness in otitis media with effusion (OME).
which sodium and chloride are unable to cross cell Otitis media with effusion (OME)—Condition of the
membranes, resulting in the development of thick middle ear in which fluid is trapped behind the
mucus in the organ systems of the body. eardrum.
Epiglottitis—Life-threatening bacterial croup Pharyngitis—Tonsillitis; marked enlargement of the
characterized by inflammation of the epiglottis and palatine tonsils.
potential tracheal occlusion. High fever with a Stridor—A high-pitched wheezing sound resulting
barky cough and inspiratory stridor (i.e., from a blockage in the upper airway.
277
Trachea Esophagus
Right Left
lung lung
Nasal cavity Eustachian tube
Pharynx
Tongue Palatine tonsil
Epiglottis Lingual tonsil
Larynx
provide practitioners with pictures of the lungs. Practitio- 2. Bacteria, especially Haemophilus influenzae and
ners are also able to view the airway directly via bronchos- Streptococcus pneumoniae.
copies and laryngoscopies. 3. Other risk factors.
a. Formula feeding.
II. Upper Airway: Otitis Media b. Attending day care.
c. Exposure to cigarette smoke.
Ear infections are some of the most common illnesses d. Anatomy and physiology of the young child’s
seen in young children. The term otitis media primarily upper airway.
refers to two conditions of the middle ear: acute i. Young children’s eustachian tubes are
otitis media (AOM) and otitis media with effusion short, wide, and straight, while older
(OME). Although the ear may become infected outside children’s and adults’ are longer, narrower,
of the eardrum, otitis externa, it is not discussed in this and slanted (Fig. 16.3).
chapter. ii. Underdeveloped cartilage allows the tube
A. Incidence. to expand.
1. Most common illness of infants and young iii. Lymphoid tissue obstructs the opening at
children, but rarely seen after 6 years of age. the oropharynx.
B. Etiology. iv. Poor immune systems with frequent
1. Variety of viral illnesses, including the common allergic responses, especially to formula
cold. and tobacco smoke.
Eustachian
tube
Eustachian
tube
A Infant B Adult
Fig 16.3 Differences in (A) infant and (B) adult ear canal angles.
v. Horizontal positioning of infants during b. Reducing the child’s exposure to factors that
sleep and during feeds that creates pooling place the child at risk of otitis.
of fluids, especially formula, in the i. Breastfeeding instead of formula feeding
pharyngeal cavity. (see Chapter 11, “Nursing Care of the
C. Pathophysiology. Child With Immunologic Alterations,” for
1. Acute otitis media (AOM). a discussion of the immunologic benefits
a. Acute inflammation of the middle ear. of breastfeeding).
b. Signs and symptoms. (1) If the child is formula feeding, not
i. Acute onset of pain, crankiness, pulling on propping the bottle or putting the
the ear, and fever. baby to bed with a bottle.
ii. Bulging, red tympanic membrane. ii. Not smoking in the baby’s vicinity.
iii. Pus-like drainage. iii. Isolating the baby from sick individuals,
2. Otitis media with effusion (OME). especially children.
a. Subacute problem with fluid trapped behind 3. AOM—The current treatment plan recommended
the eardrum. by Lieberthal and colleagues (2013) for the
b. Signs and symptoms. American Academy of Pediatrics (American
i. Hearing loss with tinnitus. Academy of Family Physicians) is dependent on
ii. Dull, retracted tympanic membrane. the age and overall health status of the child.
D. Diagnosis. a. If the child is younger than or equal to 6
1. Usually by clinical signs alone. months of age.
2. Visualization of the tympanic membrane via an i. Antibiotics (Amoxicillin is recommended
otoscope, making sure to employ the correct as the first-line antibiotic) should be
technique (Fig. 7.2). administered at the time of diagnosis.
a. Infants. b. If the child is between 6 months and 2 years of
i. Because the canal curves upward and age.
the membrane lies horizontal along the i. Administration of antibiotics is
upper wall of the canal, the pinnae of the determined by the severity of the illness or
ear must be pulled downward and when a specific bacterial organism has
backward. been identified.
b. Three-year-olds and older. c. If the child is equal to or over 2 years of age.
i. Because the canal curves downward and i. Palliative care alone provided for up to
forward and the drum slopes inward and 3 days, often called watchful waiting,
forward, the pinnae of the ear must be unless the child is severely ill or a specific
pulled upward and backward. bacterial organism has been identified.
3. Culture and sensitivity—If drainage is present. (1) Watchful waiting is recommended
4. To distinguish OME from AOM. because many cases of AOM are
a. Pneumatic otoscopy—A test that measures the caused by viruses rather than
movement of the tympanic membrane. bacteria.
b. Tympanometry—A test that measures the (a) If after watchful waiting the AOM
pressures in the middle ear as well as is still present, antibiotics are
movement of the tympanic membrane. usually prescribed.
E. Treatment. (2) Palliative care.
1. Treatment of otitis is controversial. (a) Safe dosages of acetaminophen or
a. Because antibiotics have often been ibuprofen are administered to
administered indiscriminately, resistant control the child’s pain.Warm
organisms have developed. compresses or cold packs
2. Prevention: like much of pediatric care, (whichever the child prefers) are
prevention is important. applied to the outer ear.
a. Vaccinations that prevent proliferation of (3) Per the American Academy of
offending organisms should be administered. Pediatrics (AAP), over-the-counter
i. H. influenzae type b (Hib): administered medications (OTC meds), especially
at 2, 4, and 6 months, with a booster dose cough and cold medicines, other than
administered at 12 to 15 months of age. acetaminophen, should not be
ii. Pneumococcal conjugate (PCV13): administered to children under
administered at the same times as the Hib. 2 years of age.
i. Educate parents regarding the need to take (b) Recurrent swallowing is often an
their child to a health-care provider for a indicator of fresh bleeding
throat culture whenever he or she exhibits (c) Any vomitus should be
symptoms. assessed carefully for bright-red
ii. Educate the parents regarding the need to blood.
complete the full course of antibiotics, if (d) Any fresh bleeding should be
prescribed. immediately reported to the
iii. Educate the parents regarding sequelae surgeon.
that may occur if the child does not (2) Apply ice collar to the child’s throat
complete the antibiotics. and neck to promote vasoconstriction,
2. Tonsillectomy. to reduce inflammation, and to reduce
a. Preoperative. pain.
i. Anxiety/Deficient Knowledge. (3) Prevent the child from inserting
(1) Allow the parents and child, if straws, forks, and any other potentially
appropriate, to express their concerns harmful objects in his or her mouth.
about surgery. (4) Advise child not to cough, gargle, or
(2) Educate the parents and child, using otherwise strain the throat area.
age-appropriate language, regarding ii. Pain.
the surgical experience (Box 16.1). (1) Regularly assess pain level, using age-
(3) Educate the parents regarding appropriate tool.
postoperative care (see (2) Administer safe dosage of pain
“Postoperative”) because the child will medications employing the five rights
be discharged home shortly after the of medication administration, as
procedure. needed, per orders.
b. Postoperative. iii. Risk of Impaired Airway Clearance/Risk
i. Risk for Bleeding/Risk for Injury. for Altered Breathing Patterns.
(1) Assess the throat for fresh blood (1) Position child in semi-Fowler’s
being especially vigilant for 1 full day position on his or her side to promote
after surgery and 1 week following drainage of oral secretions and to
surgery. minimize inflammation.
(a) The back of the throat should be (2) Carefully monitor respiratory rate and
visualized frequently using a breathing patterns.
flashlight. (a) Any alteration in the child’s
breathing pattern and/or any color
change should be immediately
reported.
iv. Risk for Imbalanced Nutrition: Less than
Box 16.1 Preoperative Education of a Child
Body Requirements/Risk for Deficient
for a Tonsillectomy
Fluid Volume.
• Using puppets and dolls to convey the information may (1) Begin clear fluids, including ice pops,
help to reduce the child’s fears. when the child is awake and alert.
• Have the child try on surgical attire and look at him or (a) Because of the color of blood, red-
herself in the mirror to see how the surgical staff will colored liquids should not be
appear.
• Advise the child that pain medicine will be available. served.
• Advise the child that he or she may hold a favorite toy or (b) Because they can be painful to
blanket before and after surgery. swallow, citrus juices should not
• Inform the child about: be served.
• The possible sight of dried blood around his or her (2) Because dairy products may increase
mouth.
• The postoperative sore throat. mucus production, coughing, and
• IV therapy throat clearing, they usually are not
• The need for an ice collar. added to the diet until the child is
• The possibility of his or her speech sounding strange. postoperative day 2 or 3.
• The postoperative diet. (3) The child’s diet should be advanced
• The nursing assessments, including visualizing the back of
the throat with a flashlight. slowly to a soft diet during the week
after surgery.
! A definitive diagnosis of epiglottitis is made when a (a) Epinephrine rapidly reverses the
cherry-red, swollen epiglottis is visualized. It is, however, inflammation, but epinephrine has
dangerous to do so. There is a strong likelihood that when a a very short half-life, so the child
child with epiglottitis opens his or her mouth wide that the must be watched carefully for a
action will result in marked inflammation and total tracheal return of respiratory distress.
occlusion. Nurses who suspect that a child has epiglottitis (b) IV antibiotics.
should NEVER assess the child’s throat and should seek (3) Administer humidified oxygen, as
immediate medical assistance. If a physician performs a needed and as prescribed.
visual examination, the nurse should make certain that (4) If intubated, the child’s airway should
intubation and tracheostomy trays are immediately available be suctioned, as needed.
in case they are needed. (5) The child should be allowed to assume
the most comfortable posture.
(2) The epiglottis should be assessed by a (6) The child’s respiratory effort should be
primary health-care provider only. assessed frequently for altered lung
(3) An intubation and tracheostomy tray sounds and for signs of respiratory
should be immediately available. distress, including stridor, rales, and
e. Treatment. wheezing.
i. Prevention. (7) Assess the child’s oxygenation status
(1) Immunizations against Haemophilus via continuous pulse oximetry and
influenzae type b (Hib) and blood gas assessments, as ordered.
pneumococcal bacteria (PCV) (see (8) Administer safe dosage of antipyretics,
Chapter 11: “Nursing Care of the as ordered.
Child With Immunologic Alterations”) ii. Anxiety/Fear/Risk for Altered Coping.
have markedly reduced the number of (1) Maintain as calm a demeanor as
children contracting epiglottitis. possible while caring for the child.
ii. Treatment. (2) Allow the parents to remain with the
(1) Intubation. child to provide reassurance and
(2) IV epinephrine. distraction.
(3) IV antibiotics. (3) Allow the parents to express their
(4) Humidified oxygen administration. concerns/fears.
f. Nursing considerations. (4) Calm the child with
i. Infection/Risk of Ineffective Breathing nonpharmacological means,
Pattern/Impaired Gas Exchange/Ineffective including, for example, distracting the
Airway Clearance. child, allowing the child to keep a
(1) Assist with intubation. favorite toy/object, and singing to the
(2) Safe dosages of the medications, child.
employing the five rights of iii. Risk of Deficient Fluid Volume.
medication administration, should be (1) Monitor the child for signs of
administered, per orders. dehydration (See Chapter 13, “Nursing
Care of the Child With Fluid and
Electrolyte Alterations”).
MAKING THE CONNECTION (2) Administer warm fluids (if safe) and
The priority nursing actions for a child with epiglottitis IV fluids, as prescribed.
who is still breathing effectively is the administration (3) Monitor the child’s temperature at
of IV medications (i.e., epinephrine and antibiotics), least every 4 hr.
because the only action that will reverse the illness is iv. Deficient Knowledge.
the administration of the medications. Primary health- (1) Remind the parents regarding the
care providers, however, often intubate children before importance of vaccinations.
inserting the IV catheter in preparation for the admin- (2) Advise the parents that viral croup
istration of the medications. IV insertion is a painful may recur, but bacterial croup rarely
procedure, leading children to cry and to open their does.
mouths wide, which would likely result in an obstructed (3) Inform the parents regarding actions
airway. Intubating the child before the IV insertion that should be taken if signs of croup
reduces the likelihood of a compromised airway. appear and when to proceed to the
emergency department.
b. Maintain as calm an environment as possible. iv. Either heart failure or pneumonia are
c. Provide the parents with information usual causes of death.
regarding the illness, therapies, and the need b. Gastrointestinal system.
for isolation. i. Meconium ileus: early sign of the disease.
(1) Meconium stool expelled after 24 hr of
age.
VI. Lower Airway: Cystic Fibrosis ii. Pancreatic involvement.
(1) Absence of pancreatic enzymes
A. Incidence.
resulting in:
1. Cystic fibrosis (CF) is one of the most common
(a) Altered fat digestion.
autosomal recessive illnesses.
(b) Inadequate absorption of fat-
2. Seen most commonly in those of northern
soluble vitamins.
European descent, but mutations are seen in all
(c) Reduced caloric intake and failure
ethnicities.
to thrive.
3. 1/3,500 live Caucasian births.
(d) Steatorrhea: fatty, bulky, smelly
B. Etiology.
stools.
1. Autosomal recessive illness:
(i) Often leads to rectal prolapse
a. Punnett square: example of probability of
and high risk for
inheritance if both parents are carriers (Aa) for
intussusception (see Chapter
the illness.
14, “Nursing Care of the
A a Child With Gastrointestinal
A AA Aa Problems”).
a Aa aa (2) Acquired diabetes mellitus.
Key: A—normal allele; a—CF allele; Aa—carrier genotype; (a) From chronic pancreatic
aa—disease genotype involvement.
25% probability of disease (aa)
(3) Liver disease resulting from
b. CF patients exhibit variable expressivity of the obstructed bile duct.
disease, with some children having a very c. Reproductive system.
serious form, while others exhibit few i. Most men are sterile.
symptoms. (1) From aspermia related to thick mucus
C. Pathophysiology. production or from congenital
1. CFTR gene mutation leading to the production of absence of the vas deferens.
a malfunctioning protein and resulting in the ii. Females are often infertile.
inability of the chloride molecule to cross cell (1) Secondary to fallopian tube
membranes. obstruction resulting from mucus
a. Because sodium and chloride are markedly production.
attracted to each other, CF basically is an D. Diagnosis.
abnormality in salt and water transport across 1. Prenatal DNA analysis if family history.
epithelial surfaces. a. Via amniocentesis or chorionic villus sampling
2. Results in thick mucus developing in the organ (CVS).
systems of the body. 2. Newborn screening of the most common CF
3. Predominately affects the pulmonary, mutations is performed in all 50 states.
gastrointestinal, and reproductive systems. a. Neonates are not always screened for less
4. Signs and symptoms. common mutations.
a. Respiratory system. 3. DNA analysis of the child’s CFTR genes.
i. Copious amounts of thick mucus that are 4. Sweat test: reliable assessment.
virtually impossible to cough up without a. The two-part noninvasive test, which must be
the assistance of chest physical therapy performed using a precise technique, measures
(CPT) and medication. the quantity of chloride in the child’s
ii. Frequent bouts of bronchitis and bacterial perspiration.
pneumonia. b. Diagnostic chloride levels vary according to
iii. Chronic lower airway symptoms, the child’s age (Cystic Fibrosis Foundation,
including crackles, wheezing, intercostal 2011).
retractions, diminished breath sounds, and i. For infants 6 months of age or younger,
chronic hypoxia. chloride levels:
(1) Over 60 mEq/L are diagnostic. in the salt molecules and water to
(2) Between 30 and 59 mEq/L are cross cell membranes.
suggestive, and the test must be c. Anti-inflammatories, to help to maintain lung
repeated. function (e.g., ibuprofen).
(3) Below 30 mEq/L are negative. d. Inhaled corticosteroids (e.g., Flovent or
ii. For children older than 6 months, chloride Pulmicort).
levels: 3. Gastrointestinal.
(1) Over 60 mEq/L are diagnostic. a. High-calorie, high-protein diet.
(2) Between 40 and 59 mEq/L are b. Pancreatic enzymes with every meal and snack
suggestive, and the test must be to facilitate fat digestion.
repeated. c. Water-miscible forms of fat-soluble vitamins.
(3) Below 40 mEq/L are negative. d. Extra salt intake during times of increased
E. Treatment. perspiration (e.g., heat and exercise) to enable
1. CF is considered to be an incurable disease, the child to maintain normal electrolyte
although lung transplantation and gene therapies balance.
are being used in some children. F. Nursing considerations.
2. Respiratory: maintenance therapies as well as 1. Ineffective Airway Clearance/Impaired Gas
acute illnesses. Exchange.
a. Chest physiotherapy. a. Assess respiratory function.
i. Percussion and vibration with postural i. During routine examinations or during
drainage, oscillating therapy devices, and periods of respiratory compromise
other methods used to mobilize the thick multiple assessments may be performed
mucus. (e.g., lung sounds, respiratory rate,
ii. Daily exercise. oxygen saturations, blood gases, and
(1) Swimming is often recommended as a skin color).
daily exercise because while ii. Assess for signs of chronic hypoxemia
swimming, the child: (e.g., check for clubbing and
(a) Breathes in humidified air and polycythemia).
(b) Breathes out into the water. b. Perform chest physiotherapy two to three
b. Medications times per day or as needed.
i. Inhaled bronchodilators (e.g., albuterol). i. At least 1 hr before meals or 2 hr after
ii. Mucolytics to loosen and liquefy the meals to reduce episodes of nausea and
mucus. vomiting.
(1) Pulmozyme (dornase alfa) inhaled c. Teach “huffing” technique to increase mucus
via nebulizer, which works by mobilization.
fragmenting the DNA of the d. Administer safe dosages of medications,
extracellular mucus. including bronchodilators, mucolytics, Tobi,
(2) Inhaled hypertonic, sterile saline and others, per orders.
solution, if over 6 years of age, via e. Administer oxygen, carefully, per order.
nebulizer that helps clear the thick i. Because the child likely is chronically
mucus in the lungs. hypercapnic, the child may become
iii. Inhaled Tobi (tobramycin) via nebulizer. apneic if oxygen is administered in
(1) Administered daily to prevent high doses.
Pseudomonas aeruginosa pneumonia f. Allow the child to assume posture of
infection because most CF patients are comfort.
chronically colonized with the g. When physically able, promote exercise (e.g.,
bacteria. swimming).
iv. Kalydeco (ivacaltor), an oral medication 2. Risk for Infection/Infection.
approved by the FDA in 2012, is the first a. Perform meticulous handwashing.
drug to treat the etiology of CF. b. Encourage parents and child, if appropriate, to
(1) The drug has been approved for avoid contact with children and adults with
children aged 6 and older with specific active infection.
CF gene mutations. c. Administer all childhood vaccinations, per
(2) The medication enables the affected recommended schedule.
protein to function, therefore resulting d. Administer safe dosage of Tobi, per order.
e. Monitor for signs of infection: fever, chills, VII. Lower Airway: Asthma
dyspnea, and elevated white blood cell count.
f. If pneumonia has been diagnosed, administer Asthma, a reversible obstructive airway disease, is the
safe dosages of IV antibiotics, as prescribed. most common admitting diagnosis in children’s hospitals.
3. Imbalanced Nutrition: Less than Body A. Incidence.
Requirements/Delayed Growth and Development. 1. Higher incidence in African American children
a. Provide a well-balanced diet that is high in and children living in crowded, urban locations.
calories and protein. a. Severity often lessens as the child grows and
b. Administer pancreatic enzymes with every his or her airway matures.
food intake. B. Etiology.
i. Infants frequently are fed predigested 1. A trigger (may be an infection, smoke, change in
formula. temperature, food allergy, pet allergy, allergy to
ii. Younger child: open capsules and spread pollen, exercise, or another irritant) stimulates an
the enzymes on a cracker or other non- inflammatory response within the bronchi.
protein food. 2. Each person’s trigger is individual and must be
iii. Older child: have the child swallow the identified in order to control the disease.
enzyme capsules. C. Pathophysiology.
c. Administer water-miscible forms of fat-soluble 1. Inflammation of the bronchi with concurrent
vitamins. airway obstruction as a result of edema and
d. Monitor consistency and frequency of stools. mucus production.
e. Chart height and weight progression at each 2. Signs and symptoms.
medical checkup. a. Minor attack.
4. Deficient Knowledge. i. Prolonged exhalation: resulting from
a. Educate the parents and child, when difficulty in exhaling air from the lungs
appropriate and using age-appropriate through the inflamed bronchi.
language, regarding the genetic and chronic ii. Coughing.
nature of the illness. iii. Wheezing.
b. Educate the family, child, and others iv. Mild shortness of breath.
regarding the importance of maintenance v. “Yellow” zone on expiratory flow meter
therapies. (see below).
c. Refer the parents to a genetic counselor. b. Severe attack.
d. Advise the parents to notify the child’s school i. Marked respiratory distress, including
regarding his or her illness, medications, and intercostal retractions, tachycardia,
the need for chest physiotherapy during the tachypnea, and cyanosis.
school day. (1) Initially, tachypnea leads to respiratory
5. Anxiety/Risk for Altered Coping/Anticipatory alkalosis.
Grieving. (2) If respiratory function does not return
a. Allow the family and child to express their to normal, respiratory acidosis and
anger, frustration, and guilt regarding the hypoxia develop.
genetic and chronic nature of the disease. (3) Eventually, when no air exchange is
b. Allow the family and child to discuss the occurring, patients may develop a
ultimate progression of the disease, including “silent chest.”
anticipatory grief. ii. Restlessness, apprehension, and diaphoresis.
i. In severely affected patients, death often (1) From marked anxiety and hypoxia.
occurs by the mid-20s. iii. Tripod positioning.
c. Encourage the parents and child, when iv. Chest tightening: “I can’t breathe.”
appropriate, to join a support group (e.g., v. “Red” zone on expiratory flow meter
Cystic Fibrosis Foundation). (see below).
d. Encourage the child to wear a MedicAlert vi. Death is possible if the attack goes
bracelet. untreated or if treatment is delayed.
e. Introduce the child and family to others with D. Diagnosis.
the disease. 1. Clinical signs and clinical history.
f. Encourage the parents to allow the child to 2. Peak expiratory flow assessments, that is,
engage in age-appropriate activities, as measurements of how effectively the child can
tolerated. exhale the air in his or her lungs.
a. Following the assessment, the child’s primary ii. If the child’s peak flow is in the “red” zone,
health-care provider will determine the child’s the child should be transported to the
optimal peak flow. emergency department for emergent care
b. Base on the child’s optimal peak flow, the (see below).
practitioner will determine the child’s “yellow” b. Emergent care.
zone, which will indicate when the child is i. Inhaled bronchodilators every 20 minutes.
experiencing an early attack, and the child’s ii. IV steroids, if needed.
“red” zone, when the child is experiencing a iii. Intubation and ventilator support, if
severe attack. needed.
3. Assessments of vital lung capacity, i.e., F. Nursing considerations.
measurement of the greatest amount of air that 1. Deficient Knowledge/Risk for Injury.
the child is able to exhale after breathing in his or a. Educate the parents and child, if appropriate,
her maximum. regarding the need to identify trigger(s) of
4. Blood gases. attacks.
5. Pulse oximetry. i. Educate the parents and child, if appropriate,
6. RAST testing (radioallergosorbent test) to assess to avoid contact with the known trigger(s).
for allergens. b. Educate the parents and child, if appropriate,
E. Treatment. regarding the differences between maintenance
1. Treatment regimen to prevent an acute asthma and rescue medications.
attack. i. Educate the parents and child, if
a. Identification of the trigger(s) is essential. appropriate, regarding the importance of
b. Regular exercise (swimming is an excellent taking prevention, i.e., maintenance,
respiratory therapy) as an aid in improving medications.
pulmonary function. ii. Educate the parents and child, if
c. Immunotherapy (allergy shots) to develop appropriate, regarding nebulizer and/or
immunity to the trigger. MDI usage (see Chapter 9, “Pediatric
d. Monitoring of expiratory peak flow and vital Medication Administration”).
lung capacity. (1) Spacers should be used for young
e. Medications: individualized in relation to the children who are to be medicated with
child’s trigger and pattern of attacks. an MDI.
i. Inhaled corticosteroids: by nebulizer (if c. Educate the parents and child, if appropriate,
young) or metered dose inhaler (MDI) regarding pulmonary function tests and the
(for older children, if able). use of a peak flow meter.
(1) Such as Pulmicort (budesonide) and i. Zones are determined and set by the
Flovent (fluricasone). primary health-care practitioner.
ii. Leukotriene inhibitor. d. Advise the parents to notify the child’s school
(1) Such as Singulair (montelukast) PO. nurse and teacher regarding the illness and
iii. Long-acting beta-2 adrenergic agonists medications.
(LABA). e. Encourage the child to wear a MedicAlert
(1) Such as Serevent (salmeterol) via bracelet.
MDI. 2. During an attack: Ineffective Airway Clearance/
iv. Short-acting beta-2 agonist (SABA): prior Impaired Gas Exchange/Fatigue/Activity
to exercise or exposure to known allergen. Intolerance.
(1) Such as albuterol or Xopenex a. Assess respiratory effort, including peak flow
(levalbuterol): nebulizer or MDI. assessment, auscultation of lung fields,
2. Treatments performed during an acute attack. respiratory rate, blood gases, and oxygen
a. Assess the child’s peak flow using a portable saturation.
peak flow meter. b. Administer safe dosage of bronchodilators and
i. If child’s peak flow is in the “yellow” zone, other medications, as ordered, and monitor for
the child will likely be able to be treated at effectiveness.
home. c. Administer humidified oxygen, as ordered.
(1) SABA (e.g., albuterol or Xopenex d. Assist the child to assume his or her position
[levalbuterol]) will need to be of choice.
administered via nebulizer or MDI, as e. Place intubation and tracheostomy trays at the
prescribed, as soon as possible. child’s bedside.
1.
2.
3.
4.
5.
6.
B. What objective assessments indicate that this client is experiencing a health alteration?
1.
2.
3.
4.
5.
6.
C. After analyzing the data that has been collected, what primary nursing diagnoses should the nurse assign to this client?
1.
2.
D. What interventions should the nurse plan and/or implement to meet this child’s and her family’s needs?
1.
2.
3.
4.
5.
6.
7.
E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing interventions?
1.
2.
F. What physiological characteristics should the child exhibit before being discharged home?
1.
G. What subjective characteristics should the child exhibit before being discharged home?
1.
9. A child is seen in the emergency department. The 14. A 10-year-old child has cystic fibrosis. It would be
nurse hears a high-pitched squeal every time the appropriate for the nurse to advise the parents that
child inhales. The parent states that the child’s fever the child should be monitored yearly for which of
is very high and, in addition, the child is gasping for the following illnesses?
breath and sitting in the tripod position. Which of 1. Lupus
the following actions would be appropriate for the 2. Arthritis
nurse to perform at this time? 3. Hyperthyroidism
1. Provide the child with warm liquids to drink. 4. Diabetes mellitus
2. Inspect the throat with a flashlight and tongue
15. A 4-month-old child is admitted to the pediatric
blade.
unit with a diagnosis of RSV bronchiolitis. The child
3. Check the child’s vital signs and lung fields.
is to receive ribavirin (Virazole) every 12 hr × 3
4. Get immediate medical attention for the child.
days. Which of the following actions by the nurse
10. A nurse is educating a group of parents regarding are appropriate? Select all that apply.
the rationales for the administration of vaccinations. 1. Reconstitute the medication with sterile water.
The nurse should advise the parents that the vaccine 2. Place the child on contact and droplet isolation.
that prevents infections from which of the following 3. Place an oxygen saturation monitor on the child’s
diseases has helped to reduce the numbers of foot.
children diagnosed with bacterial croup? 4. Administer the medication deep in the vastus
1. Hepatitis A lateralis muscle.
2. Hemophilus influenzae type b 5. Advise no pregnant staff or family members to
3. Rotavirus be in contact with the medication.
4. Neisseria meningitidis
16. A baby is born 12 weeks preterm. The nurse should
11. A newborn baby has been diagnosed with cystic determine that which of the following monthly
fibrosis (CF). Regarding which of the following medication injections would be appropriate for this
characteristics of the disease should the nurse child to receive?
forewarn the parents? 1. Hepatitis B immune globulin
1. Chronic conjunctivitis 2. Synagis (palivizumab)
2. Rapid weight gain 3. Pulmozyme (dornase alfa)
3. Recurrent vomiting 4. Varicella-zoster immune globulin
4. Thick respiratory mucus
17. A nurse monitoring a preterm baby with RSV
12. The parents of a child, who has had multiple bronchiolitis notes that the baby is exhibiting signs
respiratory infections since birth, tell the nurse, of respiratory distress. Which of the following signs
“When we kiss our child, all we can taste is salt.” It did the nurse observe? Select all that apply.
would be appropriate for the nurse to suggest to the 1. Huffing
primary health-care provider that the child be 2. Tachypnea
assessed for which of the following illnesses? 3. Nasal flaring
1. Cystic fibrosis 4. Expiratory grunting
2. Asthma 5. Intercostal retractions
3. Bronchiolitis
18. An 8-year-old child, who has a history of asthma, is
4. Pharyngitis
seen in the office of the school nurse with coughing
13. A neonate has been diagnosed with cystic fibrosis. and wheezing. Which of the following actions
The nurse should educate the parents regarding should the nurse perform first?
which of the following dietary needs of their baby? 1. Assess the child’s peak expiratory flow.
1. The baby must receive a dose of folic acid three 2. Educate the child to avoid triggers.
times each day. 3. Transport the child to the emergency
2. The baby must never consume any milk or milk department.
products. 4. Notify the child’s parents of his condition.
3. The baby must receive pancreatic enzymes before
bedtime every night.
4. The baby must consume a predigested formula
that is high in calories.
19. A 10-year-old child has been prescribed an MDI 20. A 3-year-old child, who has been diagnosed with
administered bronchodilator. Which of the asthma, is being prescribed albuterol (Ventolin) via
following actions should the nurse teach the child to nebulizer as a rescue medication for acute episodes.
perform when taking the medication? The parents should be advised that the child may
1. Take care not to shake the medication container exhibit which of the following common side effects
before administering. of the medication?
2. Wait no more than 10 seconds between 1. Insomnia
administrations of the medication. 2. Lethargy
3. Exhale completely before placing the medication 3. Constipation
mouthpiece in the mouth. 4. Weight gain
4. Compress the container for 30 seconds before
inhaling the medication.
REVIEW ANSWERS middle ear. To prevent fluid from entering the middle
ear, children should refrain from submerging their heads
1. ANSWER: 2, 3, and 4 in water.
Rationale: Content Area: Pediatrics—Respiratory
1. Pet ownership has not been shown to have any effect Integrated Processes: Nursing Process: Implementation;
on the incidence of ear infections. Teaching/Learning
2. Cigarette smoke places children at high risk for ear Client Need: Physiological Integrity: Reduction of Risk
infections. Potential: Potential for Complications of Diagnostic Tests/
3. Breastfeeding has been shown to have a protective Treatments/Procedures
effect on the incidence of ear infections. Cognitive Level: Application
4. Day-care attendance places children at high risk for
ear infections.
4. ANSWER: 2
Rationale:
5. Geographic location has not been shown to have an
1. This statement is incorrect. The child will no longer be
effect on the incidence of ear infections.
contagious once he or she has been on the medication for
TEST-TAKING TIP: Nurses working with pregnant women
a full 24 hr.
and with young children should encourage parents to
2. This statement is correct. In order to prevent the child
promote healthful behaviors in the home. Babies who
from developing rheumatic fever or acute glomerular
consume breast milk are less likely to develop ear
nephritis, he or she must complete the full course of
infections as well as a number of other conditions.
antibiotics.
Content Area: Pediatrics—Respiratory
3. The child’s temperature will likely be normal within
Integrated Processes: Nursing Process: Implementation
24 hr of medication administration.
Client Need: Health Promotion and Maintenance: Health
4. Penicillin V may be administered with food.
Promotion/Disease Prevention
TEST-TAKING TIP: The only sore throat bacteria that is
Cognitive Level: Application
usually treated is S. pyogenes or group A beta hemolytic
2. ANSWER: 4 strep because, if left untreated, children may develop
Rationale: serious sequelae from the infection, either rheumatic
1. This statement is correct, but it does not provide the fever or acute glomerular nephritis.
mother with an explanation of why antibiotics have not Content Area: Pediatrics—Respiratory
been prescribed. Integrated Processes: Nursing Process: Implementation;
2. This statement is likely correct, but it does not provide Teaching/Learning
the mother with an explanation of why antibiotics have Client Need: Physiological Integrity: Pharmacological and
not been prescribed. Parenteral Therapies: Medication Administration
3. This statement is not correct. Antibiotics are not Cognitive Level: Application
prescribed for illnesses that are likely viral in origin.
4. This is an appropriate statement for the nurse to
5. ANSWER: 2
Rationale:
make.
1. It is unlikely that a child would be treated for a throat
TEST-TAKING TIP: The nurse should provide the patient
culture that grew out H. influenzae.
with a clear rationale for the health-care provider’s
2. A child would be treated if his or her throat culture
treatment plan.
grew out S. pyogenes.
Content Area: Pediatrics—Respiratory
3. It is unlikely that a child would be treated for a throat
Integrated Processes: Nursing Process: Implementation;
culture that grew out S. pneumoniae.
Teaching/Learning
4. It is unlikely that a child would be treated for a throat
Client Need: Physiological Integrity: Physiological
culture that grew out M. pneumoniae.
Adaptation: Illness Management
TEST-TAKING TIP: The nurse should be familiar with
Cognitive Level: Application
pathogenic bacteria that are especially dangerous.
3. ANSWER: 4 Although H. influenzae and others do cause disease under
Rationale: some circumstances, antibiotics are not routinely
1. The child may sleep flat in bed. administered to children who have the bacteria in their
2. Little to no blood loss is expected after a myringotomy throats. Because of the serious sequelae that can develop
procedure. after a S. pyogenes infection, however, children will
3. Pain medication may be administered, but it is unlikely always be treated when sick from that organism.
that the baby will need narcotics for 48 hr. Content Area: Pediatrics—Respiratory
4. The child’s head should not be allowed to submerge in Integrated Processes: Nursing Process: Implementation
bath or pool water. Client Need: Safe and Effective Care Environment:
TEST-TAKING TIP: Tympanostomy tubes are inserted Management of Care: Collaboration With Interdisciplinary
through the eardrum to enable fluid to drain from the Team
middle ear. Unfortunately, fluid can also travel into the Cognitive Level: Application
6. ANSWER: 1 8. ANSWER: 3
Rationale: Rationale:
1. The parents should be taught to monitor the child for 1. Steam vaporizers should not be placed in children’s
excessive swallowing. rooms.
2. It is contraindicated to place warm compresses around 2. Over-the-counter cough and cold therapies are
the neck of a child who has just undergone a contraindicated for young children.
tonsillectomy. 3. Raising the head of the bed can be helpful for
3. It is contraindicated to offer citrus juices to a child children who are likely suffering from spasmodic croup.
immediately following a tonsillectomy. 4. This child has no fever and appears well. It is unlikely
4. It is contraindicated to position a child supine who has that the child has a bacterial infection.
just undergone a tonsillectomy. TEST-TAKING TIP: Positioning cool mist vaporizers near a
TEST-TAKING TIP: It could be very painful for children child’s bed is an excellent way to provide humidified air
post-tonsillectomy to drink citrus juices. Ice collars are that can often relieve the symptoms of spasmodic croup.
applied to children post-tonsillectomy to reduce On the other hand, children can be seriously burned
inflammation and the risk of excessive bleeding. Children when steam vaporizers are used.
post-tonsillectomy should be elevated and placed in the Content Area: Pediatrics—Respiratory
side-lying position to reduce inflammation and the Integrated Processes: Nursing Process: Implementation
potential for aspiration. If the child is bleeding from the Client Need: Physiological Integrity: Physiological
surgical site, he or she may be swallowing excessively. Adaptation: Illness Management
Content Area: Pediatrics—Respiratory Cognitive Level: Application
Integrated Processes: Nursing Process: Implementation;
Teaching/Learning 9. ANSWER: 4
Client Need: Physiological Integrity: Reduction of Risk Rationale:
Potential: Potential for Complications From Surgical 1. With the signs and symptoms listed, it would be
Procedures and Health Alterations inappropriate to provide the child with something to
Cognitive Level: Application drink.
2. Inspecting the throat of a child with the noted signs
7. ANSWER: 2 and symptoms could result in total occlusion of the
Rationale: trachea.
1. This statement is not correct. Clear liquids are given on 3. Vital signs and lung sounds are appropriate, but not at
the day of surgery. this time.
2. This statement is correct, the child will be given ice 4. The nurse should obtain immediate medical attention
pops on the day of surgery, but no ice cream for a day or for the child.
two. TEST-TAKING TIP: This child is exhibiting three signs/
3. This statement is not correct. Children are usually not symptoms of epiglottitis. Inspiratory stridor is especially
kept NPO after tonsillectomies. concerning. The child should be examined immediately
4. This statement is not appropriate. It provides the child by a primary health-care provider.
with no positive feedback, and children are not kept NPO Content Area: Pediatrics—Respiratory
after tonsillectomies. Integrated Processes: Nursing Process: Implementation
TEST-TAKING TIP: Unless they are experiencing nausea or Client Need: Physiological Integrity: Physiological
are vomiting, children are allowed to have clear liquids Adaptation: Illness Management
shortly after a tonsillectomy. It is recommended that the Cognitive Level: Application
fluids not be red (because blood is red) and should be
cold to reduce the bleeding potential. When milk 10. ANSWER: 2
products are consumed, children often need to clear Rationale:
their throats because of increased mucus production. Any 1. Hepatitis A vaccine prevents a fecal-oral viral illness
aggressive action, such as gargling, crying, coughing, or that affects the liver.
throat clearing, is contraindicated post-tonsillectomy 2. H. influenzae type b vaccine prevents upper
because of the potential for injuring the surgical site. respiratory infections, including bacterial croup.
Content Area: Pediatrics—Respiratory 3. Rotavirus vaccine prevents a serious gastrointestinal
Integrated Processes: Nursing Process: Implementation; infection.
Teaching/Learning 4. Meningococcal vaccine prevents bacterial meningitis
Client Need: Physiological Integrity: Reduction of Risk and meningococcemia.
Potential: Potential for Alterations in Body Systems TEST-TAKING TIP: The vast majority of cases of
Cognitive Level: Application epiglottitis are caused by H. influenzae. Administration of
the vaccine to infants has markedly reduced the numbers
of childhood cases of the disease.
Content Area: Pediatrics—Respiratory
Integrated Processes: Nursing Process: Implementation;
Teaching/Learning
Client Need: Health Promotion and Maintenance: Health Content Area: Pediatrics—Respiratory
Promotion/Disease Prevention Integrated Processes: Nursing Process: Implementation;
Cognitive Level: Application Teaching/Learning
Client Need: Physiological Integrity: Physiological
11. ANSWER: 4 Adaptation: Illness Management
Rationale: Cognitive Level: Application
1. Chronic conjunctivitis is not a sign/symptom of CF.
2. Children with CF often exhibit poor weight gain. 14. ANSWER: 4
3. Recurrent vomiting is not a sign/symptom of CF. Rationale:
4. Thick respiratory mucus is seen in children with CF. 1. Children with CF are not especially at high risk for
TEST-TAKING TIP: Because of a genetic defect, the lupus.
chloride molecule of children with CF is incapable of 2. Children with CF are not especially at high risk for
diffusing across the cell membrane. As a result, thick arthritis.
mucus production is noted in the organ systems of the 3. Children with CF are not especially at high risk for
body, especially the pulmonary, gastrointestinal, and hyperthyroidism.
reproductive systems. 4. Children with CF often become type 1 diabetics.
Content Area: Pediatrics—Respiratory TEST-TAKING TIP: The thick mucus caused by CF results
Integrated Processes: Nursing Process: Implementation; in the inability of the pancreas to produce insulin.
Teaching/Learning Children with CF, therefore, frequently develop type 1
Client Need: Physiological Integrity: Physiological diabetes.
Adaptation: Alteration in Body Systems Content Area: Pediatrics—Respiratory
Cognitive Level: Application Integrated Processes: Nursing Process: Implementation;
Teaching/Learning
12. ANSWER: 1 Client Need: Physiological Integrity: Reduction of Risk
Rationale: Potential: Potential for Alterations in Body Systems
1. There is a high concentration of salt in the sweat of Cognitive Level: Application
children with CF.
2. There is not a high concentration of salt in the sweat of 15. ANSWER: 1, 2, 3, and 5
children with asthma. Rationale:
3. There is not a high concentration of salt in the sweat of 1. Ribavirin should be reconstituted with sterile water.
children with bronchiolitis. 2. Children with RSV should be placed on contact and
4. There is not a high concentration of salt in the sweat of droplet isolation.
children with pharyngitis. 3. A pulse oximeter should be placed on the child’s foot.
TEST-TAKING TIP: The sodium molecule has a high 4. The medication is administered via a SPAG nebulizer.
affinity for the chloride molecule. In CF, the chloride 5. Pregnant women should not be in the room when the
molecule of children with CF is incapable of diffusing medication is administered.
across the cell membrane. As a result, sodium chloride, or TEST-TAKING TIP: Ribavirin is teratogenic, and, because it
salt, is in high concentrations in the sweat of children is administered via a SPAG nebulizer, the medicine
with CF. becomes aerosolized. Pregnant women, therefore, should
Content Area: Pediatrics—Respiratory not be in the same room when the medication is
Integrated Processes: Nursing Process: Implementation administered.
Client Need: Safe and Effective Care Environment: Content Area: Pediatrics—Respiratory
Management of Care: Collaboration With Interdisciplinary Integrated Processes: Nursing Process: Implementation
Team Client Need: Physiological Integrity: Pharmacological and
Cognitive Level: Application Parenteral Therapies: Adverse Effects/Contraindications/
Side Effects/Interactions
13. ANSWER: 4 Cognitive Level: Application
Rationale:
1. Children with CF are not routinely supplemented with 16. ANSWER: 2
folic acid. Rationale:
2. Children with CF may consume milk or milk products. 1. Hepatitis B immune globulin is administered only to
3. Children with CF must receive pancreatic enzymes babies whose mothers are hepatitis B surface antigen
each time they consume food. positive.
4. Babies with CF usually are fed a predigested formula 2. It would be appropriate for the baby to receive
that is high in calories. Synagis (palivizumab).
TEST-TAKING TIP: Children with CF digest fats and 3. Pulmozyme (dornase alfa) is administered to children
proteins poorly. They also gain weight slowly. To ensure with CF.
optimal nutrition, infants frequently are fed a predigested 4. Varicella-zoster immune globulin is only administered
formula. to babies born to mothers who have chicken pox.
Acyanotic defects—Cardiac defects that allow the Cyanotic defects—Cardiac defects that result in blood
blood to traverse freely through the pulmonary bypassing the pulmonary system and, therefore,
system and, therefore, enable the blood to become preventing the blood from being oxygenated.
oxygenated. Obstructive defects—Cardiac defects that are
Atresia—A passageway that should be open that is characterized by an intact vascular system but with
closed or completely undeveloped. an obstruction preventing the free flow of blood
Congestive heart failure (CHF)—A disease process through the heart.
characterized by the inability of the heart to pump Stenosis—Abnormal narrowing.
blood effectively.
299
Superior
Aortic arch Ductus infectious disease, all of which can cause defects. The
vena cava arteriosus most common heart defect seen in neonates is the ven-
Non-inflated Left tricular septal defect.
atrium
lung A. Incidence.
1. Cardiac defects are seen in 4 to 10 out of every
Pulmonary
veins 1,000 live births.
B. Etiology.
Right
atrium 1. Although the cause of the vast majority of defects
Foramen is unknown, they can be caused by a number of
ovale (open) factors, including:
Inferior
a. Prenatal rubella infection.
Ductus vena cava b. Maternal alcohol consumption.
venosus
Aorta c. Advanced maternal age.
Liver d. Maternal diabetes.
Oxygen saturation
Portal vein of blood e. Genetic diseases, such as Down syndrome,
Klinefelter’s syndrome, and Turner syndrome.
Umbilical High
vein Medium
C. Pathophysiology.
Low 1. There are three types of congenital cardiac defects
(see Table 17.1).
To legs
Umbilical DID YOU KNOW?
cord The best way to remember the pathophysiology of
each cardiac defect is carefully to break down the
Placenta Internal iliac name of the defect. For example, a ventricular
artery
Umbilical arteries
septal defect is a defect (or hole) in the septum
(or wall) between the ventricles. Similarly, aortic
Urinary bladder stenosis is a narrowing of the aortic valve.
Acyanotic Defects
Characterized by defects that result in blood being shunted from the left to the right side of the heart. As a result, the blood
enters and reenters the pulmonary system.
Name Signs and Symptoms Treatment
Atrial septal defect (ASD) Most have no symptoms, Many ASDs close
Hole between the atria. May but the child may develop spontaneously. If not, surgery
be a foramen ovale that has CHF, if the ASD is large. A or interventional cardiology
not closed or a defect murmur may be present. may be performed.
unrelated to the fetal duct.
ASD
VSD
Patent ductus arteriosus May have no symptoms, but The defect may close
(PDA) a murmur may be heard, and spontaneously. If not, it may
Most commonly seen in the child may develop CHF. be closed medically with the PDA
premature infants, especially administration of
when they weigh less than indomethacin (Indocin), a
or equal to 1,500 g at birth. prostaglandin inhibitor. If the
The fetal duct between the medication is unsuccessful,
pulmonary artery and the surgery may be needed.
aorta fails to close.
AVC
Continued
TGV
Obstructive Defects
Cardiac defects that are characterized by an intact vascular system but with an obstruction preventing the free flow of blood
through the heart.
Tricuspid atresia (TA) Rapid and sustained Surgical repair.
Characterized by a closed cyanosis.
tricuspid valve, resulting in
no movement of blood
from the right atrium to the
right ventricle. This defect is
incompatible with life
unless another defect is
present that allows mixing
of the blood. TA
PVS
AS
D. Diagnosis—A number of specialized tests are site, compare with those on the opposite
performed in order to accurately diagnose a cardiac extremity, and notify the physician of any
defect: disparity.
1. Echocardiogram. v. Assess the child for signs of pain using an
a. Noninvasive ultrasound of the heart that is age-appropriate pain rating scale.
performed to assess the structures of the heart E. Nursing considerations.
and the blood flow through the heart. 1. Cardiac defects often are not evident until after
birth. During the assessment performed on the
DID YOU KNOW? neonate on admission to the newborn nursery,
Echocardiograms are performed on babies who are
the nurse must, therefore, assess for signs and
unsedated. To keep a baby content during the
symptoms associated with cardiac defects
procedure the nurse should keep the baby as
including signs and symptoms of congestive heart
warm as possible and provide the baby with
failure (see below):
a pacifier.
a. Assess the baby’s skin color, especially
2. Cardiac catheterization. when the baby is crying and feeding, for
a. An invasive diagnostic procedure during duskiness, circumoral cyanosis, i.e., a bluish
which a radiopaque catheter is threaded discoloration around the mouth, and
through a peripheral vessel to the heart. peripheral cyanosis.
b. May be ordered to determine blood flow b. Listen to the apical heart rate for a full minute,
throughout the heart as well as to assess noting whether the heart rate deviates from
oxygen levels and pressures in the chambers of normal (110 to 160 bpm) and/or whether any
the heart. heart murmurs are present.
i. Dye is injected into the heart, and x-rays c. Listen to the lung fields for a full minute for
are taken to determine circulation adventitious sounds, noting whether the
patterns. Periodically during the respiratory rate deviates from normal (30 to
procedure, samples of blood for analysis 60 rpm).
and pressures within the chambers of the d. Palpate the brachial and femoral pulses to note
heart are taken. any variations in intensity between them.
c. Babies are sedated during the procedure. e. Perform pulse oximetry on the baby, preferably
d. The parents must be educated regarding the at least 24 hr after birth. (The number of
procedure and regarding care of the baby false-positive results drop when the test is
postcatheterization. performed after 24 hr of life.)
e. Nursing considerations following the i. The probes should be placed on the right
procedure include: hand and on one foot.
i. Apply a pressure dressing to the puncture ii. An algorithm to determine actions
site. following the screening test is available in
(1) The dressing must be assessed every Kemper and associates (2011), “Strategies
5 to 15 min for the first hour and for implementing screening for critical
frequently throughout the remainder congenital heart disease.”
of the day. f. If indicated, assess the blood pressures (normal
(2) If bleeding is noted on the dressing, 60 to 80 mm Hg/40 to 50 mm Hg) in all four
pressure should be applied and the quadrants, and note any disparity between the
physician notified. pressures in the arms versus the pressures in
(3) The dressing must be protected from the thighs. (Blood pressures often are not
fecal and urine contamination. assessed unless other signs/symptoms are
ii. Keep the extremity where the puncture present.)
was made straight for 4 to 6 hr. It often is g. Notify the neonatologist if any of the signs
helpful to have the child rest on his or her or symptoms are present. If present, an
parent’s lap during this time. echocardiogram likely will be ordered.
iii. Assess pedal pulses distal to the puncture
site, compare with those on the opposite III. Congestive Heart Failure
extremity, and notify the physician of any
disparity. Congestive heart failure (CHF) is the failure of the heart
iv. Assess the temperature and color of the effectively to circulate the blood. It can develop as a result
affected extremity distal to the puncture of either right-sided or left-sided failure.
Clubbed fingers
MAKING THE CONNECTION
The quantity of blood ejected from one of the cardiac
ventricles each minute is called the cardiac output (CO).
It is equal to the product of the stroke volume (SV),
Distorted Normal
which is the quantity of blood ejected from the left angle of
angle of
ventricle each time the heart beats, and the heart rate nailbed nailbed
(HR), or CO = SV × HR.
The SV of children changes little during pathologic
events; therefore one must monitor HR carefully. A
fluctuation of HR that cannot be explained often is an
indication of disease.
A. Incidence.
1. The most common complication of patients with
congenital heart disease.
2. Dependent on the severity of the cardiac defect.
B. Etiology.
1. In children, CHF most commonly results from
altered blood flow secondary to a cardiac defect. Fig 17.2 Clubbed fingers.
C. Pathophysiology.
1. Signs and symptoms (see Box 17.1 for a complete
list).
a. The classic signs and symptoms of CHF are:
i. Tachycardia.
Box 17.1 Signs and Symptoms of Congestive Heart ii. Tachypnea.
Failure iii. Weight gain.
b. When right-sided failure is present.
Cardiovascular i. The right ventricle is unable effectively to
• Tachycardia: rapid heart rate. pump blood into the pulmonary artery,
• Altered pulses: variation in intensity between the brachial
and femoral pulses.
which leads to decreased oxygenation of
• Cardiomegaly: enlarged heart. the blood and increased pressure in the
• Polycythemia: excessive number of circulating red blood right atrium and systemic system.
cells. ii. In addition to the classic signs and
• Clubbing: fingertips and nails that are abnormally broad symptoms, the child will exhibit systemic
and rounded (Fig. 17.2).
• Hypertension: high blood pressure.
signs and symptoms, e.g., dependent
Respiratory
edema, ascites, and hypertension.
c. When left-sided failure is present.
• Dyspnea: difficulty breathing.
• Tachypnea: rapid respiratory rate. i. The left ventricle is unable to pump blood
• Retractions: drawing in of the skin between the ribs during through the aorta, which leads to
each inspiration. pulmonary congestion.
• Recurrent upper respiratory infections. ii. In addition to the classic signs and
• Posturing: taking on a body position that helps to improve symptoms, the child will exhibit signs and
respiratory function. For example, when a child assumes a
tripod posture, he or she sits upright and slightly forward symptoms of pulmonary edema, e.g., rales,
with his or her arms straight and places his or her hands on rhonchi, wheezes, and orthopnea.
a surface to support the body (Fig. 16.4). D. Diagnosis.
Renal 1. Based on the severity of the clinical picture (see
• Fluid retention: secondary to poor renal perfusion that “Signs and symptoms”).
leads to edema—dependent, pulmonary, and/or central— E. Treatment.
and weight gain. 1. Treatment of the underlying defect.
Other Symptoms (related to poor oxygenation) 2. Oxygen, as needed.
• Infants: refusal to eat. 3. Medications.
• Toddlers and older children: sitting or squatting rather than a. Digoxin (Lanoxin): to improve the cardiac
standing; walking or crawling rather than running; taking
frequent rest periods. output by increasing the contractility of the
cardiac muscle and slowing the heart rate.
c. Assist the child with position changes, such as medications; and times to notify the
elevating the head of the bed and assisting an pediatrician of adverse effects.
older child to the tripod position. d. Include the child’s siblings and other family
d. Cluster nursing interventions to allow for rest members in the discussions.
periods. e. Always use language that is appropriate to the
e. Prevent exposure of the child to others with child’s developmental level.
infectious diseases.
4. Risk for Infection. IV. Rheumatic Fever (RF)
a. Monitor the child carefully for signs of
infection because infection increases the RF, an illness that develops subsequent to a bacterial
workload on the heart. illness, is included in this chapter because the most
b. Report temperature elevations, and request serious complication that can result from the illness is
treatment for all infections. scarring and permanent damage to the mitral valve.
c. If inpatient, place the child in a room with a A. Incidence.
noncontagious roommate. 1. Highest incidence is in school-aged children in
d. Maintain meticulous hand washing. lower socioeconomic groups, especially those
5. Activity Intolerance/Fatigue living in crowded housing.
a. If an older child, limit physical activity by B. Etiology.
encouraging quiet activities (e.g., video games, 1. The consequence of an autoimmune response
board games, puzzles). resulting from antibody development following
b. Organize nursing actions to allow for rest an infection from group A beta-hemolytic
periods. streptococci.
c. Intervene immediately to decrease the child’s a. Although there are many different strains of
frustrations, such as anticipating demands and streptococci, including Streptococcus
needs. pneumoniae that causes ear infections and
d. Cuddle and give the older child explanations pneumonia and Streptococcus mutans that is
to reduce anxiety. one of the leading causes of tooth decay,
6. Imbalanced Nutrition: Less than Body Streptococcus pyogenes (i.e., group A beta-
Requirements. hemolytic strep) is the only one that
a. Provide small, frequent feeds to reduce causes RF.
exertion time (babies may breastfeed or b. RF may occur following a case of strep throat
formula feed). (see Chapter 16, “Nursing Care of the Child
b. Alter the feeding method as needed, such as With Respiratory Illnesses”), impetigo (See
gavage feed or increase the hole in a bottle’s Chapter 19: “Nursing Care of the Child
nipple. With Integumentary System Disorders),
c. Feed in the upright posture to facilitate scarlet fever (See Chapter 11: “Nursing
breathing. Care of the Child With Immunologic
d. For the older child, provide highly nutritious, Alterations), or any other illness caused
easily digested but palatable foods, such as by S. pyogenes.
milk shakes and frozen yogurt. 2. RF is usually seen about 2 weeks following the
e. Use incentives to encourage the child to eat, infection.
including the use of picnic-style lunches and C. Pathophysiology.
book readings during the meal. 1. A serious inflammatory disease affecting the
7. Deficient Knowledge/Anxiety/Altered Family heart, joints, central nervous system, and
Processes. subcutaneous tissues.
a. Allow the parents and child, if appropriate, to 2. The inflammation may lead to chronic valvular
express their concerns and feelings. stenosis and/or regurgitation.
i. Parents become frightened when a newborn D. Diagnosis.
is diagnosed with a heart defect. 1. Diagnosed using the Jones criteria (see Table 17.2).
b. Educate the parents, using understandable E. Treatment.
language or pictures, regarding the child’s 1. Antibiotics.
condition. a. If group A beta-hemolytic strep is still present,
c. Educate the parents regarding all medications, the strep infection is treated with oral
including how to take the apical pulse; how to penicillin V (drug of choice) for 10 full days or
administer the medications; side effects of the one dose of penicillin G benzathine IM.
Normal PR Prolonged PR
b. Children who are allergic to penicillin usually infections, especially flu and chickenpox. It is,
receive erythromycin. however, an excellent therapy for children who
c. Antibiotics must be taken until all the have been diagnosed with inflammatory illnesses
medication is gone. such as RF. The nurse must carefully educate the
d. Prophylactic penicillin (either monthly IM or parents regarding the rationale for the
daily PO) usually is prescribed to prevent a administration of the aspirin.
recurrence of the disease in children who have
3. Bedrest.
had RF.
a. To reduce the workload on the heart.
2. Anti-inflammatories.
F. Nursing considerations.
a. Aspirin and corticosteroids: administered to
1. Infection.
prevent cardiac damage and to treat arthritis
a. Culture the possible source of infection (e.g.,
and other inflammatory symptoms.
throat, skin) per accepted technique. (The
DID YOU KNOW? culture may come back negative because
To prevent the development of Reye syndrome, the child’s strep infection already may have
aspirin is contraindicated in children who have viral been eradicated from the body.)
a. No other disease can explain the findings. language that is appropriate to the children’s
b. Fever that lasts for at least 5 days plus the developmental levels.
presence of four of the following five 2. Risk for Injury.
signs/symptoms: a. Monitor temperature and dress the child in
i. Nonpurulent conjunctivitis. lightweight, cotton clothing.
ii. Changes in the oral mucosa (see above). b. Monitor vital signs, EKG, skin color, and
iii. Erythematous palms and soles, followed oxygen saturation levels for deviations from
by desquamation. normal.
iv. Characteristic rash on trunk. c. Administer IVIG as prescribed and as per
v. Cervical lymphadenopathy. hospital protocol.
c. Other tests that are performed. i. Monitor the child closely for signs of
i. Laboratory findings, including elevated transfusion reaction.
white blood cell (WBC) count, elevated ii. Have diphenhydramine (Benadryl),
erythrocyte sedimentation rate (ESR), and acetaminophen (Tylenol), and epinephrine
elevated C-reactive protein. available in case of a transfusion
ii. Electrocardiogram (EKG): heart block emergency.
may be seen during phase 1. 3. Altered Skin Integrity.
iii. Echocardiogram—to assess for coronary a. Monitor rash.
aneurysms b. Cleanse affected areas with water only—no
E. Treatment. soap or other irritants.
1. The goal of therapy is to minimize the c. Use salve on cracked lips, as needed.
cardiovascular pathology. Results are much better d. Report excessive pruritus, and request an order
when the intervention is administered within for antipruritic medication, if needed.
10 days of the onset of the fever. 4. Imbalanced Nutrition: Less than Body
a. High-dose IV immune globulin (IVIG): 2 g/kg Requirements.
once over 10 to 12 hr. (See Chapter 9, a. Provide favorite foods in attractive ways.
“Pediatric Medication Administration,” b. Provide bland foods, and avoid citrus or other
regarding the administration of IV infusions irritating foods/drinks.
and blood products.) 5. Risk for Deficient Fluid Volume.
i. A nonspecific immune globulin is a. Monitor temperature elevation.
administered because the exact organism, b. Carefully monitor the child’s hydration status
and therefore the exact antibody, has not (see Chapter 13, “Nursing Care of the Child
yet been identified. With Fluid and Electrolyte Alterations”),
ii. The IVIG should be clear with no sediment including:
or cloudiness. i. Calculating the percentage of weight
iii. The nurse should check and document the loss.
expiration date and lot number of the ii. Assessing for additional physiological
IVIG. signs of dehydration, including low
b. High-dose aspirin: 80 to 100 mg/kg/day in urinary output, poor skin turgor, absence
four evenly divided dosages until the fever of tears, and altered vital signs.
resolves, then 3 to 5 mg/kg once per day for c. Maintain adequate fluid intake, including IV
approximately 8 more weeks. and oral fluids.
F. Nursing considerations. d. Monitor laboratory data, especially electrolyte
1. Deficient Knowledge/Anxiety/Altered Family values.
Processes. 6. Acute Pain.
a. Educate the parents regarding the a. Assess pain level using an age-appropriate pain
pathophysiology of the disease and reason for rating tool.
IV intervention. b. Monitor for arthritic changes.
b. Allow the parents to express their fears, c. Administer aspirin, as prescribed,
concerns, and feelings. using safe medication administration
c. Educate the parents regarding all protocol.
medications that are administered to d. Maintain bedrest, as needed.
the child. 7. Fear/Anxiety.
d. Include the child’s siblings and other family a. Allow for regression of developmental
members in the discussions. Always use behavior during the hospital stay.
b. Provide transition object and activities d. Provide nap and nighttime rituals to maintain
appropriate to the age level of the child (e.g., consistency of care and to promote needed rest
favorite doll, blanket, videos). periods.
c. Encourage the parents to provide support and
comfort.
1.
2.
3.
4.
5.
6.
B. What objective assessments indicate that this client is experiencing a health alteration?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse assign to this client?
1.
D. What interventions should the nurse plan and/or implement to meet this child’s and his family’s needs?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
1.
2.
3.
F. What physiological characteristics should the child exhibit before being discharged home?
1.
2.
3.
I. Description for anemia. They often have poor eating habits at the same
time that young women start to menstruate, and all teens
Hematology is the study of the blood and blood products. are experiencing rapid growth. SCA and hemophilia are
Relatively few hematologic illnesses are predominately genetic illnesses that are diagnosed in childhood. Thank-
seen in children. Iron-deficiency anemia, although seen fully, although not true in the past, because of improved
throughout the life span, often is seen in infants and tod- therapies, many children affected with these illnesses are
dlers who consume large quantities of milk instead of living well into adulthood. Acute lymphoblastic leukemia
foods that contain iron. Teenagers, too, are at high risk is the most common cancer in children. (Because cancer
321
Table 18.1 Normal Lab Values in Childhood for CBC Blood Cell Types
Cell Type Important Statistics Related Definition of Each Statistic Normal Values of Important Statistics
to the Cell Type With Important Age Differences
Erythrocytes RBC count. Number of RBCs in 1 cubic 3.0 to 4.5 million/mm3: 1 to 6 months
(Red Blood millimeter (mm3) of venous 3.7 to 5.3 million/ mm3: 6 months to 6 years
Cells [RBCs]) blood. 4.0 to 5.2 million/ mm3: 6 to 12 years
4.5 to 5.3 million/ mm3: male adolescents
4.1 to 5.1 million/ mm3: female adolescents
Hematocrit (Hct). Percent of RBCs in total blood 28% to 42%: by 2 months
volume. 35% to 45%: until 12 years
37% to 49%: male adolescents
36% to 46%: female adolescents
Hemoglobin (Hgb). Total amount of hemoglobin, 9.0 to 14.0 g/ dL: by 2 months
the oxygen-carrying protein, 11.5 to 15.5 g/ dL: until 12 years
in the RBCs. 13.0 to 16.0 g/ dL: male adolescents
12.0 to 16.0 g/ dL: female adolescents
Reticulocytes Reticulocyte count. Percent of RBCs that are 0.5% to 1.5%: after 12 weeks of age
(Immature reticulocytes.
RBCs)
Leukocytes Total WBC count. Cells whose chief action is to By 1 mo: 5,000 to 19,500 cells/mm3
(White Blood protect the body from 1 to 3 yr: 6,000 to 17,500 cells/mm3
Cells [WBCs]) microorganisms (divided 4 to 7 yr: 5,500 to 15,500 cells/mm3
into two categories— 8 to 13 yr: 4,500 to 13,500 cells/mm3
granulocytes and Adolescents: 4,500 to 11,000 cells/mm3
agranulocytes).
Differential report: Includes the percentage of each
type of WBC in the blood.
Granulocytes. WBCs that contain granules in
the cytoplasm. They are
produced in the bone
marrow.
Neutrophils: primary Neutrophils: 57% to 67% of total WBC
function is to kill and count
digest bacteria.
Eosinophils: primarily assist Eosinophils: 1% to 3% of total WBC count
the body during allergic
episodes.
Basophils: contain histamine Basophils: up to 0.75% of total WBC count
and heparin; improve
circulation to injured
tissues while also
preventing coagulation.
Agranulocytes. WBCs that contain no granules
in the cytoplasm.
Monocytes: phagocytic cells Monocytes: 3% to 7% of total WBC count
that act like neutrophils.
Lymphocytes: (See the discussion on HIV in Lymphocytes: 25% to 33% of total WBC
T Lymphocytes (also called Chapter 11, “Nursing Care of count
T-cells): involved with Children With Immunologic
cellular immunity. Alterations.”)
B Lymphocytes: involved
with humoral or
antibody immunity.
Thrombocytes Platelet count. Cells that are essential in the 150,000 to 400,000 cells/mm3: throughout
(Platelets) blood clotting process. They life
collect together en masse to
prevent blood from leaking
from small breaks in blood
vessels.
the potential for hypoxia, acidosis, and/or 2. Hemophilia A: one in 4,000 to 1 in 5,000 males.
dehydration (e.g., prolonged periods in the 3. Hemophilia B: approximately 1 in 20,000 males.
sun, hyperthermia, intensive aerobic activities). B. Etiology.
d. Educate the parents and/or child, if 1. Von Willebrand disease.
appropriate, regarding the need to wear a a. Three types: type 1, autosomal dominant
MedicAlert bracelet. inheritance; type 3, autosomal recessive
e. Refer the family to genetic counseling. inheritance; type 2 may be either autosomal
2. Ineffective Peripheral Tissue Perfusion/Risk for dominant or recessive inheritance.
Decreased Cardiac Tissue Perfusion during crises. b. The mutated gene results in a deficiency or
a. Monitor vital signs and oxygen saturation. altered functioning of the Von Willebrand
b. Administer IV fluids, as prescribed. factor.
c. Administer oxygen, per order. 2. Hemophilia A: also called classic hemophilia.
d. Monitor strict intake and output (I&O). a. X-linked recessive inheritance.
e. Administer blood transfusion, as prescribed. b. The mutated gene results in factor VIII
f. Assess laboratory values: RBC count, deficiency or an altered form of factor VIII.
hemoglobin, hematocrit, and reticulocyte 3. Hemophilia B: also called Christmas disease.
count. a. X-linked recessive inheritance.
3. Pain during crises. b. The mutated gene results in either factor IX
a. Monitor pain level using an age-appropriate deficiency or an altered form of factor IX.
pain rating scale.
b. Administer narcotic analgesics, as prescribed
DID YOU KNOW?
Many genetic illnesses exhibit a range of
and as needed.
expressivity. Expressivity refers to the severity of
c. Utilize nonpharmacological pain-relieving
the disease. Some children with hemophilia will
measures (e.g., warmth, guided imagery,
exhibit mild expressivity (i.e., will bleed only when
distraction).
seriously injured). Others will exhibit moderate or
d. Encourage quiet activities (e.g., video games,
severe expressivity (i.e., will bleed with mild to
board games, puzzles).
moderate injury or spontaneously with no injury
e. Perform passive range-of-motion exercises.
at all).
4. Ineffective Coping/Anxiety/Fear.
b. Educate the parents, child, and others C. Pathophysiology.
regarding the disease process. 1. Altered clotting mechanism: specific to the type
c. Allow the parents, child, and others to express of hemophilia, resulting in inability to form a
concerns regarding the health and well-being blood clot, especially during periods of trauma.
of the child. 2. Signs and symptoms include:
i. Include the child’s siblings and other family a. Hemarthrosis, or bleeding into the joint: most
members in the discussions. common problem.
ii. Always use language that is appropriate to i. Can lead to crippling deformities.
the children’s developmental levels. ii. Early signs: stiffness, tingling, and achiness
b. Inform the parents, child, and others regarding in the joint.
the importance of following the prevention iii. Later signs: decreased range of motion,
regimen. signs of inflammation (warmth, redness,
c. Refer the family to a local chapter of the swelling, severe pain).
Sickle Cell Foundation, and introduce the b. Subcutaneous (subcu) and intramuscular
family to other families whose children hemorrhages.
have SCD. c. Spontaneous hematuria.
d. Even more serious manifestations.
IV. Hemophilia i. Bleeding into the neck, mouth, and/or
thorax, any of which may lead to
Hemophilia is a group of hereditary illnesses character- respiratory compromise.
ized by slowed to markedly altered blood clotting result- ii. Intracranial hemorrhage that may lead to
ing from a deficiency of one of the factors necessary for stroke.
blood coagulation. iii. Bleeding into the GI tract that may lead to
A. Incidence. severe hypovolemia or obstruction.
1. Von Willebrand disease: one in 100 to 1 in 10,000 iv. Hematomas in the spinal column that may
individuals; most common bleeding disorder. lead to paralysis.
B. Etiology.
MAKING THE CONNECTION
1. Unknown, but chromosomal anomalies
Because of the following considerations, only nurses
predispose some children to leukemia.
who have been especially trained in the administration
a. Trisomy 21 (Down syndrome): 15 times the
of chemo may administer these drugs:
risk of general population.
b. Translocation of chromosomes 7 and 14: Vesicants: many chemotherapeutic agents cause
frequently seen in children with ALL. serious blistering when exposed to healthy tissue.
Extravasation: if an IV infiltrates while the chemo is
DID YOU KNOW? infusing, the tissue surrounding the vessel can become
All cancers are genetic in origin. That does not
seriously damaged, resulting in minor symptoms of
mean that all cancers are inherited; very few
discomfort, pain, and rash to severe complications
cancers are inherited. Rather, it means that all
related to tissue necrosis, including permanent
cancers develop as a result of a mutation in the
damage.
DNA of the respective cells. In the case of ALL, for
example, a mutation in the bone marrow, the In addition, chemotherapeutic medications can result
etiology of which is unknown, results in the in severe, life-threatening allergic reactions, called
proliferation in the production of lymphoblasts. anaphylactic reactions, that are characterized by
Concurrently, the bone marrow fails to produce hyperthermia, tracheal swelling, and respiratory
mature WBCs, RBCs, and platelets. compromise.
C. Pathophysiology.
1. Hyperproduction of immature white blood cells
(WBCs), called blast cells, in the bone marrow. b. The chemotherapy regimen for children with
2. Poor production of other blood cells and ALL is divided into three phases: induction,
inadequate maturation of WBCs in the bone consolidation, and maintenance.
marrow, resulting in: i. Goal of the induction phase: remission
a. Reduced erythrocyte production resulting in (i.e., to reduce the percentage of blast cells
anemia characterized by fatigue and lack of in the blood to 5% or less).
energy. (1) Response to the medications is
b. Reduced platelet production resulting in monitored by serial bone marrow
thrombocytopenia characterized by petechiae aspirations.
and bruising. (2) If the child does not go into remission,
c. Reduced number of mature WBCs resulting the protocol is changed to a different
in neutropenia characterized by low-grade set of chemotherapeutic agents.
fevers, recurring infections, and
lymphadenopathy.
DID YOU KNOW?
When ALL patients receive chemo, the therapeutic
D. Diagnosis.
goal is to inhibit the production of lymphoblast
1. Initial suspicions from:
cells by the bone marrow. Concurrently, however,
a. Clinical picture.
the chemo inhibits the bone marrow from
b. Altered findings on CBC (see Table 18.1):
producing all blood cells, including RBCs and
i. RBC count less than normal.
platelets. As a result, the medication causes the
ii. Platelet count less than normal.
patients to become even more severely anemic,
iii. Altered WBC count.
thrombocytopenic, and neutropenic than they had
2. Bone marrow biopsy with DNA analysis is
been from the disease. The neutropenia, or
performed to confirm the diagnosis.
immunosuppression, is especially concerning
a. Staging of the disease is based on the results of
because the patients are at very high risk of
the bone marrow biopsy as well as the results
contracting severe, potentially life-threatening
of a lumbar puncture. When blast cells are
infections. All health-care professionals must
found in the cerebral spinal fluid, the
engage, therefore, in excellent infection control and
prognosis is less favorable.
caregiving practices when caring for patients who
E. Treatment.
are receiving chemo.
1. Chemotherapy (chemo) is the conventional
therapy. ii. Goal of the consolidation phase: maintain
a. Exact combination of drugs is dependent on remission and prevent the progression of
the specific protocol for the specific genetic the disease to the central nervous system
type of leukemic cells. and/or the testes, in males.
(1) During this phase, the chemo is 2. Infection or Risk for Infection resulting from
usually administered intrathecally periods of neutropenia.
(i.e., into the spinal column) to a. Monitor vital signs frequently, especially
prevent migration of the cells into temperature.
the CNS. b. Practice meticulous handwashing and aseptic
(2) The testes are radiated if blast cells are technique when performing procedures.
found in that organ. c. Monitor the child for signs of infection, such
iii. Goal of the maintenance phase: continued as:
remission. i. Thrush with stomatitis (inflammation of
(1) Chemo is administered periodically— the mucous membranes in the mouth).
PO and/or IV—over the next few ii. Diarrhea.
years. iii. Urinary tract infections.
(2) Periodic blood counts and bone d. Obtain cultures to identify the pathogen, when
marrow biopsies are performed to appropriate.
monitor for possible relapse. e. Practice safe but meticulous oral hygiene.
2. Bone marrow and/or cord blood transplants may i. Soft toothbrushes should be provided.
be performed f. Administer antibiotics, antivirals, and/or
a. A transplant may be either autologous antifungals, as prescribed.
(patient’s own cells) or allogeneic (donor cells). g. Avoid contact with other children/adults with
b. If the transplant is allogeneic, to prevent active infections or objects that may carry
rejection, antirejection medications are pathogens.
administered, (e.g., prednisone, cyclosporine, h. If febrile, administer anti-pyretic medications,
tacrolimus). as prescribed.
3. Additional medications/interventions that may be i. Because of the potential for bleeding,
administered while the child is undergoing chemo aspirin should be avoided.
and/or transplant include antibiotics, antifungals, i. Administer dead, attenuated vaccines as
antivirals, RBC production stimulators (e.g., recommended by ACIP.
Epogen), white blood cell production stimulators i. Live, attenuated vaccines should not be
(e.g., Leukine), and blood transfusions. administered.
F. Nursing considerations.
1. Anxiety/Fear/Pain. ! As long as a child is immunosuppressed, all live vaccines
(i.e., varicella, MMR, and nasal flu) are contraindicated.
a. Allow the parents and child, if appropriate, to
Immunosuppressed children who receive live vaccines could
discuss their fears and concerns regarding the
die from the unchecked production of the virus in their
diagnosis, including the fear of dying (See
bodies. Even though the viruses had been attenuated, or
Chapter 8, “Nursing Care of the Child in the
made much less potent, immunosuppressed children’s bodies
Health-Care Setting”)
are unable to control the infection.
b. Provide adequate pain and emotional support
when needed, especially during painful and 3. Risk for Altered Tissue Perfusion/Activity
scary procedures. Intolerance/Fatigue resulting from the anemia.
i. Lumbar punctures and bone marrow a. Monitor vital signs carefully.
aspirations, both of which are painful, also b. Monitor for signs of ineffective perfusion
are especially frightening to children (e.g., fatigue, decreased activity, tachycardia,
because they are performed out of one’s pallor).
field of vision. c. Assess and monitor blood counts.
ii. Use age-appropriate pain rating tools, and d. Provide the child with needed rest periods.
assess pain on a regular basis. e. Encourage quiet, age-appropriate activities
iii. Use nonpharmacological pain remedies (e.g., video games, puzzles, reading books).
in conjunction with pharmacological 4. Bleeding or Risk for Bleeding resulting from the
methods, if appropriate and as thrombocytopenia.
prescribed. a. Assess skin for petechiae, purpura, and
c. Query the parents/family regarding whether bruising.
they are using complementary and/or b. Assess stools and urine for the presence of
alternative therapies. blood.
i. These therapies may be beneficial or c. Apply gentle pressure to injuries, including
harmful to the child’s recovery. puncture sites.
d. Avoid contact injuries, especially potential c. Monitor tooth eruption (delayed tooth
head injuries. eruption is common).
e. Provide stool softeners to prevent straining at d. Use nonirritating lotions and soaps, wash
stool. cloths, and towels.
f. Pinch and ice nose bleeds, if they occur. e. Change the child’s position frequently, if
5. Risk for Imbalanced Nutrition: Less than Body bedbound.
Requirements/Risk for Deficient Fluid Volume f. Warn the child and monitor for loss of hair.
resulting from complications of illness and i. Educate the child that his or her hair will
medical therapies (e.g., poor appetite, stomatitis, regrow, although it may look and feel
nausea and vomiting). different.
a. Administer antiemetics with chemo, as needed ii. Encourage the child to wear colorful
and as prescribed. headgear and/or wigs.
b. Administer chemo at night, if possible. 7. Risk for Injury related to side effects of
c. Monitor for signs of dehydration. medications.
d. Maintain strict I&O. a. Monitor for signs of injury—short term as well
e. Assess weight regularly. as long term—related to chemotherapeutic
f. Obtain a referral to a nutritionist. agents, including:
g. Offer favorite foods and fluids in as appealing i. Constipation.
a manner as possible. ii. Foot drop.
h. Refrain from serving foods or fluids that iii. Cognitive dysfunction.
irritate the oral mucosa, e.g., citrus juices, iv. Reproductive dysfunction.
highly salted foods. v. Skeletal changes.
i. Provide the child with high-calorie, high- vi. Altered growth and development.
protein supplements. 8. Deficient Knowledge.
i. Milk shakes are often excellent foods a. Use pictures, microscopes, and all other
because they are nutritious and appealing. available visual tools to provide the child and
In addition, because they are cold they are parents with as complete an understanding of
less irritating to the mucous membranes. how the blood works as possible.
6. Risk for Impaired Skin Integrity/Altered Body b. Keep the parents and child, if appropriate,
Image resulting from side effects of the illness and informed of the progress of the disease and
of the medications. treatments, including side effects of the
a. Assess oral mucosal for ulceration. treatments.
b. Provide the child with saline or sodium c. Allow time for repeated discussions related to
bicarbonate mouthwashes to maintain oral topics such as the disease process, treatment
health. needs, and pain management.
1.
2.
3.
4.
B. What objective assessments indicate that this client is experiencing a health alteration?
1.
2.
3.
4.
5.
6.
7.
1.
D. What interventions should the nurse plan and/or implement to meet this child’s and his family’s needs?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing interventions?
1.
2.
3.
4.
5.
F. What physiological characteristics should the child exhibit before being discharged home?
1.
2.
3.
4.
G. What subjective characteristics should the child exhibit before being discharged home?
1.
REVIEW QUESTIONS 6. A school-age child has sickle cell anemia. The child’s
parents ask the school nurse regarding the high-risk
1. A toddler has been diagnosed with iron-deficiency nature of 4 activities the child is requesting to
anemia. Which of the following information should participate in. Which of the following activities
the nurse educate the parents regarding medication should the nurse advise the parents is most high
administration? risk for the child to perform?
1. Add the iron elixir to his morning bottle. 1. Perform the lead role in the school play.
2. Have the child drink orange juice right after he 2. Play the violin in the school orchestra.
takes his medicine. 3. Create an oil painting in art class.
3. Administer the medicine right before his meals. 4. Join the after-school wrestling team.
4. Crush the tablets and mix the medicine with his
applesauce. 7. A child with sickle cell anemia weighs 68 lb. How
many mL of fluid should this child consume per
2. The maximum safe dosage of elemental iron for a day (i.e., what are this child’s daily maintenance
child 6 months to 2 years of age is 6 mg/kg/day in fluid needs)? (If rounding is needed, please
divided doses tid or qid. Which of the following calculate to the nearest tenth.)
prescriptions is safe for an 18-month-old child
weighing 22 pounds? mL
1. 15 mg qid
2. 20 mg qid 8. A 12-year-old boy with a history of sickle cell
3. 25 mg tid anemia and a diagnosis of vaso-occlusive crisis is
4. 30 mg tid being assessed by the admitting nurse in the
emergency department. Which of the following
3. A child has been prescribed 20 mg of elemental iron signs/symptoms would the nurse expect to see?
tid. The nurse has determined that the dosage is safe Select all that apply.
for the child. Ferrous sulfate elixir is available as: 1. Priapism
44 mg/5 mL. How many mL of medication will the 2. Pain level of 2/10
child consume each day? (If rounding is needed, 3. Hematuria
please calculate to the nearest tenth.) 4. Elevated liver enzymes
mL 5. Hematocrit 39%
9. A 10-year-old child, diagnosed with hemophilia A,
4. A 12-week-gestation African American woman asks is in the emergency department after experiencing
her obstetrician’s nurse whether her baby could be a fall on the school playground. Which of the
born with sickle cell disease. Which of the following following laboratory data would the nurse expect to
replies is appropriate for the nurse to give? see?
1. It is possible because one out of every 500 1. Leukocyte count 15,000 cells/mm3
African Americans is diagnosed with sickle cell 2. Platelet count 75,000 cells/mm3
anemia. 3. Partial prothrombin time (PTT) 90 sec (normal
2. If either you or the baby’s father has sickle cell 60–70 sec)
anemia, your child may be born with the disease. 4. Prothrombin time (PT) 9 sec (normal
3. The baby could only have sickle cell anemia if 11–12.5 sec)
both you and the baby’s father carry a sickle cell
gene. 10. A pregnant woman with a family history of
4. If the child is a boy, he could have sickle cell hemophilia B and who has been seen by a genetic
anemia, but if the child is a girl, she will counselor makes the following statements. The
definitely be healthy. nurse must clarify the information in which of the
statements?
5. A young child is admitted to the emergency 1. “Because the disease is X-linked, only my
department in vaso-occlusive crisis. Which of the daughters can be born with hemophilia B.”
following orders is the highest priority for the nurse 2. “Prenatal testing can be performed to determine
to perform? whether my fetus has hemophilia B.”
1. Morphine 1 mg subcu STAT 3. “Some children with hemophilia B have worse
2. IV D5W ¼ NS at 90 mL/hr bleeding problems than other children with the
3. Oxygen 2 L/min same genetics.”
4. Arterial blood gases STAT 4. “Children with hemophilia B are lacking one of
the important factors needed to clot blood.”
11. A 16-year-old male has hemophilia A. The nurse is 15. The nurse is caring for a child with stomatitis after
assessing the actions performed by the family when receiving chemotherapy. Which of the following
administering the teen’s medications. Which of the food items would be appropriate for the nurse to
following actions would the nurse expect to see? provide the child?
1. His mother draws up the factor replacement into 1. Orange juice
a syringe. 2. Whole-grain crackers
2. The young man washes his hands carefully and 3. Dried apple chips
puts on sterile gloves. 4. Milkshake
3. The missing factor is infused every night while
16. An 11-month-old child is receiving chemotherapy
the teen sleeps.
for a diagnosis of acute lymphoblastic leukemia
4. Antifibrinolytic medication is taken before each
(ALL). Which of the following vaccinations is safe
factor infusion.
for the nurse to administer to the child?
12. The nurse is taking a health history from a young 1. Var (varicella)
adult with hemophilia. The nurse should ask the 2. MMR (measles, mumps, rubella)
client whether he is experiencing any signs and 3. LAIV (live attenuated influenza vaccine)
symptoms of which of the following chronic 4. PCV (pneumococcal)
illnesses?
17. The mother of a child with acute lymphoblastic
1. Osteoarthritis
leukemia (ALL) states that their family is employing
2. Diabetes mellitus
complementary therapies to improve the child’s
3. Asthma
chances of survival. The child is also receiving
4. Hypothyroidism
chemotherapy. The nurse should discuss with the
13. A child has been diagnosed with acute mother that which of the following therapies may
lymphoblastic leukemia (ALL). With which of the actually be in conflict with the child’s medical care?
following signs/symptoms did the child likely 1. Therapeutic touch
present to the primary health-care provider? Select 2. Healing meals
all that apply. 3. Pet therapy
1. Bruising 4. Folic acid supplements
2. Lethargy
3. Jaundice
4. Leukopenia
5. Erythema
14. A child is receiving chemotherapy for a diagnosis of
acute lymphoblastic leukemia (ALL). The nurse
monitors the child for which of the following
common side effects? Select all that apply.
1. Malaise
2. Alopecia
3. Priapism
4. Anorexia
5. Epistaxis
341
vii. Have the child change into clean clothes a full-blown infection that migrates throughout
and, if needed, to wash the child’s the subcutaneous layer of the skin.
bedding each day. 2. Unless a pustule develops, the infection is not
viii. Avoid the spread of the infection to contagious.
another surface, such as refraining from: 3. Signs and symptoms.
(1) Scratching the lesions and touching a. Classic inflammatory signs and symptoms, i.e.,
another surface of the body. redness, edema, warmth, and pain.
(2) Using a towel or touching another b. The inflammatory responses often are
vector that has been in contact with accompanied by elevated temperature, malaise,
the affected body part. lymphadenopathy, and induration.
c. If the cellulitis is periorbital, the tissues
VI. Cellulitis surrounding the eye may appear bluish in color.
D. Diagnosis.
A. Incidence. 1. Clinical picture.
1. Cellulitis is seen in children of all ages. 2. Culturing of the discharge, if present.
B. Etiology. a. If discharge is not present, a culture of an
1. Bacterial infection of the lower layers of the skin aspirate of the area may be performed.
that is caused most frequently by S. aureus or 3. Blood cultures, if indicated.
group A streptococci. In some instances, 4. Complete blood count (CBC).
community-associated MRSA (methicillin- E. Treatment.
resistant S. aureus) has been found to be the 1. Intramuscular (IM), IV, and/or oral antibiotics.
pathogen causing cellulitis (see “Pustules or a. If the child is infected with MRSA, antibiotics
Boils”). specifically shown to be effective against the
2. Bacteria usually enter the body through a bacteria must be administered.
puncture wound, scratch, abrasion, or other break 2. Acetaminophen or ibuprofen is prescribed for the
in the epidermis. pain.
3. Cellulitis also can develop after a serious upper 3. Warm soaks are applied to the area to promote
respiratory infection, dental infection, or otitis circulation and to reduce discomfort.
media. 4. Excision and drainage of the wound may be
C. Pathophysiology (Fig. 19.3). required.
1. Cellulitis usually begins as an inflammatory F. Nursing considerations.
response but, as bacteria proliferate, develops into 1. Impaired Skin Integrity/Infection/Deficient
Knowledge.
a. If the child is hospitalized, a safe dosage of IM
or IV antibiotics, employing the five rights,
will likely be administered.
b. If the child is treated at home, educate the
parents and child, if appropriate, to:
i. Practice meticulous handwashing.
ii. Follow the therapeutic regimen carefully
and to complete the full course of
medication.
iii. Apply warm soaks to the area—usually
every 4 hr.
iv. Monitor the child carefully for early signs
of inflammation in the future and to
report signs to the primary health-care
provider in a timely manner.
2. Pain.
a. Assess the child’s pain level using an age-
appropriate pain scale.
b. If hospitalized, administer safe dosages of pain
medication, as prescribed and as needed.
c. If treated at home, educate the parents
regarding the safe dosage and administration
Fig 19.3 Periorbital cellulitis. of pain medication.
2. Two of the more common dermatophytes— v. If infected with tinea pedis, wearing light-
Trichophyton rubrum and Trichophyton colored socks and shoes that promote air
tonsurans—usually are transmitted from person to exchange.
person. Other types are transmitted from animal
to human or from inanimate object to human. IX. Acne
C. Pathophysiology.
1. The fungus, which resides on dead skin cells, A. Incidence.
usually is transmitted during direct contact. 1. Most frequently seen in adolescents, with a higher
2. Signs and symptoms. incidence in males.
a. Skin, which is highly pruritic, appears B. Etiology.
reddened, dry, and scaly, and a distinct rash 1. Acne can be caused by many things, including
ring may be present. bacterial invasion, stress, hormonal secretion, and
b. Patches of hair may fall out if the scalp or heredity.
bearded areas of the body are infected. C. Pathophysiology.
c. If the infection is not treated, cellulitis may 1. Sebum is secreted resulting in a blockage of the
result. sebaceous glands and proliferation of
D. Diagnosis. Propionibacterium acnes bacteria.
1. Clinical picture is highly suggestive. a. For example, it is secreted during adolescence
2. Scrapings of the skin may be sent for fungal as a result of the increased hormone
culture. production.
E. Treatment. 2. If blockage is not reversed, black heads, white
1. Oral or topical antifungal medications. heads, and/or pustules develop.
a. Scalp infections usually require oral 3. A rupturing of the sebaceous gland blockage may
medications. result in scar formation.
2. Complete eradication of the fungi may require D. Diagnosis.
many weeks of therapy. 1. Clinical picture.
F. Nursing considerations. E. Treatment.
1. Impaired Skin Integrity/ Infection/ Deficient 1. Depends on the precise form that the acne has
Knowledge. taken.
a. Educate the parents and child, if appropriate, a. Topical medications.
regarding prevention strategies, including: i. Including benzoyl peroxide and tretinoin
i. Practicing frequent handwashing. (Retin-A) to prevent the development of
ii. Refraining from sharing hairbrushes, caps, the acne lesions.
hats, and unwashed clothing. ii. Antibiotics to reduce the P. acnes
iii. Inspecting pets for signs of tinea colonization levels.
infections. b. Oral medications are prescribed in severe
iv. Refraining from walking on damp, cases.
communal surfaces on which fungi may c. Additional topical therapies to remedy skin
reside (e.g., near pools and in locker lesions (e.g., dermabrasion).
rooms). F. Nursing considerations.
b. If child is infected, educate the parents and 1. Impaired Skin Integrity/Risk for Infection/
child, if appropriate, regarding treatment Deficient Knowledge.
strategies, including: a. Educate the parents and teen regarding the
i. Maintaining excellent hygiene and etiology of acne.
handwashing practices. b. Educate the patient regarding the
ii. Only using his or her own personal individualized treatment regimen, including
items, including towels, hair supplies, washing the face twice daily with antibacterial
and caps. soap and washing the hair daily.
iii. Carefully following the prescribed c. Advise the teen to refrain from injuring
treatment regimen and reporting any side the face by overscrubbing or picking at
effects of the medication to the primary lesions.
health-care provider d. Encourage the teen to use water-based
iv. If infected with tinea cruris, taking cosmetics only.
soothing sitz baths (i.e., plain water hip e. Reinforce the importance of eating a nutritious
baths). diet and living a healthy lifestyle.
X. Pediculosis (Lice)
A. Incidence. Fig 19.6 A female body louse.
1. Pediculosis (lice) are prevelant in children,
especially in preschoolers and school-age
children, with girls being affected more frequently b. Sexually active individuals should be
than boys. encouraged to engage only in monogamous
B. Etiology. relations, carefully examine the genitalia
1. Small insects that survive by sucking human of their sexual partners and, if infested, to
blood. avoid all sexual contact until they have been
a. Pediculosis capitis: head lice. treated.
b. Pediculosis corporis: body lice. 2. Treatment: the goal of treatment is to kill both the
c. Pediculosis pubis: pubic lice or “crabs.” insects and the eggs.
2. Acquired through direct contact. a. Over-the-counter pediculicides, such as
a. Pubic lice are contracted during sexual activity. permethrin (e.g., Nix) or pyrethrins (e.g., Rid
C. Pathophysiology. and Triple X) are the primary treatment.
1. Head lice. i. All persons who have had intimate
a. Lice rarely are visible because they scurry to contact with the infected person should be
evade light, but the child experiences marked treated at the same time to prevent
pruritus from the movement of the lice. reinfestation.
i. Lesions, seen predominantly on the neck ii. All clothing that has been in contact with
and behind the ears, develop from the infected site should be removed.
recurrent itching. iii. The area of infestation should be
b. Nits (i.e., lice eggs) are seen on the shaft of the washed well with regular shampoo and
hair. dried.
(1) Hair conditioner should not be used.
DID YOU KNOW? iv. The medication should be applied to the
You can easily differentiate nits from dandruff. Nits
affected area and, as stated on the label,
are difficult to remove because of the “lice glue”
removed after having been left in place for
holding them in place, while dandruff is easily
the allotted time.
brushed from the hair.
(1) If after 8 to 12 hr the lice are still as
2. Body lice (Fig. 19.6). active as before the treatment, the
a. Pruritus and lesions of affected areas. primary health-care practitioner
3. Pubic lice. should be notified because a
a. Itching in the genital area. prescription medication may be
b. May see blue spots on the thighs. required (e.g., lindane).
D. Diagnosis. v. The nits, or lice eggs, should be removed
1. Clinical picture. from the shafts of the hair with a fine-
E. Treatment. toothed comb.
1. Prevention. (1) The hair should be inspected each day
a. Children should be encouraged to avoid using following treatment and, if the nits
others’ combs and brushes and wearing others’ reappear, they should be removed
hats. with the fine-toothed comb.
3. If first-degree burn.
a. Cool down the site with a cool washcloth and
cool water.
i. Ice should not be used for first-degree
burns because it may result in additional
injury to the flesh.
ii. Apply soothing lotions.
4. If second-degree burn.
a. Cool down the site, as with first-degree
burns.
b. Unless the burn is extensive, usually the child
Healthy skin 1st degree burn
will be cared for as an outpatient.
i. Site is cleansed daily using aseptic
technique.
ii. Tetanus booster is administered if it has
been more than 5 years since the last
injection.
(1) Burn sites are easy portals of entry to
tetanus bacteria.
5. If third-degree burn: hospitalization is likely.
a. Care as discussed for second-degree burns,
plus:
b. Debridement of the wound, which entails
2nd degree burn 3rd degree burn removing the eschar or dead tissue.
c. Application of antibiotic dressings and
Fig 19.8 Degree of burn injury. ointments.
i. Silvadene (silver sulfadiazine cream) is
most commonly used.
E. Treatment.
F. Nursing considerations.
1. Prevention:
1. Deficient Knowledge regarding the potential for
a. It is essential to provide parent education
accidental burns.
regarding activities that place children at high
a. Children should be kept out of direct sunlight,
risk for burns (see “Nursing considerations”).
especially between 10 a.m. and 4 p.m., unless
2. Dependent on the severity of the burn.
they are covered with sun protection lotion.
a. Primary intervention, when indicated.
The lotions should:
i. Reverse fluid imbalance by administering
i. Contain both UVA and UVB protectant.
IV fluids (see Chapter 13, “Nursing Care of
ii. Be applied at least every 2 hr and reapplied
the Child With Fluid and Electrolyte
whenever the child gets wet.
Alterations”).
(1) Lactated Ringer’s solution often is DID YOU KNOW?
ordered. The Food and Drug Administration (FDA) has
ii. Assess serum electrolytes, and replace established strict guidelines for the contents and
electrolytes, as needed. labeling of sunscreen products. For specific
(1) With cell wall damage, shifts in information, see the FDA’s Web site: www.fda.gov/
electrolytes often are seen. ForConsumers/ConsumerUpdates/ucm258416.htm.
9%
18%
(back)
9% 9%
18%
18%
18%
(back)
1%
9% 9%
18%
18% 18%
18% 18%
(back)
14% 14%
9% 18% 9%
14% 14%
b. Fire and smoke alarms should be installed d. Dangerous items (e.g., matches, electrical
throughout the home, and batteries should be cords, electrical sockets) should be kept out of
changed yearly. reach of young children.
e. The hot water heater should be set no higher
DID YOU KNOW? than 120°F.
In order to help parents to remember to replace
f. Pots should be placed on the back burners of
the fire and smoke alarm batteries, they can be
the stove, and the handles should face toward
taught to change the batteries at the same time
the wall.
each year (e.g., every spring when the time changes
g. Stove knobs should be covered with childproof
or every year on a specific holiday).
covers.
c. Have fire drills for home safety, including h. Children should be kept at a distance from hot
teaching children to “stop, drop, and roll.” foods, drinks, and other hot substances.
i. Grills, fireplaces, radiators, and other c. Prevent the child from further injuring his
such heat-producing items should be or her skin by, for example, keeping the
gated off. fingernails short.
j. It is important to teach parents that young d. Administer a tetanus booster, as prescribed.
children often hide in closets, bathrooms, and e. Monitor for signs and symptoms of infection,
under beds when frightened, so those locations including elevated white blood cell (WBC)
should be searched carefully at the time of a count and temperature and purulent drainage
fire. from the burn.
k. Parents should be taught immediate f. Intervene to maintain normothermic state.
intervention measures if their child should be i. Provide antipyretic agents for
burned. hyperthermia, as prescribed, and/or:
i. Cool down the site with a cool washcloth ii. Provide warmth for hypothermia, as
or cool water. indicated.
g. Perform range-of-motion (ROM) exercises to
! Ice should not be used because it may result in prevent contracture development.
additional injury to the flesh.
4. Imbalanced Nutrition: Less than Body
ii. Unless it has adhered to the burn, any Requirements.
clothing that is touching the burned area a. Determine the percentage of affected body
should be removed. surface.
iii. If blistering or charring are present, the b. Provide a high-protein, nutritious diet, and
child should be seen in the emergency administer vitamin and mineral supplements,
department. as indicated, to restore nitrogen and nutrient
iv. The burned area should be covered with a loss.
clean sheet. i. Administer total parenteral nutrition, if
2. Risk for Deficient Fluid Volume. prescribed.
a. Assess the extent of fluid loss by determining 5. Acute Pain.
the percentage of the body surface that is a. Assess the level of pain, using an age-
affected. appropriate pain scale.
b. Weigh the child daily. b. Administer safe dosages of pharmacological
c. Determine the level of dehydration based on pain therapy, as prescribed, especially prior to
the percentage of weight loss and other signs painful interventions.
of dehydration (see Chapter 13, “Nursing Care c. Employ nonpharmacological pain
of the Child With Fluid and Electrolyte interventions, as appropriate.
Alterations”). 6. Risk for Disturbed Body Image/Anxiety/Risk for
d. Calculate the daily minimum volume (DMV) Altered Coping.
for the child based on the child’s most recent a. Calmly provide the child and parents with
weight (See Chapter 13). information regarding burn care, employing
i. The child’s fluid needs will markedly simple and concise language.
exceed his or her DMV. b. Provide opportunities for the child and parents
e. Administer safe dosages of IV medications to express fears, concerns, and guilt.
employing the five rights of medication c. Refer the family, as needed, to social services
administration, as needed and as prescribed. and/or child protective services.
f. Carefully monitor strict intake and output d. Encourage the family, if appropriate,
(I&O). to seek spiritual guidance from a
g. Monitor laboratory values, especially serum clergyperson.
electrolytes, renal function studies, and e. Assist the family to identify support systems
complete blood count (CBC). and coping strategies.
3. Risk for Infection/Impaired Skin Integrity. f. Allow the parents and child to express
a. Gently clean the burn, and debride the wound, concerns/fears regarding the child’s future
as needed. appearance.
b. Maintain aseptic technique. g. Provide the child and family with
i. Admit to the burn unit, and maintain honest answers regarding care and
reverse isolation. prognosis.
ii. Perform meticulous handwashing. h. Provide grief counseling, as needed.
1.
2.
3.
B. What objective assessments indicate that this client is experiencing a health alteration?
1.
C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse assign to this client?
1.
D. What interventions should the nurse plan and/or implement to meet this child’s and her family’s needs?
1.
2.
3.
E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing interventions?
1.
1.
1.
10. A 17-year-old young woman is being seen in the 14. An 8-year-old child is admitted to the emergency
primary health-care provider’s office for a chief department with burns over 30% of the body.
complaint of acne. Which of the following Which of the following orders is highest priority for
diagnoses would be appropriate for the nurse to the nurse to perform?
include in the client’s plan of care? 1. Injection of tetanus booster
1. Powerlessness 2. Debridement of the burns
2. Risk for Ineffective Coping 3. Application of Silvadene ointment
3. Risk for Self-mutilation 4. Administration of intravenous fluids
4. Self-neglect
15. A mother telephones the nurse at her child’s
11. The school nurse notifies the mother of a 7-year-old primary health-care provider and states, “My child
girl that her child has head lice (pediculosis capitis). spilled my coffee on her arm. About one-half of the
Which of the following information should the forearm is red, and there are 2 or 3 blisters that have
nurse advise the mother regarding the problem? developed. What should I do?” Which of the
1. “I strongly suggest that you cut your child’s hair following is the best response for the nurse to give?
short before using the lice medicine, and keep it 1. “Run cool water over the burned area and then
short from now on.” call me back.”
2. “Your child will need to be kept at home until 2. “Apply ice to the blisters for ten minutes on and
she has received the second treatment, one week ten minutes off.”
after the first.” 3. “Proceed to the emergency department for a
3. “After using the lice medicine, you will need to complete assessment.”
comb your child’s hair with a fine-toothed 4. “Cover the burned area with petroleum jelly and
comb.” sterile bandages.”
4. “For up to three weeks after being treated with
16. The mother of a 10-year-old child telephones the
the lice medicine, your child may complain of
child’s primary health-care provider’s office. The
itching.”
mother informs the nurse, “A spider bit my
12. The clinic nurse is educating the parents of a daughter a couple of days ago, and today it is
10-year-old child with scabies regarding medication looking really bad. The bite is oozing, and the skin
administration. Which of the following information around the bite is red and painful.” Which of the
should the nurse include in the teaching? following statements by the nurse is appropriate at
1. The child should have been bathed at least this time?
24 hours prior to the administration of the 1. “I bet the bite is infected with a dangerous
medication. bacteria. She must be seen immediately, so that
2. The oral medication must be administered on an we can start her on antibiotics.”
empty stomach. 2. “I would like her to be seen today. Please cover
3. The topical medication must remain on the skin the bite, and bring her in for an appointment.”
for 8 full hours. 3. “Spider bites are notorious for getting worse
4. The parent should readminister the medication before they get better. It should clear up in a
in one week if the child continues to complain of couple of days.”
itching. 4. “It sounds like the bite has been inflamed. I want
you to put warm compresses on it three times a
13. A 5-year-old child who was playing with matches is
day until it gets better.”
admitted to the pediatric emergency department.
The child has blistered burns covering both anterior
thighs. Which of the following responses is
consistent with the child’s presentation?
The depth and extent of the burns are:
1. Depth: 1°; extent: 10%
2. Depth: 2°; extent: 7%
3. Depth: 2°; extent: 18%
4. Depth: 3°; extent: 3%
3. This is correct. After the treatment, the nits must be 14. ANSWER: 4
removed using a fine-toothed comb. Rationale:
4. The child should not complain of itching once he or 1. This is important, but it is not the priority action.
she has been treated. 2. This is important, but it is not the priority action.
TEST-TAKING TIP: Some parents have the incorrect 3. This is important, but it is not the priority action.
assumption that short hair will prevent a lice infestation. 4. Administration of IV fluids is the priority action.
This is not true. In addition, cutting the child’s hair can be TEST-TAKING TIP: Fluid and electrolyte balance is the
traumatic for the child. child’s highest priority. A large extent of the child’s body
Content Area: Pediatrics is affected. The intracellular fluid loss, therefore, is
Integrated Processes: Nursing Process: Implementation extensive. The nurse should administer the IV fluids
Client Need: Physiological Integrity: Physiological before performing any other action.
Adaptation: Illness Management Content Area: Pediatrics
Cognitive Level: Application Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Physiological
12. ANSWER: 3 Adaptation: Illness Management
Rationale:
Cognitive Level: Analysis
1. The child should bathe and thoroughly dry himself or
herself shortly before the medication is administered. 15. ANSWER: 1
2. Topical medication is applied to the skin. Rationale:
3. This statement is correct. The topical medication must 1. The skin should be cooled as soon as possible by
remain on the skin for 8 full hours. running cool water over the burned area.
4. This statement is incorrect. It is common for the itching 2. Ice should not be applied to burned skin. The ice can
to persist for 2 to 4 weeks after treatment. cause further damage to the skin.
TEST-TAKING TIP: The inflammatory response causes the 3. The child will likely be treated as an outpatient by the
itching. Even after the mites are killed, the inflammation primary health-care provider. The nurse should, however,
often persists for up to 4 weeks. advise the parent to transport the child to the health-care
Content Area: Pediatrics provider’s office after the burn has been cooled.
Integrated Processes: Nursing Process: Evaluation 4. Petroleum jelly should not be applied to burned skin.
Client Need: Physiological Integrity: Reduction of Risk TEST-TAKING TIP: If a medication is needed, Silvadene or
Potential: Potential for Alterations in Body Systems an antibiotic ointment will be applied to the burn.
Cognitive Level: Application Content Area: Pediatrics
Integrated Processes: Nursing Process: Implementation
13. ANSWER: 2 Client Need: Physiological Integrity: Physiological
Rationale:
Adaptation: Illness Management
1. The child has a second-degree burn over approximately
Cognitive Level: Application
7% of the body.
2. The child has a second-degree burn over 16. ANSWER: 2
approximately 7% of the body. Rationale:
3. The child has a second-degree burn over approximately 1. The bite may be infected with community-associated
7% of the body. methicillin-resistant S. aureus (CA-MRSA). It is
4. The child has a second-degree burn over approximately inappropriate, however, for the nurse to make frightening
7% of the body. statements to the child’s parent.
TEST-TAKING TIP: Depth: second-degree burns are 2. This is the appropriate statement for the nurse to
characterized by blistering. Extent (Fig. 19.9): the child is make. The lesion should be covered, and the child
almost 5 years of age. The anterior portion of both of should be seen.
the child’s thighs are burned. Each leg accounts for 3. The bite may be infected with CA-MRSA. The child
approximately 14% of the child’s body surface area. The should be seen.
anterior portion of the thigh of each leg, therefore, 4. The health-care provider may order warm compresses
accounts for approximately 3.5% of the child’s body to the area, but the child should be seen.
surface area. (The entire anterior of the leg equals 7%; the TEST-TAKING TIP: The CDC and the Infectious Disease
anterior thigh of the leg equals 3.5%.) The total portion Society have developed guidelines for the treatment of
of the child’s body that has been burned, therefore, is lesions infected with CA-MRSA. Although antibiotics may
approximately 7%. ultimately be prescribed, the first intervention usually is
Content Area: Pediatrics excision and drainage of the wound.
Integrated Processes: Nursing Process: Analysis Content Area: Pediatrics
Client Need: Physiological Integrity: Physiological Integrated Processes: Nursing Process: Implementation
Adaptation: Alterations in Body Systems Client Need: Physiological Integrity: Physiological
Cognitive Level: Application Adaptation: Alterations in Body Systems
Cognitive Level: Application
363
Continued
Bone Bend The bone in this type of “fracture” actually does not
break but rather bends into a curve. Commonly seen
in young children because their bones are soft and
healthy.
a. The sooner interventions are instituted, the less the disease is seen in adolescent girls during their
likely the child will experience permanent pubertal growth spurt.
damage. B. Etiology.
b. Traction often is instituted following surgery. 1. In the vast majority of cases, there is no apparent
2. Immobility of the joint, including bedrest and/or cause.
crutch walking, both before and following surgery 2. There is a rare autosomal dominant form of the
is usually prescribed. disease.
F. Nursing considerations: (see “Traction Care”). a. A genetic test is available for the small, at-risk
1. Pain/Deficient Knowledge. population.
a. Carefully explain the pathophysiology of the 3. Scoliosis is also seen in conjunction with other
disease and rationale for therapy. diseases (e.g., cerebral palsy, muscular dystrophy).
b. If prescribed, reinforce education by the 4. It is believed that scoliosis is neither caused by
physical therapist (PT), or, if PT is unavailable, nor worsened by carrying heavy backpacks and/or
educate the child regarding safe crutch walking by engaging in sports.
(Box 20.5). C. Pathophysiology (Fig. 6.4).
c. Administer safe dosages of analgesics, as 1. Scoliosis is characterized by a lateral curvature
prescribed. and rotation of the spine, defined in terms of
i. If moderate to severe pain, narcotics degrees of curvature.
should be administered. a. A deviation of greater than 10 degrees is
(1) Patient-controlled analgesia is an diagnostic.
excellent mode of medication 2. The rotation of the spine is related to weakness
administration for this age patient. in muscles and ligaments on the opposite side
ii. For mild pain, NSAIDS should be of the body.
administered. 3. Signs and symptoms.
iii. When the child is discharged, educate the a. Uneven posture with:
parents and child, if appropriate, regarding i. One scapula protruding farther than the
the safe administration of analgesics. other.
d. Provide nonpharmacological pain ii. Uneven shoulder and waist heights.
interventions, as needed. iii. Hip and rib asymmetry.
2. Risk for Ineffective Coping/Risk for Altered iv. In severe cases, respiratory and cardiac
Growth and Development. compromise because of thoracic
a. Provide the parents and child the opportunity compression.
to verbalize anger and frustration with the D. Diagnosis.
diagnosis and treatment plan. 1. Clinical picture is suggestive.
b. Strongly encourage the child to continue close i. Deviation and asymmetries are seen when
relationships with friends and to invite friends the child bends at the waist and allows his
to visit when in the hospital or confined to the or her arms to fall freely (Fig. 20.9).
home.
c. Advise the child and parents that the child is
able to and should keep up with schoolwork.
3. Readiness for Enhanced Self-Health Maintenance.
a. Encourage the primary health-care provider to
refer the child and family for nutrition
counseling.
b. Support the education provided during
nutrition counseling.
c. Provide positive reinforcement for dietary
changes made.
d. Following convalescence, strongly encourage
the child to begin a wellness exercise program.
VIII. Scoliosis
A. Incidence.
1. Although scoliosis is seen in other children,
including neonates, by far the highest incidence of Fig 20.9 Adolescent with scoliosis.
ii. Scoliometer is a device placed on the back ii. Educate the parents and child regarding
of the child as he or she bends from the the importance of wearing the brace to
waist to measure the curvature of the spine. prevent further deviation.
2. Definitive diagnosis is made by x-ray. iii. Allow the parents and child to express
E. Treatment. anger and frustration over the need to
1. Mode of treatment is dependent on many factors, wear a brace and, if required, the need to
including the extent of the deviation and the age refrain from normal physical activities.
of the child. iv. Educate the parents and child regarding
2. Bracing usually is the treatment of choice for how to put on the brace in order to
relatively minor deviations. prevent complications.
a. It is important to realize that bracing is not v. Consider introducing the child to a child
curative; braces merely help to prevent any of the same age and gender who is
further deviation. compliant with the therapy.
b. It is not uncommon for children to refuse to vi. Provide the child with consistent
wear the braces. Therefore, to promote encouragement and positive reinforcement
compliance: when complying with therapy.
i. Most braces currently used are small vii. Introduce the child and family to relevant
enough to hide under one’s clothing. community organizations (e.g., National
ii. Some braces are designed only to be worn Scoliosis Foundation).
while sleeping. 2. If surgery:
3. Exercises often are employed in conjunction a. Risk for Anxiety/Fear/Anger/Deficient
with bracing, but exercises alone are not Knowledge.
effective. i. Allow the child and parents to express
4. In severe cases and when bracing fails to prevent their anxieties, fears, and anger regarding
further injury, surgery is performed. the need for surgery.
a. Most frequently, one or more rods are inserted ii. Provide the child and parents with
adjacent to and wired to the spine. comprehensive education regarding the
b. Bone grafts from the child’s hip or other surgical procedures as well as preoperative
site are used to fuse and/or stabilize the and postoperative care.
vertebrae. iii. Parents should be advised that the child
c. Renal and/or neurological damage, as well as may regress during the surgical period, for
extensive blood loss, are possible complications example:
from the surgery. (1) The child may wish to hold a favorite toy
d. Following surgery, the child will usually be or other possession from when he or she
required to wear a brace until the site is fully was younger while in the hospital.
healed. (2) The child will likely request his or her
F. Nursing considerations. parents to stay with him or her
1. If bracing: immediately pre- and postsurgery and
a. Risk for Impaired Skin Integrity. throughout the remainder of the
i. The child’s skin should be thoroughly hospitalization.
dried before donning the brace. b. Risk for Impaired Mobility/Risk for Injury.
ii. The child should wear a cotton tee shirt i. Immediately following surgery, log rolling
under the brace. should be performed when changing the
(1) Care should be taken to eliminate all child’s position to prevent injury to the
wrinkles in the shirt. surgical site.
iii. The skin should be assessed daily for signs ii. Provide needed assistance for the
of breakdown. application of the postoperative brace and
iv. The use of lotions and powders on the educate the parents to do the same.
skin under the brace should be avoided. iii. Assist with physical therapy interventions,
b. Risk for Ineffective Coping/Deficient as prescribed.
Knowledge/Anger/Risk for Disturbed Body iv. Carefully monitor for postoperative
Image. complications and report any adverse
i. Carefully explain to the parents and child findings.
the pathophysiology of the disease and the (1) Because the spinal column is
rationale for therapy. manipulated during surgery, thorough
“Nursing Care of the Child With Respiratory i. Signs of inflammation (e.g., redness,
Illnesses”). warmth, swelling, pain) over the site of the
c. Educate the parents to protect the child from infection.
others with active infection. ii. Limping, if the child is ambulatory.
d. Educate the parents immediately to seek iii. Children sometimes complain of pain in
medical care whenever the child exhibits signs a nearby joint, even though the joint is
of respiratory infection. unlikely the site of the infection.
e. Educate the parents and child regarding signs D. Diagnosis.
and symptoms of congestive heart failure and 1. The clinical picture is suggestive, including the
immediately to seek medical care if signs and characteristic signs and symptoms plus:
symptoms appear (See Chapter 17, “Nursing a. Laboratory evidence, including elevated WBC
Care of the Child With Cardiovascular count, elevated erythrocyte sedimentation rate
Illnesses”). (ESR), and/or positive blood cultures.
5. Risk for Injury/Impaired Urinary and Bowel 2. Definitive diagnosis is made from:
Elimination. a. X-ray, MRI, CT scans, and/or bone scans.
a. Educate the parents and child to monitor daily b. Culture and sensitivity of the aspirate from the
I&O. bone.
b. Educate the parents regarding the child’s DMV E. Treatment.
needs. 1. High-dose, IV antibiotics, including
c. Encourage the parents to provide the child aminoglycosides, which must often be
with a high-fiber diet. administered for 6 weeks or more.
d. Administer stool softeners/laxatives, as needed. 2. Surgery is often required when:
a. An abscess is present and/or the infection is
X. Osteomyelitis not treated effectively by the antibiotics.
b. Bone necrosis has occurred.
A. Incidence. F. Nursing considerations.
1. Osteomyelitis most frequently affects children in 1. Knowledge Deficit/Risk for Impaired Coping/
the late toddler and preschool period. Anxiety/Fear/Anger.
2. Boys are more frequently affected than are girls. a. An excellent nursing history must be
B. Etiology. conducted in an attempt to determine how the
1. Bacterial invasion into the bone occurs either bacteria entered the child’s body.
indirectly via the vascular system or directly as a b. Once a correct diagnosis is made, educate
result of a break in the skin. the parents and child, if appropriate, regarding
2. The most common pathogen is Staphylococcus the etiology and pathophysiology of the
aureus. Other responsible bacteria are Escherichia disease.
coli, Haemophilus influenzae, and Streptococcus c. Allow the parents and child, if appropriate, to
pyogenes. In addition, pathogens found in the soil express concerns, anxiety, and fears regarding
(e.g., Pseudomonas aeruginosa) also are seen. the disease and treatment plan.
C. Pathophysiology. d. Allow the child to express, in his or her own
1. Either via the vascular tree or directly via a break way, anger at the requisite physical restrictions.
in the skin, bacteria enter the bone, most 2. Pain.
commonly the epiphyseal plate. a. Assess pain using an age-appropriate pain
2. Pus develops in the area but, because the pus is rating scale.
unable to be evacuated from the site, abscesses b. Administer safe dosages of analgesics utilizing
often develop. appropriate technique, as prescribed.
3. Over time, the blood supply to the area is c. Prior to discharge, educate the parents and
adversely affected. child, if appropriate, regarding the safe
4. If unsuccessfully treated, an acute or subacute administration of analgesics.
form of the disease can result in a chronic disease. d. Provide nonpharmacological pain
5. Signs and symptoms. interventions, as needed.
a. In infants and young toddlers: nonspecific 3. Risk for Injury that may develop from prolonged
signs and symptoms: use of antibiotics.
i. Elevated temperature, irritability, poor a. Administer safe dosages of antibiotics using
feeding, and lethargy. the five rights of medication administration.
b. Older children exhibit more specific b. Monitor the IV site for signs and symptoms of
symptoms. phlebitis and/or infiltration of the IV (see
Vital Signs
Temperature: 102.4 °F
Heart rate: 154 bpm
Respiratory rate: 60 rpm
1.
2.
3.
B. What objective assessments indicate that this client is experiencing a health alteration?
1.
2.
3.
4.
5.
6.
7.
C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse assign to this client?
1.
D. What interventions should the nurse plan and/or implement to meet this child’s and his family’s needs?
1.
2.
3.
4.
5.
E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing interventions?
1.
2.
F. What physiological characteristics should the child exhibit before being discharged from the emergency department?
1.
2.
G. What subjective characteristics should the child exhibit before being discharged from the emergency department?
1.
2.
8. The nurse is teaching the parents of a child with 12. A 13-year-old girl, who has been diagnosed with
developmental dysplasia of the hip (DDH) scoliosis, has been ordered to wear a therapeutic
regarding the application of the Pavlik harness. brace for 20 hours each day. The nurse identifies
Which of the following information should the which of the following nursing diagnoses for this
nurse include in the teaching? child?
1. Three diapers should be worn at all times under 1. Risk for Disturbed Body Image
the harness. 2. Bathing Self-care Deficit
2. Harness should be removed for ten minutes 3. Risk for Impaired Urinary Elimination
every hour. 4. Ineffective Breathing Pattern
3. Harness should always keep the legs fully
13. An adolescent is being admitted to the pediatric
adducted.
intensive care unit following rod placement for a
4. Clothing should always fit loosely over the
diagnosis of scoliosis. Which of the following
harness.
assessments is highest priority for the nurse to
9. An 8-year-old child has been diagnosed with perform?
Legg-Calve-Perthes disease. Which of the following 1. Pain level
information should the nurse include in the patient 2. Intravenous flow rate
teaching regarding the illness? 3. Blood loss
1. “You will have to stay home from school and 4. Electrolyte values
learn from a tutor until you get better.”
14. A nurse must change the position of an adolescent
2. “The infection in your bone will be treated with
who is 2 hours’ post-op rod placement for a
a special medicine that you will receive through
diagnosis of scoliosis. Which of the following
your vein.”
actions should the nurse perform?
3. “You will have to use crutches and be allowed
1. Elevate the head of the bed to thirty degrees.
only to walk on your healthy leg until your
2. Lower the bed into the Trendelenburg position.
bones are all better.”
3. Turn the child while keeping the child’s spine
4. “The cast must stay on your ankle and calf for a
straight.
few weeks until they are fully healed.”
4. Place a pillow under the knees and keep the
10. A nurse who works with overweight children child supine.
monitors them carefully for signs and symptoms of
15. A nurse is reviewing the results of a genetic analysis
which of the following musculoskeletal illnesses?
performed on a child with Duchenne muscular
1. Scoliosis
dystrophy (DMD). Which of the following results
2. Legg-Calve-Perthes
would the nurse expect to see?
3. Slipped capital femoral epiphysis
1. 46 XY, X-linked recessive inheritance
4. Duchenne muscular dystrophy
2. 46 XX, autosomal dominant inheritance
11. A nurse is observing a child with a leg cast who is 3. 46 XY, autosomal recessive inheritance
learning how to crutch walk. Which of the following 4. 46 XX, mitochondrial inheritance
assessments would lead the nurse to identify
16. The nurse is educating the parents of a child with
deficient knowledge as a priority nursing diagnosis
Duchenne muscular dystrophy (DMD) regarding
for the child? While using the crutches, the child:
priority actions that they should take when caring
1. bends her elbows at all times.
for their child. Which of the following actions
2. swings her legs forward before moving the
should the nurse include during the teaching
crutches.
session? Immediately report to the child’s primary
3. keeps a space between her axillae and the
health-care provider if the child:
underarm supports.
1. has diarrhea.
4. moves both crutches forward at the same time.
2. refuses to eat.
3. develops an upper respiratory infection.
4. complains of pain in any limbs.
17. An ambulatory 11-month-old child has been 19. An 8-year-old child diagnosed with osteomyelitis is
diagnosed with osteomyelitis. Which of the being cared for at home with IV antibiotics that are
following signs/symptoms would the nurse expect being administered by a home-care nurse via a
to see? peripheral intravenous central catheter (PICC). The
1. Feeding problems home-care nurse should immediately call the
2. Pain emergency contact number if the child exhibits
3. Warmth at the site which of the following signs/symptoms? Select all
4. Limp that apply.
1. Dyspnea
18. A child with osteomyelitis is receiving IV
2. Chest pain
gentamycin. The nurse should monitor which of the
3. Tachycardia
child’s laboratory values to assess for possible
4. Hypertension
toxicity from the medication?
5. Hyperthermia
1. Hematocrit
2. Platelet count
3. Serum sodium
4. Blood urea nitrogen
Anorexia is one of the more frequent systemic symptoms 19. ANSWER: 1, 2, 3, and 5
seen. Rationale:
Content Area: Pediatrics—Neuromuscular 1. The nurse should monitor the child for dyspnea.
Integrated Processes: Nursing Process: Assessment 2. The nurse should monitor the child for chest pain.
Client Need: Physiological Integrity: Physiological 3. The nurse should monitor the child for tachycardia.
Adaptation: Alteration in Body Systems 4. The nurse should monitor the child for hypotension.
Cognitive Level: Application Hypertension is not related to an adverse reaction to a
PICC line.
18. ANSWER: 4 5. The nurse should monitor the child for hyperthermia.
Rationale:
TEST-TAKING TIP: Two of the serious complications that
1. A child’s hematocrit is unrelated to whether he or she is
can develop when a child has a PICC line in place are air
developing gentamycin toxicity.
embolism and infection. Dyspnea, chest pain, and
2. A child’s platelet count is unrelated to whether he or
hypotension are all symptoms of an air embolism.
she is developing gentamycin toxicity.
Tachycardia and hyperthermia are both symptoms of an
3. A child’s serum sodium is unrelated to whether he or
infection.
she is developing gentamycin toxicity.
Content Area: Pediatrics—Medication
4. A child’s blood urea nitrogen (BUN) levels should be
Integrated Processes: Nursing Process: Implementation
monitored when he or she receives an aminoglycoside
Client Need: Physiological Integrity: Pharmacological and
antibiotic.
Parenteral Therapies: Adverse Effects/Contraindications/
TEST-TAKING TIP: Gentamycin, an aminoglycoside, can
Side Effects/Interactions
cause nephrotoxicity. BUN is one of the renal function Cognitive Level: Application
tests that should be monitored by the nurse.
Content Area: Pediatrics—Neuromuscular
Integrated Processes: Nursing Process: Evaluation
Client Need: Physiological Integrity: Pharmacological and
Parenteral Therapies: Adverse Effects/Contraindications/
Side Effects/Interactions
Cognitive Level: Application
I. Description B. Etiology.
1. PKU is an autosomal recessive disease. A child
The endocrine system is classically defined as the glandu- must carry both affected alleles to exhibit the
lar tissues of the body in which hormones are produced. disease.
This chapter, however, begins with a discussion of phe- DID YOU KNOW?
nylketonuria (PKU) that results because of the inability Newborn screening tests are conducted in all 50 of
of the liver to produce an enzyme to break down an essen- the United States. All states are mandated to screen
tial amino acid—phenylalanine. The chapter continues for 21 disorders, including PKU, while some states
with a discussion of the more common endocrine disor- screen for many more. In other words, each state
ders seen in children and the glands in which the hor- decides whether to screen for a number of
mones are produced. additional diseases. To learn more about newborn
screening and/or to determine which diseases are
II. Phenylketonuria tested in each state, parents and nurses can visit
the following Web sites: Genetics Home Reference
A. Incidence. (http://ghr.nlm.nih.gov/nbs) and National Newborn
1. The disease is seen in about 1 in 15,000 live Screening and Global Resource Center (http://
births. genes-r-us.uthscsa.edu/).
389
a. Any girl 10 to 13 years of age or boy 12 to patterns of children, however, the care and monitoring of
16 years of age growing less than 5 cm per children must be vigilant. Initially, parents must assume
year, and/or: the majority of the management of the disease, but,
b. When there is a marked flattening of the because of the chronic nature of the disease, the child
child’s normal growth curve; or when the must take on more responsibility as he or she grows older.
child’s height falls below the 5th percentile. This disease will be subdivided into type 1 and type 2
2. Thorough examination, including laboratory data diabetes.
and x-rays of the growth plates of the wrist. A. Incidence.
3. Hormonal studies. 1. The risk of developing type 1 diabetes mellitus
a. To assess the child for other hormonal (DM) is higher than virtually all other chronic
deficiencies because many hormones work diseases of childhood.
together to enhance maturation (i.e., thyroid 2. Peak ages at time of diagnosis are: 5 to 7 years of
studies and sex hormones). age and at puberty.
4. Definitive diagnosis. 3. Rarely seen in children younger than 2 years of
a. Growth hormone (GH) levels assessed. age but type 1 DM has been seen in infants.
i. The hormone is naturally secreted during B. Etiology.
the night, so the pituitary is stimulated to 1. Multiple genetic predisposition loci are present in
produce GH during the day. the genome, but no absolute genetic inheritance
(1) Examples of stimulating medications: pattern has been identified.
insulin, clonidine hydrochloride 2. Likely multifactorial etiology.
(Catapres, Duraclon). C. Pathophysiology.
ii. GH levels less than 10 ng/mL, on two 1. Autoimmune inflammatory process, resulting in
separate occasions, are diagnostic. destruction of beta cells in the islets of
E. Medical management. Langerhans.
1. Administration of synthetic GH. 2. No insulin is produced, therefore the cells of the
a. Administered subcutaneously at bedtime six to body are unable to utilize glucose, resulting in:
seven times/week. a. Excess circulating glucose, eventually spilling
i. Expect 2 cm/yr growth over pretherapy into the urine.
growth. b. The body compensating for lost fuel by the
ii. Given until the child reaches desired height catabolism (breaking down) of fats and
or until the growth plates close. proteins.
b. Child’s growth monitored closely. i. Ketones are formed, resulting in metabolic
F. Nursing considerations. acidosis.
1. Delayed Growth and Development/Risk for 3. Signs and symptoms.
Situation Low Self-Esteem/Risk for Altered a. Hyperglycemia.
Coping/Risk for Disturbed Body Image. b. The three “polys”:
a. Allow the child and the parents to express i. Polyuria.
their concerns, fears, and/or anger. ii. Polydipsia.
b. If appropriate, reassure the child and parents iii. Polyphagia.
that the injections will help. c. Weight loss.
i. It is important, however, not to provide d. Blurred vision.
false hope because the child may not reach e. Fatigue.
the full desired height. f. Headache.
c. While the child is receiving GH, carefully
measure the child’s growth on growth charts.
DID YOU KNOW?
Diabetes mellitus in children often is not suspected
2. Deficient Knowledge.
until a child develops ketoacidosis and exhibits
a. Educate the parents and child, if appropriate,
marked confusion or, in some cases, coma. Only
regarding reconstituting the medication and
then do parents recognize that the child is seriously
injection technique.
ill. Once the child is admitted into the emergency
b. Educate the parents and child regarding the
department, the child’s serum laboratory values are
use of growth charts.
analyzed, and a clear diagnosis of type 1 diabetes
is made.
VI. Type 1 Diabetes Mellitus
4. Ketoacidosis, coma, and death may result if
Diabetes in children is the same disease that is seen in insulin is not administered. Ketoacidosis is a
adults. Because of the growth patterns and activity medical emergency.
i. Glucagon, which is administered via d. Refer the parents and child to diabetic and
injection, is a hormone that stimulates the nutrition counselors.
release of glucose from the liver. e. Assist the parents and child on ways to prevent
ii. Emergency glucagon kits, available by hyperglycemic episodes, including diet
prescription only, should be prescribed for counseling and exercise routines.
any child with type 1 DM. f. Educate the parents and child regarding the
iii. Glucagon must be mixed in the syringe potential for hyperglycemia during times of
immediately before administering. It may illness.
be injected into any muscle in the body. g. Inform the primary health-care provider if the
iv. Common side effects of glucagon are: child repeatedly experiences hyperglycemic
(1) Nausea and vomiting; therefore, the episodes.
child should be positioned on his or 2. Risk for Injury from hypoglycemia.
her side to prevent aspiration of any a. Educate the parents, child, school officials, and
vomitus. others regarding the signs and symptoms of
(2) Hyperglycemia; therefore, the child’s hypoglycemia, including:
glucose levels should be closely i. Tachycardia, clammy skin, irritability,
monitored following the injection. slurred speech, and loss of consciousness.
v. It is essential that the child’s parents, (1) Hypoglycemia may be mistaken
teachers, sports coaches, and other for temper tantrums in young
pertinent individuals be educated children.
regarding how to administer an emergency ii. If uncertain whether the child is hypo- or
glucagon injection. hyperglycemic, one should always assume
F. Nursing considerations. hypoglycemia.
1. Risk for Injury from hyperglycemia. iii. Educate the parents, child, school officials,
a. Educate the parents, child, school officials, and and others regarding the need to treat
others regarding the signs and symptoms of hypoglycemia immediately with:
hyperglycemia (see earlier “Signs and (1) Simple sugars (including juice,
symptoms”). candies, and soda) if the child is alert
b. Instruct the parents and child, if appropriate, and can swallow.
regarding the need for blood glucose testing (2) Glucagon injection, if unable to
throughout the day. swallow.
c. Educate the parents and child, if appropriate, iv. Educate the parents, child, school officials,
regarding insulin administration, including and others regarding the need to recheck
rotation of injection sites and the principles of the blood glucose level after he or she has
injecting different types of insulin. consumed the simple sugar.
VII. Type 2 DM
v. Once the child’s glucose level returns to
normal and the child is alert, educate the A. Incidence.
parents, child, school officials, and others 1. Up to 45% of new cases of DM in children.
to have the child consume a protein 2. Primarily diagnosed during adolescence.
source in order to maintain the normal 3. Highest incidence in African American, Native
glucose level. American, Hispanic American, and Asian-Pacific
vi. Inform the primary health-care Islander populations.
practitioner if the child repeatedly B. Etiology.
experiences hypoglycemic episodes. 1. Type 2 DM is not an autoimmune disease.
3. Imbalanced Nutrition: Less than Body 2. Primarily seen in children who are obese and who
Requirements. are sedentary.
a. Educate the parents and child, if appropriate, C. Pathophysiology.
regarding the interaction between food intake 1. Reduced insulin secretion and/or cellular
and insulin needs. resistance to the utilization of insulin.
a. Although the pancreas produces insulin, the b. Encourage the parents and children to
cells are unable to utilize the glucose. participate in weight management programs
2. Signs and symptoms. Most common include: and healthful diet choices as a means of
a. The three “polys”: polyphagia, polydipsia, and preventing the illness.
polyuria. i. Family-centered dietary changes should be
b. Hyperglycemia. encouraged because:
c. Fatigue. (1) Dietary patterns usually are learned
d. Acanthosis nigricans: darkening of the skin, at home; therefore, additional family
often around the neck. members may also be at risk of poor
i. Sign of insulin resistance syndrome. health, including the child’s parents
e. Ketoacidosis rarely is seen. and siblings.
D. Diagnosis. (2) Dietary changes, when family based,
1. Same as type 1 (see earlier). often are better received because the
E. Treatment. child feels less like he or she is being
1. Blood glucose monitoring: at least once per day. singled out or punished.
2. Weight control regimen with physical exercise. c. Encourage children to engage in daily exercise
3. Oral hypoglycemic agents or, if needed, injectable of their choice.
insulin. i. If the child is reluctant to begin an
a. Metformin (Glucophage) is often the first drug exercise routine, family-centered exercise
of choice. programs can also be encouraged
F. Nursing considerations. because:
1. See earlier type 1 DM nursing considerations and (1) Other family members may also be
modify accordingly. exhibiting sedentary lifestyles.
2. Deficient Knowledge. (2) They often are better received because
a. Educate the parents regarding the potential for the child feels less like he or she is
type 2 DM in children. being singled out.
i. Especially parents of high-risk children.
1.
2.
3.
4.
5.
B. What objective assessments indicate that this client is experiencing a health alteration?
1.
2.
3.
4.
5.
6.
7.
8.
C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse assign to this client?
1.
1.
2.
3.
4.
5.
6.
E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing interventions?
1.
2.
3.
4.
5.
6.
7.
F. What physiological characteristics should the child exhibit before being discharged home?
1.
2.
3.
4.
5.
6.
7.
G. What psychological characteristics should the child and family exhibit before being discharged home?
1.
2.
3.
4.
5.
10. A 2-year-old child has just been diagnosed with 13. The school nurse is responsible for caring for a
type 1 diabetes. The nurse is providing education to number of school children with type 1 diabetes.
the parents regarding signs of hypoglycemia. Which Before which of the following activities should the
of the following information should the nurse nurse make sure a child consumes a snack? The
include in her teaching session? child who:
1. Child’s breath will smell like fruit. 1. sculpts in art class.
2. Child will complain of excessive thirst. 2. plays in the band.
3. Child will complain of sleepiness and will appear 3. acts in the school play.
fatigued. 4. plays on the soccer team.
4. Child’s behavior will resemble a burst of anger or
14. A child has recently been diagnosed with type 1
a temper tantrum.
diabetes mellitus. Which of the following factors in
11. A nurse is providing education to 4 sets of parents his medical and family histories would the nurse
whose children have been diagnosed with type 1 expect to see?
diabetes. The nurse should provide follow-up 1. Child’s grandfather has been diabetic since
education to the parents who state that they will childhood.
perform which of the following actions? 2. Child’s body mass index is 30.
1. Parents of a 2-year-old: “We will have our 3. Child rarely engages in aerobic activities.
daughter prick her finger for each glucose 4. Child has recently gained 15 pounds.
testing.”
15. A teenage child has been diagnosed with type 2
2. Parents of a 5-year-old: “We will give our
diabetes. The nurse determines that the child will
daughter a code word that she will say when she
likely be administered which of the following
feels a hypoglycemic episode developing.”
medications?
3. Parents of a 9-year-old: “We will monitor our
1. Metformin (Glucophage)
daughter as she draws up and administers her
2. Aspart (Novolog)
insulin injections.”
3. Detemir (Levemir)
4. Parents of a 17-year-old: “We will allow our
4. Glargine (Lantus)
daughter to take responsibility for all of her own
diabetic care.” 16. Four sick children with type 1 diabetes have been
admitted to the hospital. Which child is most at risk
12. The nurse advises the parents of a 1½-year-old who
of developing hypoglycemia? The child with:
is newly diagnosed with type 1 diabetes that the
1. bacterial sepsis.
child’s blood glucose level before dinner should be
2. intussusception.
between 90 and 140 mg/dL. The mother states, “But
3. jaundice.
that is much higher than I read on an Internet Web
4. chickenpox.
site.” Which of the following responses by the nurse
is appropriate?
1. “I am sorry, I was thinking of the level for after
dinner. The correct before dinner level is 70 to
110 mg/dL.”
2. “The level is higher than what you will usually
see because young children’s diets are not as
predictable as the diets of older children and
adults.”
3. “The level before breakfast should be 70 to
100 mg/dL, but the before dinner level should be
a higher level.”
4. “You will find that your primary health-care
provider will change the level at each visit. The
goal starts at a high level and drops as your child
responds to the insulin.”
TEST-TAKING TIP: Those with bacterial sepsis have Content Area: Pediatrics
bacteria in their bloodstream. Most bacteria utilize Integrated Processes: Nursing Process: Implementation
glucose for fuel. Because the bacteria would be Client Need: Physiological Integrity: Reduction of Risk
consuming much of the glucose in the child’s Potential: Potential for Alterations in Body Systems
bloodstream, he or she would be at most high risk for Cognitive Level: Analysis
developing hypoglycemia.
Brudzinski sign—Pain and hip flexion when chin is Meningitis—A viral or bacterial infection of the
flexed onto chest. meninges.
Cerebral palsy (CP)—Disorder caused by a hypoxic Papilledema—Swelling of the optic disk due to
insult to the brain prenatally or during or after increased intracranial pressure.
delivery, resulting in permanent motor disability. Reye syndrome—Brain damage and impaired liver
Decerebrate posturing—Body positioning in which function seen in children who had been given
the arms and legs are rigid, with toes pointed aspirin following viral illnesses, most notably
inward, and head and neck held stiffly backward. varicella (chickenpox) and influenza.
Decorticate posturing—Body rigidity in which the Spina bifida—Birth defect in which the neural tube
arms are bent toward the body with hands in tight fails to completely close during fetal development.
fists and legs held stiffly straight. Tonic-clonic seizure—A type of seizure consisting of a
Hydrocephalus—An imbalance in either the period of muscle stiffening (the tonic phase)
production or absorption of cerebrospinal fluid, followed by shaking or jerking movements (the
leading to increased fluid in the ventricles of the clonic phase).
brain. Ventriculoperitoneal (VP) shunting—Procedure used
Increased intracranial pressure (ICP)—A rise in the to relieve intracranial pressure resulting from excess
pressure of the cerebral spinal fluid. cerebrospinal fluid.
Kernig sign—Pain when the leg and knee are elevated
and extended.
407
Table 22.1 Glasgow Coma Scales for Children Under 2, Children Aged 2 to 5, and Children Aged 6 and Over
Score Children Under 2 Children (Aged 2–5) Children (Aged 6 and Over)
Eye 4 Spontaneous Spontaneous Spontaneous
Opening 3 To verbal stimuli To verbal stimuli To verbal stimuli
2 To pain To pain To pain
1 No response No response No response
Verbal 5 Coos and babbles Oriented, speaks, interacts Oriented to time, place, and person;
Response uses appropriate words and phrases
4 Irritable and cries but is Confused and disoriented but Confused
consolable consolable
3 Cries persistently to pain Inappropriate words or verbal Inappropriate words or verbal response
response, inconsolable
2 Moans to pain Incomprehensible, agitated Incomprehensible
1 No response No response No response
Motor 6 Normal, spontaneous Normal, spontaneous Obeys commands
Response movement movement
5 Withdraws to touch Localizes pain Localizes pain
4 Withdraws to pain Withdraws to pain Withdraws to pain
3 Flexion to pain (decorticate)* Flexion to pain (decorticate) Flexion to pain (decorticate)
2 Extension to pain Extension to pain (decerebrate) Extension to pain (decerebrate)
(decerebrate)*
1 No response No response No response
From Teasdale, G., & Jennett, B. (1974). Assessment of coma and impaired consciousness. The Lancet, 304(7872), 81–84.
*For illustrations of decorticate and decerebrate posturing, see Figures 22.3 and 22.4, p. 419.
the skin of the lumbar, lumbosacral, or i. Depends on the level of the defect.
sacral area. ii. May be taught to walk with braces or
2. Degree of neurological dysfunction. crutches, or the child may be
a. Related to the anatomic level of the wheelchair-bound.
defect and whether spinal nerves are iii. May need bowel training and/or repeated
involved. urinary catheterizations.
3. Hydrocephalus (see the following
“Hydrocephalus” section).
DID YOU KNOW?
In some cases, when the defect is diagnosed
a. Present in 90% to 95% of children with spina
prenatally, corrective surgery can be performed
bifida.
on the fetus in utero. Babies who have been
4. Children with spina bifida are at high risk of
repaired as fetuses have been born with minimal
developing an allergy to latex.
permanent injury and normal growth and
a. Symptoms of the allergy can range from
development, including the ability to walk,
urticaria, watery eyes, wheezing, and rales to a
urinate, and stool normally (The Children’s
full anaphylactic response.
Hospital of Philadelphia, 2011).
5. Signs and symptoms: dependent on the degree
and level of the defect but include: F. Nursing considerations.
a. Spina bifida occulta. 1. Prevention:
i. Tuft of hair at base of spine. a. Deficient Knowledge.
ii. Dimpling at base of spine. i. Provide preconception counseling to
b. Meningocele and/or meningomyelocele. women of childbearing age regarding
i. No control over bladder and/or bowel the importance of taking a multivitamin
function. supplement including folic acid from the
ii. Diminished or absent sensation distal to cessation of use of birth control until the
the defect. birth of the baby.
iii. Partial or complete paralysis of the lower 2. Treatment:
limbs. a. Deficient Knowledge/Risk for Altered
iv. Increased ICP. Coping/Anger/Anxiety/Fear/Grieving.
D. Diagnosis. i. Allow the parents to express grief over the
1. Prenatally. loss of the perfect child.
a. Screening: indicates possible presence of the ii. Explain the pathophysiology and rationale
defect. for care to the parents and child, if
i. Elevated alpha-fetoprotein levels. appropriate.
(1) May be obtained either via serum or
amniotic fluid testing. MAKING THE CONNECTION
ii. Ultrasound visualization confirms the Although not totally preventable, folic acid intake
diagnosis. during pregnancy does significantly reduce the proba-
2. Newborn: direct visualization. bility of delivering a baby with spina bifida. Mothers are
a. X-ray, ultrasound, MRI, and/or CT scan are strongly encouraged to take a folic acid supplement
used to determine the severity of the defect. and to consume foods high in folic acid to prevent
E. Treatment. neural tube defects. It is important that the mothers be
1. Prevention. advised that they should begin folic acid intake before
a. Folic acid supplementation preconceptually trying to become pregnant so that the vitamin is present
and throughout pregnancy (see “Making the in the system during the entire organogenic period of
Connection”). the first trimester of pregnancy.
2. Treatment. Foods that are high in folic acid are dark-green, leafy
a. Surgical closure: prenatally or after delivery. vegetables; most fruits, including oranges and bananas;
i. When surgery is performed prenatally, potatoes; and, beginning in 2005, grain products in the
fewer physical deficits may be present. United States have been enriched with folic acid.
ii. If surgery is performed after delivery, The dosage of folic acid for women with no family
it is usually completed within 48 hr of or personal history of spina bifida is 400 mcg per day.
delivery. However, the recommended dosage is increased tenfold
b. Extensive physical therapy is often required to for those women who have a family or personal history
enable the child to reach his or her optimal to 4 mg per day.
level of functioning.
iii. Encourage the family and child to discuss (a) The medications are often
their concerns and guilt regarding the administered before and after
diagnosis. surgical procedures to prevent
iv. Help the parents to develop realistic goals allergic symptoms.
for the child’s growth and development 4. Postoperative considerations.
and to provide toys and activities that will a. Risk for Infection.
maximize the child’s growth and i. Perform meticulous handwashing.
development. ii. Monitor the surgical site for
v. Consider introducing the parents to other complications, including performing the
parents with children with spina bifida. REEDA (redness, edema, ecchymosis,
vi. Encourage the parents to join a supportive discharge, approximation) assessment, and
organization (e.g., Spina Bifida report any deviations from normal.
Association). iii. Change diapers and underpads, as needed,
3. Preoperative considerations. to prevent contamination of the site.
a. Risk for Infection/Impaired Skin Integrity. b. Risk for Injury/Risk for Altered Development/
i. Practice meticulous handwashing. Pain.
ii. Prevent the sac from drying out. i. Monitor for signs of increased ICP.
(1) Maintain moist, sterile dressings over ii. Maintain prone position until the surgical
the defect using aseptic technique. site is completely healed.
(2) Reinforce moist dressings with a dry, iii. Monitor vital signs and intake and output
sterile dressing to prevent bacteria (I&O).
from entering the sac via the moist iv. Maintain body temperature.
dressings. v. Provide tactile stimulation.
iii. Monitor for signs of infection, including (1) Place the baby on the parent’s lap,
elevated WBC, hyperthermia, and redness and encourage the parents to stroke
or purulent discharge at the site. and caress the baby.
iv. Monitor the sac for signs of rupture, CSF vi. Provide visual and auditory stimulation,
leakage, or drying. including drawings, music, and mobiles.
v. Place the child in the prone position to vii. Assess pain level using an age-appropriate
prevent damage to the exposed sac. pain rating scale.
vi. Change soiled diapers and underpads viii. Provide safe dosages of pharmacological
immediately to prevent contamination of pain management, employing professional
the site. guidelines.
vii. Monitor for signs of pressure points on ix. Provide nourishment, as prescribed.
dependent surfaces. 5. Long-term considerations.
b. Hypothermia. a. Risk for Ineffective Self-Health Management/
i. Monitor for drop in temperature. Risk for Impaired Mobility/Risk for Impaired
ii. If needed, place the baby in a warmer or Elimination/Deficient Knowledge.
Isolette, but ensure that the dressing i. At each well-child visit, growth and
remains moist and intact. development milestones must be assessed
c. Risk for Injury. carefully.
i. Monitor for signs of hydrocephalus (see ii. Assess for the level of the disorder to
the following “Hydrocephalus” section). determine the potential motor
ii. Assess for additional defects (e.g., dysfunction.
developmental dysplasia of the hip, (1) May be paralysis or spasticity
clubfoot) (see Chapter 20, “Nursing Care (e.g., hip flexors, and adductors
of the Child With Musculoskeletal [innervated by L1 to L3]) and
Disorders). extensors and abductors [innervated
(1) Musculoskeletal defects are by L5 to S1]).
commonly seen in children with (2) May exhibit complete incontinence of
spina bifida. stool.
iii. Avoid unnecessarily exposing the child to (3) May exhibit complete incontinence of
products that contain latex. urine or bladder spasticity.
(1) Administer antihistamines and iii. Perform range-of-motion exercises to help
steroids, as prescribed and as needed. to prevent contractures.
iv. Educate the parents and child, when subarachnoid space. In hydrocephalus, however, there is
appropriate, regarding the level of the either an imbalance in the production or the absorption
defect and the potential for motor and of CSF. The imbalance leads to an accumulation of fluid
elimination dysfunction. in the ventricles of the brain.
(1) Refer the child to physical therapy, A. Incidence.
occupational therapy, and orthopedic 1. Occurs in about 1 of every 500 children.
management, as prescribed 2. If left untreated, 50% to 60% of the children will
(a) Therapy will likely be a long, die and less than 10% of the survivors will achieve
continuous process. normal intelligence.
(2) Apply braces or other assistive devices, 3. If treated, there is an 80% survival rate, with the
when needed, to facilitate mobility. surviving children exhibiting varying levels of
b. Impaired Urinary Elimination/Risk for intelligence.
Infection (urinary). B. Etiology.
i. Educate the parents to monitor urinary 1. May be congenital or may develop as a result of
output and signs of urinary tract infection. such things as CNS infections and tumors.
ii. Educate the parents and child, frequently 2. The vast majority of children with spina bifida
at about 6 years of age, to perform (see earlier) also have hydrocephalus.
intermittent catheterizations, if needed. C. Pathophysiology: two main forms of hydrocephalus.
iii. Educate the parents to administer 1. Communicating hydrocephalus: impaired
antispasmodic medications to reduce absorption of CSF into the subarachnoid space.
bladder spasms, if prescribed. 2. Noncommunicating hydrocephalus: obstruction
c. Bowel incontinence. of the flow of CSF within the ventricles (most
i. Provide support to the parents and child, common form in children).
if appropriate, regarding the prolonged a. When seen in infancy, hydrocephalus is
period of bowel training. usually either congenital or secondary to an
ii. Refer the child to an occupational infection or perinatal hemorrhage.
therapist for assistance with bowel b. When seen in older children, the pathology
training, if needed. is usually secondary to the presence of a
iii. Educate the parents and child, when tumor.
appropriate, regarding diet and D. Diagnosis.
medications (to prevent constipation and 1. Clinical picture is suggestive.
diarrhea) (e.g., high-fiber foods, a. Presence of spina bifida, and/or
supplements, laxatives, suppositories). b. Signs of increased ICP.
iv. Educate the parents and child regarding 2. Definitive diagnosis is made by CT and/or MRI.
the necessity for regular toileting. E. Treatment.
d. Risk for Altered Development. 1. Ventriculoperitoneal (VP) shunt insertion: to
i. Encourage age-appropriate tasks to drain excess fluid from the ventricles (Fig. 22.2).
maximize abilities.
(1) If no paralysis:
DID YOU KNOW?
VP shunt catheters are placed in the ventricles of
(a) Place toys and other interesting
the brain. They are then threaded under the skin via
objects just out of the baby’s
the neck and thorax, finally ending in the peritoneal
reach.
cavity. Extra tubing, to allow for growth of the
(b) Praise the baby for attempts at
child, is positioned in the peritoneal cavity.
obtaining the desired object.
(2) If paralysis: a. Shunts often become obstructed and need to
(a) Provide toys to foster upper-body be revised or replaced.
development. F. Nursing considerations.
(b) Praise the baby for successfully 1. Preoperative VP shunt insertion.
achieving upper-body function. a. Risk for Injury.
i. Monitor vital signs.
IV. Hydrocephalus ii. Monitor for signs of increased ICP (see
earlier).
In the healthy brain, CSF is produced by the choroid (1) If infants, mark the exact point on the
plexus in the lateral ventricles, circulates throughout the head where the head circumference is
ventricular system, and finally is absorbed into the measured.
b. Monitor the child’s pain level during physical well as when playing contact sports like football,
therapy and occupational therapy sessions, hockey, and soccer).
following surgeries, and during and after any
other painful experiences. C. Pathophysiology.
c. Provide nonpharmacological and safe dosages 1. Dependent on extent of injury.
of pharmacological pain interventions, as a. Fractures of the skull.
needed. b. Contusions, i.e., bruises of the brain.
4. Anxiety/Fear/Anger/Grieving/Risk for Ineffective c. Concussion, i.e., a brain injury defined as “a
Coping. complex pathophysiological process affecting
a. Allow the parents to express grief over the loss the brain, induced by biochemical forces”
of the perfect child. (McCrory et al, 2013).
b. Carefully explain the pathophysiology and i. Concussion can result from a direct hit to
rationale for care to the parents and child, if the head or from an impact sustained in
appropriate. another part of the body that results in
c. Encourage the family and child, if appropriate, brain injury.
to discuss their concerns, frustrations, and (1) All contact sports place children at
guilt regarding the diagnosis and therapy. high risk for a concussion.
d. Help the parents to develop realistic goals for (2) Females are at higher risk than are
the child’s growth and development. males.
e. Consider introducing the child and family to ii. Concussions, although serious, usually
another family with a child with CP. resolve in time. If more than one
f. Refer the child and family to community concussion occurs within a short period of
resources (e.g., United Cerebral Palsy). time, however, the length of time needed
to recover increases dramatically.
iii. Concussions may or may not result in loss
VI. Head Injury of consciousness.
iv. A lengthy list of signs and symptoms
Severe head injuries are also referred to as total brain
has been developed by an international
injuries (TBIs).
panel of experts on concussions and the
A. Incidence.
sequelae that can develop as a result of
1. Leading cause of death in children over 1 year of
concussive injuries (McCrory and
age in the United States.
Colleagues, 2013).
B. Etiology.
d. Intracranial hemorrhage.
1. Babies under 1 year of age.
i. Epidural hemorrhage, or bleeding above the
a. Trauma sustained during automobile accidents.
dura, usually results in rapid onset of
b. Trauma sustained as a result of shaken baby
symptoms.
syndrome (SBS).
ii. Subdural hemorrhage, or bleeding below
2. Older children.
the dura, may be difficult to diagnose
a. Trauma sustained from automobile, bicycle,
because physiological changes often develop
skate boarding, skiing, and other such
slowly.
accidents.
2. Signs and symptoms of a TBI are dependent on
b. Trauma sustained during sporting events (e.g.,
the extent of the injury but frequently mimic
hockey, football, soccer).
those of increased ICP (see earlier).
DID YOU KNOW? D. Diagnosis.
Prevention is the key. To prevent SBS, all parents 1. History of injury.
should be educated regarding the potential for 2. Clinical picture is suggestive (see signs and
serious injury that can result from shaking an infant. symptoms of increased ICP).
Many hospitals are requiring new parents to view a. Comprehensive diagnostic assessments have
videos on SBS prior to being discharged from the been developed by an international panel of
postpartum unit. All children should be in age- experts for use by health-care providers. All
appropriate restraint devices when riding in are available online in the British Journal of
automobiles, and children should be seated in the Sports Medicine.
back seat of the car until at least age 12. In addition, i. Sport Concussion Assessment Tool–3rd
children’s heads must be protected with helmets Edition (SCAT3) (http://bjsm.bmj.com/
when they are engaged in potentially dangerous content/47/5/259.full.pdf): to be used for
activities (e.g., bicycling, skiing, skateboarding, as anyone over the age of 12.
2. With physiological maturation, which usually ! Safe dosages of antipyretics should be given as the
occurs by the school-age period, the majority of temperature is rising. Parents should NOT wait until the
children outgrow the disorder. temperature reaches its peak.
3. Although children who develop febrile seizures
are slightly at higher risk for epilepsy, in the vast iii. The child should be kept well hydrated
majority of cases, the children experience no and clothed in lightweight clothing.
long-term effects from the seizures. iv. Advise the parents that old remedies are
4. Signs and symptoms. no longer recommended.
a. Loss of consciousness. (1) Alcohol and/or tepid baths often result
b. Generalized, systemic tonic-clonic activity. in the child becoming chilled.
i. The tonic portion consists of a period of (a) Shivering results when one is
muscle rigidity during which the child chilled, resulting in the child’s
may stop breathing and become cyanotic. temperature rising rather than
ii. The clonic portion is characterized by a lowering.
shaking and jerking of both the arms and b. During a seizure:
the legs. i. Protect the head from injury.
iii. The seizures may last up to 15 min. (1) The remainder of the body should not
D. Diagnosis. be restrained.
1. Clinical evidence is suggestive. To distinguish ii. Loosen any restrictive clothing, e.g.,
febrile seizures from epilepsy, a thorough history unbutton a shirt at the neck.
of the seizure should be obtained from the iii. Document and report the characteristics
parents. of the seizure, including specific
2. Supportive evidence may be obtained from: physiological changes (e.g., breathing
a. Video recordings. pattern, length of seizure, focal versus
b. Electroencephalogram. tonic/clonic movements, skin color)
c. CT and/or MRI. iv. Institute CAB, as needed, following any
d. Lumbar puncture. seizure.
E. Treatment.
1. Safe dosages of antipyretics are administered to VIII. Reye Syndrome
prevent a rapid temperature rise.
a. Administration of safe dosages of Reye syndrome is a relatively rare, mainly preventable
acetaminophen and ibuprofen are often syndrome that follows viral illnesses, most notably vari-
alternated every 2 to 4 hr. cella (chickenpox) and influenza.
2. Unless a febrile seizure lasts longer than 15 min, A. Incidence.
it is rare for antiseizure medications to be 1. May be seen at any age, although it is rare after 14
ordered. years of age.
a. Children should have an epilepsy work-up if B. Etiology.
the child exhibits atypical febrile seizures, e.g., 1. Related to ingestion of aspirin during a viral
seizure that lasts longer than 15 min, is focal episode (usually varicella or influenza).
in nature, and/or a family member has C. Pathophysiology.
epilepsy. 1. In some individuals, the viral illness, often in
F. Nursing considerations. conjunction with the ingestion of aspirin, leads to
1. Risk for Injury/Deficient Knowledge. a disruption in fat metabolism, most notably in
a. Prevention. the liver, kidneys, and brain.
i. Parents must learn to be proactive when 2. Cytokines are released, resulting in serious
they think that their child is ill, seeking changes in the affected organs.
medical care, as needed. 3. Signs and symptoms.
(1) Any underlying illness (e.g., bacterial a. Elevated serum ammonia levels.
infection) should be treated. b. Hypoglycemia.
ii. Because the seizure usually occurs c. Signs and symptoms of increased ICP (see
as the temperature is rising, the nurse earlier).
should educate parents whose children 4. The syndrome is staged based on signs and
have had febrile seizures to intervene symptoms. Children who recover from the illness
early as a means of preventing future (reversal of symptoms can happen at any stage of
seizures. the illness) may suffer permanent brain injury.
F. Nursing considerations.
1. Deficient Knowledge.
a. Educate the parents to medicate childrens’
viral illnesses, especially varicella and
influenza, only with acetaminophen or
Fig 22.3 Decorticate posturing. ibuprofen.
2. Risk for Injury
a. Provide care, as cited earlier, for the client with
increased ICP.
b. Administer oxygen, as prescribed, and
mechanical ventilation, if needed.
c. Maintain IV therapy.
d. Administer safe dosages of anticonvulsants, as
Fig 22.4 Decerebrate posturing. prescribed.
e. Administer safe dosages of diuretics, as
prescribed.
a. Stage 1. f. Provide hemodialysis, as prescribed.
i. Sleepiness with vomiting. 3. Risk for Altered Coping/Grieving.
ii. Tachypnea in some children. a. Explain the pathophysiology and rationale for
b. Stage 2. care to the parents and child, if appropriate.
i. Hyperreflexia and combative behavior. b. Encourage the family and child to discuss their
ii. Positive Babinski reflex. concerns, guilt, and fear regarding the
iii. Failure to respond to pain. diagnosis and possible death.
c. Stages 3 to 5.
i. Children slowly deteriorate from IX. Meningitis
decorticate posturing (arms bent toward
the body, with hands in tight fists and legs Meningitis is the most common infection of the central
held stiffly straight, as shown in Fig. 22.3). nervous system seen in children and is the exemplar pre-
ii. To decerebrate posturing (rigid arms and sented in this chapter. Other infections of the CNS include
legs, with toes pointed inward and head encephalitis, infection of the brain, and myelitis, infection
and neck held stiffly backward, as shown of the spinal cord. Encephalitis may develop from viral
in Fig. 22.4). illnesses, including mumps and rubella and those trans-
iii. To paralyzed posturing, and death, as they mitted by insect vectors. Myelitis may develop in a baby
continue to seize. born with spina bifida.
d. Children who are unable to be staged correctly A. Incidence.
because they are on medications are classified 1. Meningitis most commonly is seen in children
as stage 6. less than 5 years of age, although meningococcal
D. Diagnosis. meningitis is seen in older children living in
1. Clinical picture, i.e., severe illness characterized confined spaces (e.g., college dormitories).
by lethargy and vomiting followed by agitation, 2. The number of children diagnosed with
combative behavior, and seizures, that develops meningitis has dropped significantly since the
about 1 week after a viral syndrome that was Hemophilus influenzae type b (Hib),
treated with aspirin. pneumococcal, and meningococcal vaccinations
2. Confirmatory findings include: have become routine.
a. Elevated AST and ALT. B. Etiology: there are a number of causative organisms.
b. Elevated serum ammonia. 1. Bacteria.
E. Treatment. a. Infants aged 0 to 3 months old: most
1. Palliative therapy because there is no specific common organisms are Escherichia coli or
cure. group B strep.
a. Oxygen and mechanical ventilation, if needed. b. Children 3 months of age to 12 years: most
b. IV therapy. common organisms.
c. Anticonvulsants for seizures. i. Neisseria meningitides: prevented by the
d. Diuretics for cerebral edema. meningococcal vaccine.
e. Hemodialysis for markedly elevated ammonia (1) If N. meningitides enters the blood-
levels. stream, the child will develop
2. Postoperative. B. Etiology.
a. Routine postoperative nursing care, including 1. Although the exact cause of the mutation is
pain management, REEDA assessment, vital unknown, neuroblastoma is a cancer of the
sign assessments, monitoring of gastrointestinal peripheral nervous system that originates from
functioning, and bleeding potential. embryonic tissue.
b. Risk for Injury. 2. A small number of neuroblastomas are hereditary.
i. Perform complete age-appropriate 3. Some neuroblastomas are environmental in
neurological assessments including origin; some of the parents of children with
Glasgow assessments and immediately neuroblastoma have worked in industries that
report any deviations from normal to the exposed them to cancer-causing chemicals.
neurosurgeon. C. Pathophysiology.
(1) Immediately report to the 1. Neuroblastomas originate from embryonic tissue.
neurosurgeon any signs and symptoms Rather than developing into normal sympathetic
of increased ICP that may develop as a nerve cells, some of the tissue mutates and
result of bleeding into the brain, develops into cancer cells.
hydrocephalus, or swelling of the 2. Neuroblastomas may be relatively small, round
brain tissue. tumors or may grow into more mature tumors.
ii. Elevate the head of the bed, as prescribed. 3. Metastasis to other organs is common.
(1) To prevent worsening of the ICP, the D. Diagnosis.
bed should never be placed in the 1. Diagnosis is often difficult because the signs and
Trendelenburg position. symptoms, depending on the location of the
c. Risk for Infection/Impaired Skin Integrity. tumor(s), are similar to those of other diseases.
i. Perform meticulous handwashing. a. Diagnosis is usually made with x-ray, MRI,
ii. Use aseptic technique when performing and/or CT
dressing changes. b. Once identified, the exact genetic mutation is
iii. Monitor the child for signs of infection, at determined. The clinical prognosis is often
the surgical site as well as urinary and dependent upon the age of the child in
pulmonary infections, and monitor conjunction with the genetics of the tumor.
laboratory data. c. Once diagnosed, additional tests to determine
d. Risk for Imbalanced Fluid Volume. the extent of metastasis may be performed.
i. Strict I&O. 2. Signs and symptoms of neuroblastoma range from
ii. Report if the child is excreting below the a large abdominal mass, to hypertension, to
minimum output for his or her weight. marked sweating, to marked diarrhea, to signs
iii. Monitor the child’s weight daily. and symptoms of spinal cord compression.
e. Risk for Delayed Growth and Development/ a. Children often complain of pain related to the
Risk for Impaired Coping. specific nerve involvement.
i. Perform growth and development E. Treatment.
assessments to determine the extent of the 1. Surgical removal of the tumor.
child’s disability. 2. Depending on the extent of tumor involvement,
ii. Refer the child to programs that provide the genetics of the tumor and the child’s age,
early educational intervention, if needed. surgery may be followed by chemotherapy and/or
iii. Depending on additional deficits exhibited radiation.
by the child, refer the family for a. See the discussion of acute lymphoblastic
specialized care, e.g., occupational therapy, leukemia (ALL) in Chapter 18, “Nursing Care
physical therapy, sensory assessments. of the Child with Hematologic Illnesses” for
iv. Provide children with clear, simple information regarding chemotherapy.
explanations of all tasks/treatments. F. Nursing considerations.
v. Refer the family for counseling, if 1. Preoperative.
prescribed. a. Anxiety/Fear/Anger/Grieving/Deficient
Knowledge/Pain.
XI. Neuroblastoma i. Provide age-appropriate information to
the parents and child, if appropriate,
A. Incidence. regarding the diagnosis and the surgery.
1. The most common malignancy in infants. ii. Allow the parents and child, if appropriate,
2. Over 15% of all children who die from cancer to express anger, fears, and anxiety related
have been diagnosed with neuroblastoma. to a life-threatening diagnosis.
1.
2.
B. What objective assessments indicate that this client is experiencing a health alteration?
1.
2.
3.
4.
5.
6.
7.
8.
C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse assign to this client?
1.
D. What interventions should the nurse plan and/or implement to meet this child’s and his family’s needs?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
1.
2.
3.
4.
5.
F. What physiological characteristics should the child exhibit before being discharged home?
1.
2.
3.
4.
G. What subjective characteristics should the child exhibit before being discharged home?
1.
11. The nurse is educating the parents of a child who 15. A 7-year-old child has just had a lumbar puncture
has been diagnosed with febrile seizures. Which of in the emergency department for complaints of
the following actions should the nurse advise the elevated temperature and a stiff neck. Which of the
parents is important for them to perform if their following cerebral spinal fluid findings would
child has another seizure? indicate that this child has bacterial meningitis?
1. Protect the child’s head. 1. Markedly lower than normal pressure
2. Restrain the child’s arms and legs. 2. Glucose 20 mg/dL
3. Place a tongue blade in the child’s mouth. 3. White blood cell count 3 cells/mm3
4. Administer mouth-to-mouth resuscitation. 4. Clear fluid
12. A nurse is providing health promotion/disease 16. A child is admitted to the pediatric unit with a
prevention education to a group of parents at a diagnosis of meningitis. Which of the following
neighborhood clinic. Which of the following actions should the nurse perform? Select all that
information should the nurse include in the apply.
teaching? 1. Raise the head of the bed.
1. The rotavirus vaccine will protect their children 2. Dim the lights in the room.
from the infection that causes meningitis. 3. Place the child on droplet isolation.
2. Aspirin should be administered to children who 4. Administer intravenous antibiotics, as
are sick with viral illnesses. prescribed.
3. A well-padded helmet should be worn by any 5. Perform passive range-of-motion exercises of the
child who plays a contact sport or rides a bicycle. neck.
4. The parent should carefully check the tongue for
17. A nurse is providing counseling to parents
injury whenever a child experiences severe head
regarding an important action they can take to
trauma.
prevent their children from developing meningitis.
13. A 12-year-old child is being assessed in the Which of the following actions did the nurse
emergency department for possible Reye syndrome. suggest?
The child was diagnosed with influenza by a 1. Have children sleep in separate beds during
primary health-care provider 2 weeks earlier. Which sleepover parties.
of the following findings would the nurse expect to 2. Have children receive all recommended
see? Select all that apply. immunizations.
1. Child’s Babinski reflex is positive. 3. Teach children to wash their hands after toileting
2. Child has had vomiting episodes for the past and before eating.
24 hr. 4. Teach children to cover their faces with a tissue
3. Child’s serum ammonia levels are markedly when they sneeze.
lower than normal.
18. A child who is experiencing high fever and neck
4. Child was administered ibuprofen (Advil) when
pain is diagnosed with viral meningitis. Which of
the child had the flu.
the following should the nurse include in the
5. Child is unusually argumentative and aggressive.
discharge teaching?
14. A teenager has been in an automobile accident. The 1. Keep the child isolated until the temperature
parents are advised that their child has experienced returns to normal.
a cerebral contusion. When they ask what that 2. Pad the child’s bed headboard.
means, the nurse should provide which of the 3. Rent a commode for the child to use at home.
following explanations? 4. Administer over-the-counter analgesics as
1. “Your child has ruptured a blood vessel between needed.
the layers that protect the brain from injury.”
2. “Your child has a bruise of the brain tissue.”
3. “Your child has a fracture in one part of the
skull.”
4. “Your child has a great deal of swelling of the
part of the brain that is called the brain stem.”
19. The nurse has taken a health history from a 20. A nurse is admitting a 7-month-old infant with a
school-age child who is being assessed 6 weeks’ diagnosis of neuroblastoma to the pediatric
post-surgery for a benign brain tumor. The nurse in-patient unit. The infant is the parents’ third child.
should report which of the following findings to the The infant’s father asks, “The doctor keeps talking
health-care provider? about the genetics of the tumor. What the heck does
1. The child states that he fell at school three times that mean?” Which of the following responses by
last week. the nurse is appropriate?
2. The child states that he has had no headaches all 1. “The doctor wants to determine whether any of
week. your other children is at high risk of developing
3. The child states that he did very well on a neuroblastoma.”
yesterday’s history test. 2. “The doctor wants to determine whether the
4. The child states that he has decided to join the genetic code in your baby’s tumor is different
school’s swim team. from the genetic code in the rest of the baby’s
cells.”
3. “The doctor is mandated by law to report to the
health department any genetic mutation that is
caused by environmental contaminants.”
4. “The doctor will be better able to determine how
the baby’s therapy will work once the exact
genetic code of the tumor is identified.”
Content Area: Newborn-At-Risk TEST-TAKING TIP: In healthy babies, the neonatal grasp
Integrated Processes: Nursing Process: Analysis reflex begins to fade at about 3 months of age and is
Client Need: Physiological Integrity: Reduction of Risk replaced by a voluntary grasp by about 5 months of age.
Potential: Potential for Alterations in Body Systems A grasp reflex that does not fade is consistent with a
Cognitive Level: Analysis diagnosis of CP.
Content Area: Pediatrics—Neuromuscular
6. ANSWER: 4 Integrated Processes: Nursing Process: Assessment
Rationale: Client Need: Physiological Integrity: Physiological
1. The correct patient-care goal would be for the baby to Adaptation: Alteration in Body Systems
maintain prone positioning. Cognitive Level: Application
2. Because of the defect, the baby will not have normal
elimination patterns. 9. ANSWER: 3
3. Because of the defect, the baby will not exhibit a Rationale:
normal startle reflex. 1. The symptoms of CP do not get worse over time.
4. The baby would be expected to consume feedings and 2. Although medicines are available for some of the
gain weight. comorbidities associated with CP, there is no medication
TEST-TAKING TIP: Patient-care goals are expectations of that treats the underlying cause of CP.
patients’ behavior. A baby with a meningomyelocele 3. This statement is accurate.
would not be expected to have normal elimination 4. This statement is false. The pathology of CP is in the
patterns or a normal startle (Moro) reflex because brain.
of the nerve damage sustained from the defect. TEST-TAKING TIP: The signs and symptoms of CP result
In addition, to prevent injury to the surgical site, from a hypoxic insult to the brain. The therapeutic
the baby must be placed in the prone position. interventions are aimed at enabling the child to reach his
After surgery, the baby would be expected to feed or her highest potential.
and gain weight. Content Area: Pediatrics—Neuromuscular
Content Area: Newborn-At-Risk Integrated Processes: Nursing Process: Implementation
Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity: Physiological
Client Need: Physiological Integrity: Reduction of Risk Adaptation: Alterations in Body Systems
Potential: Potential for Alterations in Body Systems Cognitive Level: Application
Cognitive Level: Application
10. ANSWER: 4
7. ANSWER: 1 Rationale:
Rationale: 1. Tepid baths are no longer recommended.
1. The child should be seen in the emergency 2. Antipyretics should be administered as soon as the
department. child’s temperature begins to rise. In addition, to prevent
2. This child is exhibiting signs of increased ICP. The child liver damage, only safe dosages of acetaminophen should
needs to be seen as soon as possible. be administered.
3. The child is exhibiting signs of increased ICP. 3. Children who experience febrile seizures rarely develop
4. This child is exhibiting signs of increased ICP. The child a permanent seizure disorder.
needs to be seen as soon as possible. 4. Most children do outgrow febrile seizures by the time
TEST-TAKING TIP: Ventriculoperitoneal (VP) shunts drain they reach 6 years of age.
the cerebral spinal fluid from the ventricles of the brain TEST-TAKING TIP: Febrile seizures usually occur as a
in order to maintain normal intracranial pressures. When child’s temperature is rising. It is recommended,
they malfunction, patients exhibit signs of increased ICP. therefore, to administer antipyretics as soon as an
The child needs to be assessed as an emergency so elevation is noted. When placed in tepid baths, children
that the needed shunt revision can be scheduled and usually shiver. Shivering actually stimulates the body to
performed. raise its temperature.
Content Area: Pediatrics—Neuromuscular Content Area: Pediatrics—Neuromuscular
Integrated Processes: Nursing Process: Implementation Integrated Processes: Nursing Process: Implementation;
Client Need: Physiological Integrity: Physiological Teaching/Learning
Adaptation: Alternations in Body Systems Client Need: Physiological Integrity: Physiological
Cognitive Level: Application Adaptation: Alterations in Body Systems
Cognitive Level: Application
8. ANSWER: 1
Rationale: 11. ANSWER: 1
1. Positive grasp reflex would be consistent with the Rationale:
diagnosis. 1. The parents should be taught to protect their child’s
2. Pigeon chest is unrelated to a diagnosis of CP. head.
3. Harlequin sign is unrelated to a diagnosis of CP. 2. The child’s arms and legs should not be restrained.
4. Circumoral cyanosis is unrelated to a diagnosis 3. A tongue blade should not be inserted into the child’s
of CP. mouth.
4. Only if the child fails to start breathing after the seizure 14. ANSWER: 2
has stopped, which happens rarely, should CPR be Rationale:
instituted. 1. This explanation is a subdural hematoma.
TEST-TAKING TIP: During tonic-clonic seizures, patients 2. A cerebral contusion is a brain bruise.
are unconscious and are thrashing indiscriminately. In 3. This explanation simply is a fractured skull.
order to prevent the child from experiencing a head 4. This child has severe increased ICP.
injury, his or her head should be protected, but TEST-TAKING TIP: Although this question refers to a
restraining a child’s arms and legs may actually result in conversation between parents and a nurse, it simply is
an injury. asking for the definition of a contusion.
Content Area: Pediatrics—Neuromuscular Content Area: Pediatrics—Neuromuscular
Integrated Processes: Nursing Process: Implementation; Integrated Processes: Nursing Process: Implementation
Teaching/Learning Client Need: Physiological Integrity: Physiological
Client Need: Physiological Integrity: Reduction of Risk Adaptation: Pathophysiology
Potential: Therapeutic Procedures Cognitive Level: Comprehension
Cognitive Level: Application
15. ANSWER: 2
12. ANSWER: 3 Rationale:
Rationale: 1. Cerebral spinal fluid pressures are elevated with a
1. The rotavirus vaccine protects children from an diagnosis of bacterial meningitis.
infection that causes severe gastrointestinal illness. 2. Low glucose (below 45 mg/dL) is consistent with a
2. Aspirin should not be administered to children who are diagnosis of bacterial meningitis.
sick with viral illnesses. 3. Elevated white blood cell counts are consistent with a
3. A well-padded helmet should be worn by any child diagnosis of bacterial meningitis (normal is less than
who plays a contact sport or rides a bicycle. 5 cells/mm3).
4. The ears and nose should be checked carefully for the 4. Cerebral spinal fluid is cloudy with a diagnosis of
leakage of blood or fluid whenever a child experiences bacterial meningitis.
severe head trauma. TEST-TAKING TIP: When a child has bacterial meningitis,
TEST-TAKING TIP: Children can experience very serious he or she has bacteria in the cerebral spinal fluid. The
head injuries, including contusions, concussions, fractures, bacteria use the glucose for energy. As a result, glucose
and hematomas, when they fall or are hit while engaged levels drop.
in a variety of activities. Whenever possible, they should Content Area: Pediatrics—Neuromuscular
wear helmets for protection. Because of the potential for Integrated Processes: Nursing Process: Assessment
developing Reye syndrome, aspirin should not be Client Need: Physiological Integrity: Physiological
administered to children suffering from a viral illness. Adaptation: Alterations in Body Systems
Content Area: Child Health Cognitive Level: Application
Integrated Processes: Nursing Process: Implementation;
Teaching/Learning 16. ANSWER: 1, 2, 3, and 4
Client Need: Health Promotion and Maintenance: Health Rationale:
Promotion/Disease Prevention 1. The head of the bed should be raised.
Cognitive Level: Application 2. The room lights should be dimmed.
3. The child should be placed on droplet isolation.
13. ANSWER: 1, 2, and 5 4. The child will receive IV antibiotics.
Rationale: 5. The nurse should refrain from moving the child’s neck.
1. A positive Babinski reflex is seen in children with The movement is very painful.
Reye syndrome. TEST-TAKING TIP: The bacteria that cause meningitis are
2. Vomiting episodes are seen in children with Reye transmitted via the respiratory route. The child, therefore,
syndrome. should be placed on droplet isolation. Once the child has
3. Serum ammonia levels rise with Reye syndrome. been on antibiotics for a full 24 hr or if the culture report
4. Aspirin is contraindicated when a child has the flu. is negative for bacteria, he or she no longer needs to
5. Combative behavior, including being argumentative remain on isolation.
and aggressive, is seen in children with Reye syndrome. Content Area: Pediatrics—Neuromuscular
TEST-TAKING TIP: Reye syndrome is seen as a sequela to Integrated Processes: Nursing Process: Implementation
some viral illnesses, most notably varicella and influenza. Client Need: Physiological Integrity: Physiological
It is more likely to occur if a child has received aspirin Adaptation: Illness Management
during the viral illness. Cognitive Level: Application
Content Area: Pediatrics—Neuromuscular
Integrated Processes: Nursing Process: Assessment 17. ANSWER: 2
Client Need: Physiological Integrity: Physiological Rationale:
Adaptation: Alterations in Body Systems 1. Sleeping in separate beds may help to prevent
Cognitive Level: Application transmission if one child is harboring bacteria that cause
meningitis, but it is not the best response.
2. Many of the vaccinations administered to children 2. The child should no longer suffer from headaches.
immunize children against bacteria that cause 3. The nurse need not report that the child did well on a
meningitis. recent history test.
3. Teaching children to wash their hands after toileting 4. The nurse need not report that the child is joining the
and before eating helps to prevent many types of illnesses, school’s swim team.
most notably gastrointestinal illnesses. TEST-TAKING TIP: The child has communicated that he
4. Teaching children to cover their faces with a tissue has fallen, which likely is related to poor coordination.
when they sneeze helps to prevent the transmission of Even after a brain tumor has been removed, a number of
upper respiratory illnesses to other children. children will experience long-term complications.
TEST-TAKING TIP: Immunizations against H. influenzae, Content Area: Pediatrics—Neuromuscular
N. meningitides, and S. pneumoniae have prevented many Integrated Processes: Nursing Process: Implementation
children from developing meningitis. Client Need: Physiological Integrity: Physiological
Content Area: Child Health Adaptation: Alterations in Body Systems
Integrated Processes: Nursing Process: Implementation; Cognitive Level: Application
Teaching/Learning
Client Need: Health Promotion and Maintenance: Health 20. Answer: 4
Promotion/Disease Prevention Rationale:
Cognitive Level: Analysis 1. Neuroblastoma develops from embryonic tissue.
Because they are older, the parents’ other children are
18. ANSWER: 4 unlikely to be at high risk for the disease.
Rationale: 2. All cancers are caused by mutated cells. The genetic
1. It is unnecessary to be in isolation for viral meningitis. code of the neuroblastoma, therefore, is different from the
2. It is rare for children with viral meningitis to seize. infant’s other cells.
3. The child will be able to walk to the bathroom. A 3. There is no law mandating the doctor to report the
commode will not be needed. information to the health department.
4. Children with meningitis often have headaches. 4. This statement is true. The prognosis for children with
Over-the-counter analgesics are administered for the neuroblastoma is dependent upon the child’s age and
pain. the exact genetic mutation of the cancer.
TEST-TAKING TIP: Viral meningitis is much more benign TEST-TAKING TIP: Although the exact cause of the
than is the bacterial disease. Palliative care is provided to mutation is unknown, neuroblastoma is a cancer of the
the child until the meningeal inflammation diminishes. peripheral nervous system that originates from
Content Area: Pediatrics—Neuromuscular embryonic tissue. A small number of neuroblastomas are
Integrated Processes: Nursing Process: Implementation; hereditary and some neuroblastomas are environmental
Teaching/Learning in origin.
Client Need: Physiological Integrity: Physiological Content Area: Pediatrics—Neuromuscular
Adaptation: Illness Management Integrated Processes: Nursing Process: Implementation
Cognitive Level: Application Client Need: Physiological Integrity: Physiological
Adaptation: Alterations in Body Systems
19. Answer: 1 Cognitive Level: Application
Rationale:
1. The nurse should report that the child states that he
fell at school three times last week.
Refeeding syndrome—A severe drop in serum Russell’s sign—Abrasions on the fingers and knuckles
phosphate, potassium, and magnesium levels as from induced vomiting in people with bulimia.
well as sodium and fluid retention when nutrition
resumes after a period of starvation.
433
moving when the child should be sitting iii. Other medications should never be
still, and the inability to engage in administered in conjunction with the
individualized work. stimulants unless approved by the primary
b. The child’s behaviors must: health-care provider.
i. Have been evident by at least age 12. iv. Medications are highly addictive and may
ii. Be evident in more than one social setting be abused.
(e.g., school and church, school and work). v. Ritalin can delay physical growth, so the
iii. Not be explained by any other psychiatric child’s height should be carefully
diagnosis. (An exception to this statement monitored on growth charts.
is made in the case of autism spectrum g. Although there is little evidence of therapeutic
disorder because the two problems are value, discuss controversial alternative
often seen in the same child. See Chapter therapies with parents, including dietary
24, “Nursing Care of the Child With changes (i.e., removing refined sugars and
Intellectual Developmental Disabilities.”) additives from the diet), hypnosis, exercise,
iv. Be negatively affecting the child’s vitamin supplementation, and metronome
development (e.g., the child is not able to therapy.
learn up to his or her potential).
E. Treatment. III. Eating Disorders
1. Therapy or counseling, which may include
behavioral modification, family therapy, and/or A. Anorexia nervosa.
psychotherapy. 1. Incidence.
2. Medication, most notably stimulants, such as: a. Predominately in white, adolescent females
a. Ritalin (methylphenidate), Adderall from middle and upper socioeconomic strata,
(dextroamphetamine/amphetamine), and although seen in all groups of children.
Dexedrine (dextroamphetamine). b. About 1 to 2 in 10 anorexics will succumb to
i. Side effects related to these medications the disease or to suicide.
include drug dependence; arrhythmias; c. Only about 15% of anorexics fully recover.
hypertension; and, when taken over long 2. Etiology.
periods of time, growth suppression. a. There is no known cause of anorexia, although
F. Nursing considerations. the majority of patients have a pre-existing
1. Impaired Social Interaction/Risk for Injury/ emotional illness (e.g., depression).
Impaired Coping/Deficient Knowledge. b. The refusal to eat often begins with a
a. Assist with determining the diagnosis, perceived traumatic event (e.g., someone
employing the criteria published in the DSM-5. intimated that the young woman was
b. Enable family members to express their anger, overweight; a developmental change, like
frustration, and other feelings regarding the menarche; or a reprimand).
child’s behavior and/or the child’s diagnosis. c. Some attribute the disorder to an identity crisis
c. Educate the family members regarding the for the child.
diagnosis. i. Difficulty in making the transition from a
d. Educate the family members on ways to child to a sexually mature young man or
positively reinforce appropriate behavior. woman.
e. Assist with implementing the prescribed 3. Pathophysiology.
therapy when the child is in the health-care a. Refusal to eat related to a distorted view of
environment and during school time. one’s weight and appearance.
f. Educate the parents regarding the prescribed i. Self-imposed starvation: in essence, the
dosage, route, action, and side effects of patient is committing a slow suicide.
medications. Important considerations include: 4. Diagnosis.
i. Stimulants should not be administered to a. As defined by the APA (2013) in the
children with cardiac anomalies or other DSM-5:
cardiac diseases. i. Weight is 15% or more below the
(1) Hypertension and cardiac arrhythmias minimum weight for the child’s height.
are serious side effects. ii. Intense fear of gaining weight, even
ii. Stimulants can adversely affect sleep; though the child is distinctly
therefore, they should be administered underweight.
early in the day. iii. Disturbed body image.
emotionally, or, more seriously, physically or sexually b. The nurse is not required to provide absolute
injures a child, that adult must be identified and, when proof that the child is being abused or
appropriate, punished. When interacting with children, neglected.
nurses are legally obligated to identify characteristics of
child abuse and neglect.
DID YOU KNOW?
The nurse should be especially suspicious of
A. Incidence.
maltreatment when the parents’ explanation for the
1. In 2011, 9.1 out of every 1,000 children were
child’s behavior or injury is inconsistent with the
reported as victims of child abuse or neglect (U.S.
evidence. For example, if a parent states that a
Department of Health and Human Services, 2012).
5-month-old infant broke his or her leg when the
a. Each child was counted only once, even if he
infant fell while crawling up the stairs, the nurse
or she had been reported as maltreated more
must conclude that the child was abused. Five-
than once.
month-old infants are developmentally unable
b. Three times as many of the victims were
to crawl.
neglected than were abused.
c. Children under 3 years of age were maltreated 5. Signs and symptoms of child neglect.
more often than were older children. a. Examples of physical indicators of neglect. The
B. Etiology. child exhibits:
1. A number of factors contribute to the eventual i. Inadequate weight gain for age.
abuse or neglect of a child, but, in the vast ii. Poor growth patterns and failure to
majority of cases, the nurse will identify a family thrive.
in which one or more of the members are iii. Constant hunger.
dysfunctional. Examples of individual dysfunction iv. Poor hygiene.
that can lead to family dysfunction and child v. Untreated illness.
maltreatment include: vi. Inappropriate attire for the weather.
a. Alcohol, drug, and/or partner abuse by one or vii. Adult behavior (e.g., making all meals for
both of the parents. the family, maintaining the home
b. The family is facing economic challenges, environment).
especially if the parents are unexpectedly b. Examples of behavioral indicators of neglect
unemployed. exhibited by the child.
c. One or both of the parents are stressed at i. Begs or steals food.
work. ii. Attends school inconsistently.
d. One or both of the parents misunderstand iii. Arrives very early and/or stays very late at
the behaviors and/or needs of a child with school.
intellectual and developmental disabilities. iv. Is constantly fatigued or listless in class.
e. When the parents, for example adolescent c. Examples of behavioral indicators of neglect
parents, misunderstand or are unfamiliar exhibited by one or more parents.
with the normal growth and development of i. Are unresponsive when the child’s
children. appearance is discussed.
f. One or both of the parents were maltreated or ii. Fail to take the child to the physician or
sexually assaulted as a child. dentist for needed care.
C. Pathophysiology. iii. Fail to give the child needed medication.
1. Any child who is 18 years old or younger is a iv. Fail to provide a safe place for the child to
potential victim of child abuse and/or neglect. reside.
2. Depending on the state and location, any adult v. Fail to require the child to attend school.
who is cognitively and/or developmentally vi. Leave the young child or children
disabled is also a potential victim of child abuse unattended.
and/or neglect. 6. Signs and symptoms of child emotional abuse.
3. The pathophysiology can be either physical, a. Examples of behavioral indicators of emotional
emotional, or sexual in nature. abuse exhibited by the child.
4. The nurse must observe for and report signs of i. Emotional extremes (i.e., overly aggressive
maltreatment. or overly passive).
a. If the nurse has a strong suspicion of abuse, ii. Repetitive behaviors (e.g., hand banging,
he or she should report it to the primary biting).
health-care provider as well as the appropriate iii. No apparent affection for the parent.
child welfare agency. iv. Suicidal ideations.
1.
2.
3.
4.
B. What objective assessments indicate that this client is experiencing a health alteration?
1.
C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse assign to this client?
1.
D. What interventions should the nurse plan and/or implement to meet this child’s and her family’s needs?
1.
2.
3.
E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing interventions?
1.
2.
F. What physiological characteristics should the child exhibit before leaving the clinic?
1.
10. A nurse is giving a presentation to parents on 14. During a discussion with a 13-year-old student, a
behaviors that are characteristic of adolescents who school nurse believes that the student has a plan to
are using alcohol or other substances. Which of the commit suicide. Which of the following responses
following information should the nurse include in would be appropriate for the nurse to perform?
the presentation? 1. Try to talk the student out of the plan.
1. Teen asks to have a body part pierced or 2. Ask the student if it would be acceptable to
tattooed. break confidentiality in this case.
2. Teen requests to be tutored in a course he or she 3. Provide the student with the name of a
is failing. psychologist.
3. Teen stops participating in all extracurricular 4. Have someone chaperone the student and call
activities. the parents to notify them of the plan.
4. Teen asks parents to knock before entering his or
15. Four 8-year-old boys are seen in the pediatric clinic
her bedroom.
during one week. All of the parents accompanying
11. A nurse is giving a presentation to adolescents the children state that their children were injured
regarding actions they should take if they believe when they fell from a playground apparatus. The
that a friend has consumed too much alcohol. nurse reports a suspicion of child abuse to the
Which of the following information should the primary health-care provider regarding the child
nurse include in the presentation? who exhibited which of the following signs/
1. Have the friend take a cold shower. symptoms?
2. Make the friend drink coffee. 1. Greenstick fracture of the right arm
3. Call for medical emergency care. 2. Abrasions on both knees
4. Put the friend to bed to sleep it off. 3. Laceration of the right cheek
4. Bald area above the right ear
12. A nurse is giving a presentation to parents regarding
characteristics that place children and adolescents at 16. A school nurse is making rounds in the
risk of attempting suicide. Which of the following kindergarten classrooms of an elementary school.
characteristics should the nurse include in the The nurse, who interviews 5 of the boys, suspects
presentation? Select all that apply. that which of the boys is a victim of child neglect?
1. Recent suicide of a friend The child who: Select all that apply.
2. Ability easily to access a gun 1. is wearing shorts and a tee shirt on a cold winter
3. Parent who is a gay or lesbian day.
4. Often talks about death or being dead 2. steals some breakfast cereal from a closet in the
5. Parents who work long hours each day nurse’s office.
3. states that his mother is going to buy fast-food
13. During a discussion with the school nurse, a
hamburgers for supper.
13-year-old student states, “I hate myself. I just want
4. is upset because his parents will not let him learn
to die.” Which of the following responses should the
how to play hockey.
nurse make?
5. states that his parents are waiting for the two
1. “You don’t really mean that.”
teeth with cavities to fall out.
2. “You are scaring me.”
3. “You can’t do that. Have you thought about how
much that would affect your parents?”
4. “You say that you want to die. Do you have a
plan about how you might end your life?”
17. A nurse, working in a pediatric clinic, has assisted 18. A nurse, working in an emergency department,
with the care of 4 toddlers, all of whom were suspects that a 16-year-old is a victim of physical
accompanied by their parents. In which of the cases abuse. The parents state, “Our girl is hurt. She needs
should the nurse examine the child carefully for to be fixed up.” Which of the following findings are
signs of maltreatment? consistent with the nurse’s conclusions? Select all
1. The child cries when the parent attempts to pick that apply.
the child up to go home after the examination is 1. Teen states that she had a bad snowboarding
over. accident.
2. The parent holds the child firmly when the child 2. Parents report that the girl has run away twice
is receiving an injection. this year.
3. The child kicks and screams when the health- 3. Teen has sustained open fractures of the right
care provider enters the room. ulna and radius.
4. The parent demands that the child be seen by a 4. Family lives fifty miles away from the emergency
specialist for an illness that is unresolved after department.
two weeks. 5. Parents interrupt the girl whenever she tries to
give answers to the nurse’s questions.
TEST-TAKING TIP: Alcohol is a central nervous system alone by notifying the child’s/teen’s parents of the
depressant. When consumed in large quantities, alcohol intention and by referring the family to a mental health
can result in coma, respiratory depression, and death. practitioner who can intervene.
Teens must be strongly encouraged not to consume Content Area: Mental Health—Suicide
alcohol until they are 21 years of age, but, if they do, and Integrated Processes: Nursing Process: Implementation
they are in the company of someone who has consumed Client Need: Psychosocial Integrity: Mental Health
excessive quantities of the substance, the teen must be Concepts
prepared to call for medical assistance. Cognitive Level: Application
Content Area: Substance Abuse
Integrated Processes: Nursing Process: Implementation; 14. ANSWER: 4
Teaching/Learning Rationale:
Client Need: Physiological Integrity: Physiological 1. It is not appropriate to try to talk the student out of the
Adaptation: Medical Emergencies plan.
Cognitive Level: Application 2. When a student is in imminent danger of harming
him- or herself, confidentiality is no longer maintained.
12. ANSWER: 1, 2, and 4 3. Although a mental health professional should be
Rationale: contacted, it is inappropriate simply to provide the
1. The recent suicide of a friend does place children and student with the name of a psychologist.
adolescents at risk of attempting suicide. 4. This action is appropriate. Someone should be with
2. The ability to easily access a gun does place children the student at all times to make sure that the student
and adolescents at risk of attempting suicide. does not complete the plan, and the parents should be
3. A parent who is gay or lesbian does not place a child or notified of the plan.
teen at risk of attempting suicide. TEST-TAKING TIP: When a child/teen communicates that
4. A teen or child who talks about death or being dead is he or she has a plan to commit suicide, he or she is fully
at risk of attempting suicide. intending to execute that plan. It is very important,
5. A teen or child who lives with parents who work long therefore, that the child/teen never be left alone.
hours each day is not necessarily at risk of attempting Content Area: Mental Health—Suicide
suicide. Integrated Processes: Nursing Process: Implementation
TEST-TAKING TIP: There are a number of factors that Client Need: Psychosocial Integrity: Mental Health
place children and adolescents at high risk of attempting Concepts
suicide. Adults who are in close contact with children Cognitive Level: Application
and/or adolescents should monitor them carefully for
behaviors that indicate that they are seriously 15. ANSWER: 4
contemplating suicide. Rationale:
Content Area: Mental Health—Suicide 1. Greenstick fractures are commonly seen in the
Integrated Processes: Nursing Process: Implementation; pediatric population. A fracture of the right arm is
Teaching/Learning consistent with the parent’s story.
Client Need: Psychosocial Integrity: Mental Health 2. It is foreseeable that a child could sustain abrasions on
Concepts both knees after falling from a playground apparatus.
Cognitive Level: Application 3. It is foreseeable that a child could sustain a laceration
of the right cheek during a fall from a playground
13. ANSWER: 4 apparatus.
Rationale: 4. It is unlikely that a child’s hair would be pulled out
1. This is an inappropriate statement. One must assume during a fall from a playground apparatus.
that students are contemplating suicide when they say TEST-TAKING TIP: Bald spots are often seen in children
that they want to die. who have been abused. Parents, when angry, may grab
2. This may be true, but the statement is inappropriate. the child’s hair and pull it out from the scalp.
The nurse should focus on the student, not on him or Content Area: Child Health, Abuse
herself. Integrated Processes: Nursing Process: Implementation
3. This is not the best response. The nurse should assess Client Need: Psychosocial Integrity: Abuse/Neglect
the student’s current intentions. Cognitive Level: Application
4. The nurse should ask the student whether he or she
has a plan. 16. ANSWER: 1, 2, and 5
TEST-TAKING TIP: It can be a daunting task to ask a child Rationale:
or adolescent whether he or she has a plan to commit 1. A child wearing clothing that is inappropriate to the
suicide. The nurse may fear that he or she will actually weather is likely a victim of child neglect.
cause the child/teen to do so. That, however, is not the 2. A child who has not been served breakfast by his
case. Rather, if the nurse queries the child/teen and parents is likely a victim of child neglect.
learns that he or she has a plan, the nurse can then 3. Although fast food is not the most nutritious food
intervene by making sure that the child/teen is never left choice, serving fast food to one’s child is not a form of
child neglect.
Chromosomal mosaicism—A condition in which the Muscular hypotonia—Poor muscle tone throughout
cells of the body have different numbers of the body.
chromosomes. Simian creases—Unbroken “life lines” that stretch
Failure to thrive (FTT)—A child who is growing and across the palm of the hand, associated with Down
developing much slower than would be expected. syndrome.
Fragile X syndrome—A genetic condition linked to the Trisomy 21—The occurrence of three number 21
X chromosome, causing physical, cognitive, and chromosomes in the zygote; the most common
behavioral defects, seen most commonly and most cause of Down syndrome.
severely in males.
451
d. Poor or abusive parenting (e.g., shaken baby fragile X syndrome and a 50%
syndrome). probability of having a normal
e. Perinatal hypoxia that occurs during genotype.
pregnancy, labor, and/or delivery. b. Down syndrome.
f. Hypoxia of a child that may occur post- i. Trisomy 21 is the most common Down
delivery, most commonly in premature infants, syndrome genotype.
or as a result of an accident (e.g., near C. Pathophysiology.
drowning). 1. Damage to the cognitive centers of the
2. Genetic causes. cerebrum of the brain that has occurred
a. Fragile X syndrome. from one of many possible insults, including
i. Most common genetic cause of ID. hypoxic injury, teratogenic insult, or genetic
ii. X-linked recessive syndrome (Fig. 24.1). injury.
(1) A Punnett square with an example D. Diagnosis.
of the inheritance pattern for fragile 1. Prenatal screenings.
X syndrome is shown below. The a. May detect a fetus that is at high risk of a
mother is heterozygous for the genetic syndrome.
disease (i.e., she carries one affected X b. If the screening is positive, diagnostic tests
chromosome [“x”X]), and the father is (i.e., chorionic villus sampling or
unaffected (XY). amniocentesis) may be performed.
2. Genetic diagnostic tests provide accurate
“x” X diagnoses of genetic disorders.
X “x”X XX 3. Growth and development screenings (e.g., DDST,
Y “x”Y XY Ages and Stages) are performed during early
(a) If the offspring is female, there childhood.
is a 50% probability of carrying a. When a child fails to achieve expected
an affected X and potential for milestones, health-care practitioners
exhibiting symptoms of the should refer the child for additional,
fragile X syndrome and a 50% more sophisticated cognitive diagnostic
probability of having a normal testing.
genotype. 4. Cognitive diagnosis tests include the Stanford-
(b) If the offspring is male, there is Binet Intelligence Scale (SB5), the Wechsler
a 50% probability of having Preschool and Primary Scale of Intelligence
(WPPSI-III), and the Wechsler Intelligence Scale
for Children (WISC-III).
a. SB5: for assessing age 2 through adulthood.
i. Includes a comprehensive assessment of
intelligence of the child.
b. WPPSI-III: for assessing children 2 years 6
months to 7 years 3 months of age.
i. Includes a number of subscales to provide a
comprehensive assessment of intelligence of
the young child.
c. WISC-III: for assessing children over the age
of 6.
i. Includes 13 subscales for comprehensive
assessment of intelligence.
d. Tests for children under 2 are less predictive.
e. Some children are not diagnosed until in
school when they have difficulty in academic
achievement.
f. Signs and symptoms.
i. To be identified as intellectually disabled,
Normal Fragile X children must have exhibited cognitive
impairment, with an IQ below 70, before
Fig 24.1 Fragile X chromosome. the age of 18.
1 2 3 4 5
6 7 8 9 10 11 12
13 14 15 16 17 18
19 20 X X 21 22
Slanted eyes
Small, low
set ears
Wide, flat
nasal bridge
Protruding
tongue
A. Incidence. E. Treatment.
1. Known incidence is approximately 1/1,000 live 1. Prevention.
births, but the incidence is believed to be much a. Preconception counseling regarding the
higher. need to abstain from any alcohol while
B. Etiology. trying to become pregnant until the birth
1. Alcohol intake during pregnancy. of the baby.
2. There is no known safe level of alcohol intake 2. Substance abuse counseling for women of
during pregnancy. childbearing age regarding the need to change
C. Pathophysiology. behavior:
1. May occur with daily alcohol consumption or a. To prevent FASD.
with binge drinking. b. In order to provide optimal parenting of the
2. There are a myriad of physiological and FASD child.
psychological signs and symptoms associated with 3. Treatment of the injured child.
FASD. a. Surgery to correct any congenital defects.
a. Physiological. b. Repeated growth and development
i. Head and facial anomalies (Fig. 24.6). screenings.
(1) Smooth philtrum. c. Early intervention to promote learning and
(2) Microcephaly. optimal social and behavioral skills.
(3) Short palpebral fissures. F. Nursing considerations.
(4) Hypoplastic upper lip. 1. Deficient Knowledge.
ii. Small for gestational age. a. Provide preconception counseling regarding
iii. Organ defects, including: the importance of avoiding all alcohol from
(1) Cardiac, especially septal, defects. the cessation of use of birth control until the
(2) Vertebral malformations. birth of the baby.
(3) Cleft lip and/or palate. 2. Impaired Growth and Development.
(4) Renal anomalies. a. At each well-child visit, it is essential
(5) Short fingers. to assess the child’s growth and
(6) Sensory deficits. development.
b. Psychological and behavioral. b. Report any deviations from normal to the
i. Low IQ. primary health-care provider.
ii. Hyperactivity. c. Refer the family for expert intervention, as
iii. Learning disabilities. needed.
iv. Poor reasoning abilities. 3. Impaired Social Interaction/Impaired Verbal
D. Diagnosis. Communication, especially important during
1. Absence of a genetic defect that would explain the hospitalizations.
disorder. Evidence of alcohol consumption during a. Have the same nurse care for the child as
pregnancy, either by self-report, third-party much as possible.
report, and/or toxicology report in combination b. Establish a routine that is as close to the child’s
with clinical evidence (see earlier). normal as possible.
b. Encourage the parents to establish a strict f. Refer the child and family to community
routine at home and maintain the routine that resources (e.g., American Autism Society,
is as close to the child’s normal as possible American Autism Association).
during hospitalizations. 3. Risk for Injury.
c. Use alternate means of communication (e.g., a. Maintain as safe an environment as
pictures) as a way to interact with the child. possible.
d. Strongly encourage a family member to b. Provide the child with constant
accompany the child at all times. supervision.
e. Refer the child and family to educational c. Provide the child with safety equipment
resources specifically geared to autistic when needed (e.g., helmet for head
children. banging).
1.
2.
3.
4.
5.
6.
7.
B. What objective assessments indicate that this client is experiencing a health alteration?
1.
2.
C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse assign to this client?
1.
D. What interventions should the nurse plan and/or implement to meet this child’s and his family’s needs?
1.
2.
3.
4.
5.
6.
E. What client outcomes should the nurse evaluate regarding the effectiveness of the nursing interventions?
1.
2.
3.
F. What physiological characteristics should the child exhibit before being discharged home?
1.
8. A child has been diagnosed with fragile X 12. A child with nonorganic failure to thrive (NOFTT)
syndrome. The nurse would predict that the child is being discharged from the hospital. The baby’s
may exhibit which of the following signs/symptoms? mother, who is now exhibiting appropriate
1. Strabismus parenting behaviors, is providing the baby with
2. Arm flapping needed nutritional supplementation. In addition,
3. Vision deficit the mother does which of the following?
4. Nevus flammeus 1. Feeds the baby through an enlarged hole in the
nipple
9. The nurse is providing preconception counseling to
2. Faces a blank wall while feeding the baby
a young woman regarding alcohol consumption
3. Adds rice cereal to the baby’s formula
during pregnancy. Which of the following
4. Puts the baby to bed with a bottle of formula
information should be included in the teaching
session? 13. A school nurse suspects that a 5-year-old child has
1. The alcohol content in beer is safe to consume autism spectrum disorder. The nurse’s suspicion is
during pregnancy. based on which of the following observations? The
2. Once she learns that she is pregnant, she should nurse noted that the child: Select all that apply.
stop drinking alcohol. 1. has yet to learn his colors or the names of
3. It is safe to drink alcohol after the first trimester animals.
of pregnancy. 2. becomes upset each time the teacher asks the
4. Alcohol is contraindicated from conception to child to stop what he is doing.
the end of pregnancy. 3. is the first in line when it is time to go out to
play in the playground.
10. A child has been diagnosed with nonorganic failure
4. runs to the teacher to get a kiss whenever he gets
to thrive (NOFTT). The nurse would predict that
hurt while playing.
the mother may exhibit which of the following
5. covers his ears whenever the school principal
characteristics? Select all that apply.
makes an announcement on the loud speaker.
1. Abuses addictive substances
2. Owns a number of domesticated animals 14. A 9-year-old child with autism spectrum disorder
3. Expresses disinterest in caring for her baby has been admitted to the hospital. Which of the
4. Misunderstands the feeding needs of babies following interventions is important for the nurse to
5. Lacks the money needed to buy baby supplies perform during the child’s stay?
1. Follow a strict schedule for all medicines and
11. A child has been diagnosed with nonorganic failure
treatments.
to thrive (NOFTT). The nurse would expect the
2. Take the child to the playroom at least twice a
child to exhibit which of the following
day.
characteristics?
3. Keep all of the room lights on throughout the
1. Early onset stranger anxiety
night.
2. Fascination with lights and sounds
4. Provide the child with sugar-free juice at snack
3. Excessive parental attachment
time.
4. Failure to make eye contact
preoperative teaching, the nurse should adapt his or her 4. Alcohol is contraindicated from conception to the end
teaching to the child’s developmental age. of pregnancy.
Content Area: Pediatrics TEST-TAKING TIP: Although the most sensitive period of
Integrated Processes: Nursing Process: Assessment the organ development of the fetus occurs during the
Client Need: Health Promotion and Maintenance: Health first trimester, the CNS is sensitive to insults throughout
Promotion/Disease Prevention the entire pregnancy. Alcohol is teratogenic to the fetus
Cognitive Level: Application during all three trimesters of pregnancy and can lead to
ID even if consumed late in the pregnancy.
7. ANSWER: 3 Content Area: Maternity, Antepartum
Rationale:
Integrated Processes: Nursing Process: Implementation;
1. With an intellectual disability, it is unlikely that the
Teaching/Learning
child would be able to write a story about a child who has
Client Need: Health Promotion and Maintenance: Ante/
broken a leg.
Intra/Postpartum and Newborn Care
2. With an intellectual disability, it is unlikely that the
Cognitive Level: Application
child would be able to name the bones of the leg and tell
the nurse which bone was broken. 10. ANSWER: 1, 3, 4, and 5
3. Children with intellectual disabilities are usually able Rationale:
to draw pictures and should be able to draw a picture of 1. Mothers who abuse substances are at high risk for
a child who is in a hospital in traction. having a child with NOFTT.
4. With an intellectual disability, it is unlikely that the 2. Women who own a number of animals are not at high
child could complete a science project for school about risk for having a child with NOFTT.
how traction weights work. 3. Mothers who express disinterest in caring for their
TEST-TAKING TIP: Because a child with an intellectual babies are at high risk for having a child with NOFTT.
disability has a developmental age that is likely very 4. Mothers who have little knowledge of baby care are at
different from his or her chronological age, it is very high risk for having a child with NOFTT.
important for the nurse to determine the child’s 5. Mothers who live in poverty are at high risk for
developmental age. The nurse will then be able to alter having a child with NOFTT.
his or her care appropriately. TEST-TAKING TIP: The etiology of NOFTT in babies is
Content Area: Pediatrics related to a deficit in care by the primary-care provider.
Integrated Processes: Nursing Process: Analysis The practitioner should perform an excellent
Client Need: Health Promotion and Maintenance: Health psychosocial assessment of a NOFTT child’s parents to
Promotion/Disease Prevention determine the underlying cause of the baby’s problem.
Cognitive Level: Application Content Area: Pediatrics
Integrated Processes: Nursing Process: Assessment
8. ANSWER: 2 Client Need: Physiological Integrity: Physiological
Rationale:
Adaptation: Alteration in Body Systems
1. Strabismus is not associated with fragile X syndrome.
Cognitive Level: Application
2. Children with fragile X syndrome often exhibit arm
flapping. 11. ANSWER: 4
3. Vision deficit is not associated with fragile X syndrome, Rationale:
although children whose cognitive function was altered 1. Babies with NOFTT often exhibit no age-appropriate
secondary to a perinatal hypoxic insult may also exhibit stranger anxiety.
vision deficits. 2. Babies with NOFTT often show no interest in their
4. Nevus flammeus, or port-wine stain, is not associated environment.
with fragile X syndrome. 3. Babies with NOFTT often exhibit no need to be
TEST-TAKING TIP: Many children with fragile X syndrome consoled by their parents.
exhibit autistic behaviors, including arm flapping. 4. Babies with NOFTT often fail to make eye contact.
Content Area: Pediatrics TEST-TAKING TIP: Babies with NOFTT have missed the
Integrated Processes: Nursing Process: Assessment bonding and personal interaction with their primary
Client Need: Physiological Integrity: Physiological caregivers during the newborn and early infancy periods
Adaptation: Alteration in Body Systems that is so important for normal growth and development.
Cognitive Level: Application Consequently, they exhibit disinterest and apathy in
interacting with others.
9. ANSWER: 4 Content Area: Pediatrics
Rationale:
Integrated Processes: Nursing Process: Assessment
1. Alcohol is contraindicated from conception to the end
Client Need: Physiological Integrity: Physiological
of pregnancy.
Adaptation: Alteration in Body Systems
2. Alcohol is contraindicated from conception to the end
Cognitive Level: Application
of pregnancy.
3. Alcohol is contraindicated from conception to the end
of pregnancy.
Amblyopia—“Lazy eye,” or the brain ignoring the Penalization therapy—Blurring the vision of a child’s
image from the weaker of a child’s eyes. normally functioning eye to force the use of the
Conjunctiva—The translucent mucous membrane weaker eye.
covering the eye and the under portion of the Retinoblastoma—Mutation of the cells of the retina,
eyelid. resulting in a malignant tumor.
Conjunctivitis—“Pink eye,” or inflammation of the Strabismus—“Cross eyes,” or the misalignment of the
conjunctiva of the eye. eyes as a result of a lack of coordination between
Decibel (db)—The loudness of a sound. and among the muscles that control eye movement,
Enucleation—Surgical removal of the eye. all of which lie outside of the orbit of the eye.
Frequency—The pitch of a sound. White reflex—The appearance of a white (rather than
Occlusive therapy—Patching of a child’s normally red) reflection in the eye during ophthalmoscopy, a
functioning eye to force the use of the weaker eye. sign of retinoblastoma.
Ophthalmia neonatorum—A serious conjunctivitis
that neonates can acquire if they are exposed to
gonorrhea or chlamydia during birth.
467
2. The problem may develop after birth from a iii. Strabismus is suspected when movement
number of causes, including extraocular tumors is noted in the uncovered eye.
and infections. 2. Specialized assessments performed by ophthalmic
C. Pathophysiology. specialists are diagnostic.
1. Eyes are misaligned as a result of a lack of E. Treatment.
coordination between and among the muscles 1. In most cases, corrective lenses and eye exercises
that control eye movement, all of which lie are prescribed.
outside of the orbit of the eye. 2. Botox injections.
2. Signs and symptoms. a. Paralyzes strong muscles, allowing weaker
a. In addition to eye misalignment, double muscles to strengthen.
vision, squinting, eye fatigue, headaches, loss 3. Surgery, in extreme cases, is performed to tighten
of depth perception, and odd movements the weakened muscles.
when attempting to focus on a specific image. F. Nursing considerations.
D. Diagnosis. 1. Risk for Disproportionate Growth/Risk for
1. Clinical picture (i.e., the eyes do not appear to be Ineffective Coping/Anxiety/Fear/Anger/Grieving/
looking at the same image) and the results of Deficient Knowledge.
routine ophthalmic assessments are highly a. Provide parents the opportunity to verbalize
suggestive. grief, anger, and frustration over birthing a
a. Corneal light reflex test. child with a physical defect.
i. Using the ophthalmoscope, the light is b. Educate the parents and child, if appropriate,
projected onto the corneas of both eyes regarding the pathophysiology of strabismus.
simultaneously. The nurse should see the c. Educate the parents and child, if appropriate,
reflection of the light at the same place on regarding the therapeutic management of
each cornea. strabismus.
ii. If the reflection is asymmetric, strabismus i. Temporary eyelid droop is sometimes noted
should be suspected. with Botox injections.
b. Red reflex tests. d. If indicated, provide preoperative teaching to
i. First test: the parents and child, if appropriate, regarding
(1) Looking through the pupil of each the surgical procedure.
eye independently using the e. If indicated, allow the child and parents to
ophthalmoscope from a short distance express their anxieties, fears, and anger
to determine that the reflex is present regarding the need for surgery.
in each eye. This test assesses the
ability of the retina to receive visual III. Amblyopia
images.
ii. Second test: A. Incidence.
(1) Holding the ophthalmoscope 2 to 3 ft 1. About 2% to 3% of children.
from the child, the nurse should 2. Amblyopia (often called “lazy eye”) is frequently
observe both red reflexes at the same seen in children with strabismus.
time. B. Etiology.
(2) If the scope must be moved from side 1. Can result from any condition in which binocular
to side in order to view both red vision is affected, as in strabismus.
reflexes, strabismus should be C. Pathophysiology.
suspected. 1. When binocular vision is affected, the brain
c. Cover-uncover test. reduces the image from the weaker eye and only
i. This test is not as reliable as the corneal attends to the image from the stronger eye.
light and red reflex tests, especially when 2. Eventually, if not corrected, the weaker eye no
the child is very young or uncooperative. longer sends an image to the brain (i.e., the child
ii. The child is asked to look at an object or a becomes blind in the weaker eye).
toy from a distance. While the child is 3. Signs and symptoms.
looking with both eyes, the nurse covers a. Often, no symptoms are evident, but, if they are,
one of the child’s eyes and watches for symptoms often mimic strabismus, including:
any movement in the uncovered eye. i. Squinting.
The nurse repeats the process in the ii. Odd movements when looking closely at
other eye. an object.
a. Eyesight is often preserved with these c. Allow for need for repeated discussions related
interventions. to the disease process and treatment needs.
2. Enucleation (i.e., surgical removal of the eye) may d. Advise the family that children usually adapt
be performed, especially if the eyesight is lost. easily to vision changes, including adapting to
3. Chemotherapy is often administered before or in sight in one eye.
addition to other interventions. e. Advise the parents that the child should
a. If the eye is removed and the tumor has not receive thorough eye and vision examinations
metastasized, chemotherapy may not be yearly.
indicated. i. The child should be fitted with and wear
4. If metastasis has not occurred, prognosis is corrective lenses, as needed.
excellent. 3. Risk for Injury.
F. Nursing considerations. a. Parents should be encouraged to seek genetic
1. Anxiety/Fear/Pain. counseling.
a. Allow the child and parents to discuss their b. Child should be monitored closely for signs/
fears and concerns, including the fear of symptoms of osteosarcoma or, if original
dying, although the likelihood of death is tumor was unilateral, for signs/symptoms of
remote. retinoblastoma in the second eye.
b. Query the parents/family about the use of 4. If chemotherapeutic agents are administered,
complementary and alternative therapies, additional nursing diagnoses must be considered:
which may be beneficial or harmful. Infection or Risk for Infection; Bleeding or Risk
c. Advise the parents and child, if appropriate, for Bleeding; Activity Intolerance/Fatigue; Risk for
that when the eye is removed, a prosthetic eye Imbalanced Nutrition: Less than Body
will be prescribed after the site heals. Requirements; Risk for Deficient Fluid Volume;
d. Provide needed care, employing principles of and Risk for Injury.
asepsis, following surgery: a. See the “Nursing considerations” section of
i. Monitor the site for signs of bleeding, acute lymphoblastic leukemia (ALL) in
infection, and/or edema. Chapter 18, “Nursing Care of the Child With
ii. Position eye patch over the operative site Hematologic Illnesses.”
and educate the parents regarding actions
to prevent possible injury and other VI. Hearing Deficit
complications.
iii. When the temporary and permanent A. Incidence.
prostheses are inserted into the socket, 1. Between 1 and 6 out of every 1,000 neonates is
educate the parents regarding their care, born with a hearing deficit.
including times and methods of removal 2. Of the approximately three-quarters of a million
and reinsertion, as well as cleaning Americans with hearing loss, about 8% are 18
methods. years of age or younger.
e. Use age-appropriate pain assessment tools and 3. The incidence of hearing loss among Americans is
assess pain on a regular basis. on the increase.
f. Provide safe dosages of pain medication, as B. Etiology.
prescribed and as needed. 1. Congenital hearing loss can be caused by a
i. Narcotic analgesics should be number of factors, including genetic defects and
administered following surgery. environmental insults (e.g., prenatal rubella
g. Use nonpharmacological pain remedies in infection, maternal diabetes, birth trauma,
conjunction with pharmacological methods, if prematurity).
appropriate. 2. Hearing loss that develops after birth also has a
2. Deficient Knowledge/Risk for Injury. number of etiologies, including central nervous
a. Use pictures and models of the eye to provide system infection, head trauma, medication
the parents and child, if appropriate, with as toxicity, and exposure to loud sounds.
complete an understanding as possible of C. Pathophysiology: there are three main types of
where the tumor is located and how the tumor hearing loss.
developed. 1. Conductive: because of injury, inflammation, or
b. Keep the parents and child, if appropriate, blockage, sound is unable to be transmitted from
informed regarding the prescribed treatments, the outer to the inner ear. Causes of conductive
including side effects of treatments. loss are often reversible, such as:
(1) Volume of MP3 players should be kept c. Refer the parents to a genetic counselor if a
at a low level. genetic etiology of the hearing loss is possible.
(2) Earplugs or other sound-lowering d. Educate the parents and child, if appropriate,
equipment should be worn regarding the etiology and extent of the
when loud noises are likely (e.g., hearing loss.
around construction equipment, e. Educate the parents and child, if appropriate,
at music concerts, at fireworks regarding the care and use of hearing aids, as
displays). needed.
b. Allow the parents and child, if appropriate, to f. Educate the parents and child, if appropriate,
discuss their grief, anger, and fears if hearing regarding surgical procedure for cochlear
loss has been diagnosed. implantation, if appropriate.
1.
2.
B. What objective assessments indicate that this client is experiencing a health alteration?
1.
2.
C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse assign to this client?
1.
D. What interventions should the nurse plan and/or implement to meet this child’s and her family’s needs?
1.
2.
3.
Continued
1.
2.
3.
1.
G. What psychological characteristics should the child and family exhibit before being discharged home?
1.
7. A toddler has been diagnosed with bacterial 11. A 2-year-old who has been diagnosed with
conjunctivitis. Which of the following instructions retinoblastoma of the left eye is to have the eye
should the nurse include when teaching the parents removed. Which of the following statements should
about the diagnosis? Select all that apply. the nurse include in the preoperative teaching
1. Child’s towel and washcloth should not be shared session?
with others. 1. Child will require occupational therapy to
2. Medication should be administered into the develop normal depth perception using the
inner canthus of the eye. remaining eye.
3. Eyes should be cleansed from the outer canthus 2. Child will be prescribed a prosthetic eye once
to the inner canthus. the child turns 6 years of age.
4. Meticulous handwashing should be performed 3. Child will wear an eye patch over the surgical
by all family members. site for about 1 week.
5. Child should be kept home from school until all 4. Child will have a permanent prosthetic eye
discharge disappears from the eyes. sutured in place immediately following the
removal.
8. A 16-year-old adolescent has been diagnosed with
viral conjunctivitis. Which of the following actions 12. Five neonates were delivered in a hospital’s obstetric
should the nurse include in the teaching session? unit. Nurses in the neonatal nursery and in the
1. Inform the teen that the communicability of the pediatric clinic should carefully assess which of the
infection is minimal. babies for a hearing deficit? Select all that apply.
2. Advise the teen that contact lenses should not be 1. 33 weeks’ gestation, mother was diagnosed with
worn until the infection is fully treated. pneumonia at time of delivery.
3. Recommend that the teen wear white cotton 2. 35 weeks’ gestation, mother had rubella in the
mittens to bed at night. 1st trimester of her pregnancy.
4. Warn the teen to refrain from using any makeup 3. 37 weeks’ gestation, mother has been a type I
on the eyes for one full month. diabetic since her adolescence.
4. 39 weeks’ gestation, mother experienced
9. Based on which of the following comments made by
shoulder dystocia during delivery.
a child’s parents would a preschool nurse suspect
5. 41 weeks’ gestation, mother had urinary tract
that the 2½-year-old child may have retinoblastoma
infection in her 2nd trimester.
of the right eye?
1. “Every time we take a picture of our child, we 13. A 17-year-old woman is being seen in the clinic for
see a white spot in her right eye and a red spot a yearly checkup. The nurse is educating the young
in her left eye.” woman regarding actions to decrease the possibility
2. “When our child looks at picture books, she of her developing hearing loss. Which of the
always closes her right eye.” following recommendations would be appropriate
3. “We have noticed that our child’s right pupil for the nurse to include?
stays dilated even when it is very sunny outside.” 1. Only use hands-free telephoning while driving in
4. “The white part of our child’s right eye looks like a car.
it has blood in it.” 2. Refuse to mow the lawn for her parents.
3. Use ear plugs when attending music concerts.
10. A child has been diagnosed with retinoblastoma.
4. Wear a safety helmet when riding on a
The nurse should recommend that the primary
motorcycle.
health-care provider refer the family to which of the
following professionals?
1. Genetic counselor
2. Neurosurgeon
3. Orthopedist
4. Clinical psychologist
14. A nurse working on a pediatric clinical unit is 15. A 3-year-old child, with a history of frequent ear
assigned to care for an 11-year-old child with a infections, has been diagnosed with mixed hearing
profound hearing deficit who is in skeletal traction. loss. For which of the following complications
Which of the following actions should the nurse should the nurse carefully assess the child?
perform? 1. Inflammation of the mandible
1. Clap hands behind the child’s field of vision to 2. Serosanguineous discharge from the ear
see whether the child responds. 3. Recurring temporal headaches
2. Look directly into the child’s face whenever 4. Delayed language development
speaking with the child.
3. Educate the child regarding the success that
some realize from cochlear implant surgery.
4. Assess the tympanic membrane in each ear for
redness and bulging.
REVIEW ANSWERS nurse should perform the corneal light reflex test to
determine whether the light is reflected symmetrically
for the corneas. Both the second red reflex test and the
1. ANSWER: 4 corneal reflection test are employed to assess for
Rationale: strabismus.
1. Inability to see objects at far distances is consistent with Content Area: Pediatrics
a diagnosis of myopia, not amblyopia. Integrated Processes: Nursing Process: Assessment
2. Inability to hear music played at low decibel levels is Client Need: Physiological Integrity: Physiological
consistent with a hearing deficit, not amblyopia. Adaption: Alteration of Body Systems
3. Inability to hear music played at high frequencies is Cognitive Level: Application
consistent with a hearing deficit, not amblyopia.
4. Inability to see clearly out of one of eye is consistent 4. ANSWER: 2
with a diagnosis of amblyopia. Rationale:
TEST-TAKING TIP: Amblyopia is a visual disorder of 1. Botox is not administered to improve the appearance of
young children characterized by an inability to see, the child.
employing binocular vision. Those with amblyopia, 2. This statement is correct. The Botox is administered
therefore, selectively see only out of one eye, to weaken the muscles around the eye that are making
suppressing the image from the other eye. the eye deviate.
Content Area: Pediatrics 3. Botox is not administered to blur the image of the
Integrated Processes: Nursing Process: Assessment child’s eye.
Client Need: Health Promotion and Maintenance: Health 4. Botox is not administered to improve the appearance of
Screening the child.
Cognitive Level: Application TEST-TAKING TIP: The muscles of the eye are functioning
asymmetrically in a child with strabismus. The muscles
2. ANSWER: 1, 2, and 5 on one side of the eye are stronger than the muscles
Rationale: on the other side of the eye. Botox, a paralyzing agent,
1. Eye squinting is a symptom of strabismus. is sometimes injected into the stronger set of muscles,
2. Headaches are a symptom of strabismus. weakening their effect. The weaker muscles then are
3. Eyeballs protruding from the eye socket are not seen in able to strengthen. The expectation is that once the
children with strabismus. Botox is metabolized, the muscles will function
4. White reflex on ophthalmic examination is not a symmetrically.
symptom of strabismus. Content Area: Pediatrics
5. Children with strabismus often do move from side to Integrated Processes: Nursing Process: Implementation
side when looking at pictures in a book. Client Need: Physiological Integrity: Pharmacological and
TEST-TAKING TIP: The orbits of the eyes of children with Parenteral Therapies: Expected Actions/Outcomes
strabismus, or cross eyes, are misaligned. Because of the Cognitive Level: Application
strain placed on the eyes, children exhibit a number of
symptoms, including squinting, headaches, and moving in 5. ANSWER: 2
order to see an image. Rationale:
Content Area: Pediatrics 1. Paralysis of the optic nerve is not an expected side
Integrated Processes: Nursing Process: Assessment effect.
Client Need: Physiological Integrity: Physiological 2. Drooping of the eyelid is often seen when Botox is
Adaption: Alteration of Body Systems administered for strabismus.
Cognitive Level: Application 3. Blindness in the affected eye is not an expected side
effect.
3. ANSWER: 3 4. Pupillary dysfunction is not an expected side effect.
Rationale: TEST-TAKING TIP: Botox is a paralyzing agent. When
1. This is not the correct action. injected into the muscles of the eye, it is not uncommon
2. This is not the correct action. for the eyelid on the eye to droop. Once the medication
3. The nurse should hold the ophthalmoscope a few feet is metabolized, however, the drooping usually subsides.
from the child, aim the light at the corneas, and observe Content Area: Pediatrics
for symmetry of the reflections. Integrated Processes: Nursing Process: Implementation
4. This is not the correct action. Client Need: Physiological Integrity: Pharmacological and
TEST-TAKING TIP: When performing an ophthalmic Parenteral Therapies: Adverse Effects/Contraindications/
assessment, the nurse should assess for the red reflex Side Effects/Interactions
twice: 1) looking through the pupil of each eye Cognitive Level: Application
independently using the ophthalmoscope from a short
distance to determine that the reflex is present in each 6. ANSWER: 1
eye and 2) looking at both eyes simultaneously from a Rationale:
distance of a few feet to make sure that both retinas are 1. The nurse inserts erythromycin 0.5% eye ointment in
receiving an image at the same time. In addition, the both eyes.
TEST-TAKING TIP: The child will have a prosthesis Content Area: Pediatrics
designed to replicate the child’s other eye and fit into Integrated Processes: Nursing Process: Implementation;
the child’s socket. Before the prosthesis is ready, and Teaching/Learning
while the socket is healing, the child will wear a Client Need: Health Promotion and Maintenance: Health
protective eye patch. Promotion/Disease Prevention
Content Area: Pediatrics Cognitive Level: Application
Integrated Processes: Nursing Process: Implementation
Client Need: Physiological Integrity: Physiological 14. ANSWER: 2
Adaption: Alteration of Body Systems Rationale:
Cognitive Level: Application 1. There is no need to assess the child’s hearing. The child
has already been diagnosed with a profound hearing
12. ANSWER: 1, 2, 3, and 4 deficit.
Rationale: 2. The nurse should look directly into the child’s face
1. This baby is preterm. The baby is at high risk for a whenever speaking with the child. Lip reading is often
hearing deficit. employed by the hearing impaired as a means of
2. This baby’s mother had rubella in her first trimester. understanding oral communication.
The baby is at high risk for a hearing deficit. 3. It is inappropriate for the nurse to educate the child
3. This baby’s mother is a type I diabetic. The baby is at about cochlear implant surgery.
high risk for a hearing deficit. 4. There is nothing in the question that implies that the
4. This baby’s delivery was complicated by dystocia. The child has an ear infection.
baby is likely to have experienced trauma during the TEST-TAKING TIP: Although this child may be a candidate
delivery. The baby is at high risk for a hearing deficit. for a cochlear implant, it is inappropriate for the nurse to
5. This baby’s gestational age is within normal limits, and, speak with an 11-year-old child regarding an invasive
although this baby’s mother had a urinary tract infection intervention. The nurse could, however, discuss the
in her second trimester, the baby is not at high risk for a therapy with the child’s parents.
hearing deficit. Content Area: Pediatrics
TEST-TAKING TIP: Neonates who are at high risk for Integrated Processes: Nursing Process: Implementation
hearing deficits should be assessed carefully at birth and Client Need: Physiological Integrity: Physiological
in early childhood. Factors that put children at high risk Adaption: Alteration of Body Systems
include both genetic and environmental issues. Cognitive Level: Application
Content Area: Pediatrics
Integrated Processes: Nursing Process: Assessment 15. ANSWER: 4
Client Need: Physiological Integrity: Physiological Rationale:
Adaption: Alteration of Body Systems 1. The child is not at high risk for inflammation of the
Cognitive Level: Application mandible.
2. The child is not at high risk for serosanguineous
13. ANSWER: 3 discharge from the ear.
Rationale: 3. The child is not at high risk for recurring temporal
1. Using hands-free telephoning while driving in a car is a headaches.
safety recommendation. It will not decrease the potential 4. The child is at high risk for delayed language
of her developing hearing loss. development.
2. Lawn mower noise can be injurious, but the young TEST-TAKING TIP: Children with hearing loss, whether
woman could use earplugs while completing the chore. conductive, sensorineural, or mixed, are at high risk for
She should not be advised to refuse to mow the lawn. language delays. To learn to speak, children must hear
3. The young woman should be encouraged to use the sounds spoken by those around them and then learn
earplugs when attending music concerts. to replicate those sounds. If the children are unable to
4. Safety helmets are worn to protect the head from injury hear the sounds, they will be unable to replicate the
during a motorcycle accident. They are not designed to sounds.
protect the wearer’s hearing. Content Area: Pediatrics
TEST-TAKING TIP: A number of everyday activities can Integrated Processes: Nursing Process: Assessment
be damaging to one’s hearing. Adolescents, especially, Client Need: Physiological Integrity: Physiological
should be encouraged to protect their ears by taking Adaption: Alteration of Body Systems
such measures as wearing ear plugs in very loud Cognitive Level: Application
situations and keeping the volume low on their MP3
players.
Comprehensive
Final Exam
1. A 2-year-old child has been admitted to the 4. The nurse is educating the parents of a child who
pediatric emergency department following a head has just been diagnosed with phenylketonuria
injury. The nurse should monitor the child for (PKU). Which of the following information should
which of the following signs/symptoms? be included in the educational session?
1. Bulging fontanels 1. The child must consume a diet low in fats and
2. Vomiting cholesterol.
3. Hypotension 2. The child will develop no secondary sex
4. Protruding tongue characteristics during puberty.
3. The child must take medication at the same time
2. A nurse is educating the parents and a child
each day.
regarding the actions they must take to make sure
4. The child will be able to pass the recessive gene
that the child’s diet is gluten free. The nurse’s action
to a future child.
is based on which of the following
pathophysiological changes? 5. A male baby is born at 29 weeks’ gestation. Which
1. Elevated levels of histamine in the bloodstream of the following complications of prematurity would
2. Atrophy of the villi of the gastrointestinal tract the nurse expect the child to exhibit? Select all that
3. Lack of enervation to the distal portion of the apply.
bowel 1. Simian crease
4. Peritonitis secondary to perforated esophageal 2. Hypospadias
varices 3. Cryptorchidism
4. Negative Babinski
3. A girl, 15 years old, is in the school nurse’s
5. Patent ductus arteriosus
office. The nurse queries the young woman
about alcohol consumption. The teenager states, 6. A 12-month-old child, whose parents have opted
“Yeah, I drink some with my friends. Those laws not to have the child immunized or to send the
that say I can’t drink are lame!” Which of the child to day care, has had 5 watery stools in the past
following responses would be best for the nurse 4 hours. The nurse suspects that the child is infected
to reply? with which of the following pathogens?
1. “You may think they’re lame, but they are still 1. Shigella
the law.” 2. Salmonella
2. “I would like to know who your drinking 3. Giardia
friends are.” 4. Rotavirus
3. “I should call your parents about your behavior.”
4. “It worries me that you’re drinking alcohol with
friends.”
481
7. A 4-year-old child has just returned to the pediatric 11. A 5-year-old child being seen in the pediatric clinic
floor following a cardiac catheterization. Which of has been diagnosed with fifth disease (erythema
the following actions should the nurse perform at infectiosum). Which of the following information
this time? should the nurse convey to the parent about the
1. Administer oxygen via facemask at 8 to 10 liters disease?
per minute. 1. Whenever the child plays in the sun, the child’s
2. Assess the child’s upper extremities for color cheeks will become redder.
change every 5 to 10 minutes. 2. The child must be kept home from school for the
3. Keep the child’s affected extremity straight for next 24 hours.
the next 4 to 6 hours. 3. Mothers of infants who have been in contact
4. Continue the infusion of whole blood for with the child should be monitored very
another 1 to 2 hours. carefully for signs of the disease.
4. If the child’s temperature does not return to
8. A nurse is assessing a 2-month-old infant in the
normal within the next 24 hours, the child
pediatric clinic. Which of the following behaviors
should return to the clinic for a blood test.
would the nurse expect the child to exhibit?
1. Voluntarily grasping a rattle 12. A nurse is counseling a woman during a
2. Smiling socially preconception counseling visit regarding
3. Cooing and babbling environmental factors that would place the child at
4. Playing with hands and feet high risk for a cognitive deficit. Which of the
following situations should the nurse include in the
9. A 6-month-old infant has been diagnosed with
teaching session? Select all that apply.
atopic dermatitis. The nurse educates the parents to
1. Alcohol consumption during pregnancy
avoid performing which of the following actions?
2. Fetal hypoxia during labor and delivery
1. Providing the child with plastic toys for play
3. Neonatal febrile illness in the early neonatal
2. Using softeners when laundering the child’s
period
clothing
4. Lead ingestion by the father within 1 month
3. Introducing solid foods into the child’s diet
prior to conception
4. Covering the crib mattress with cotton bedding
5. Cigarette smoking by the father within 1 year
10. A nurse has identified the nursing diagnosis, prior to conception
Caregiver Role Strain, for a mother of a patient who
13. A 16-year-old soccer player has been diagnosed
has just been admitted to the pediatric floor. In
with a dislocated right shoulder. Which of the
which of the following patient-care situations would
following signs/symptoms would the nurse expect
the nursing diagnosis be most appropriate?
to see? Select all that apply.
1. 3-year-old child in remission from acute
1. Pain
lymphoblastic leukemia admitted for a follow-up
2. Edema
bone marrow biopsy
3. Bruising
2. 6-year-old child with viral diarrhea admitted for
4. Bleeding
intravenous fluid and electrolyte replacement
5. Reduced range of motion
therapy
3. 9-year-old child with cystic fibrosis and acute 14. A 3-year-old child is to receive a medication that
bacterial pneumonia admitted for intravenous is available only as an oral tablet. Which of the
antibiotics and respiratory therapy following actions should the nurse perform at
4. 12-year-old child diagnosed with idiopathic this time?
scoliosis admitted for surgical placement of a 1. Administer the tablet, and give the child a
corrective rod favorite drink with which to swallow it.
2. Crush the tablet, pour the powder in a medicine
cup, and give the child a favorite drink with
which to swallow the powder.
3. Crush the tablet, mix it with a teaspoon of
applesauce, and give the mixture to the child to
swallow.
4. Crush the tablet, mix it with a juice cup filled
with a favorite drink, and give the mixture to the
child to swallow.
15. A 5-year-old girl is due to receive a vaccination. 19. A mother telephones the school nurse and states,
Which of the following statements would be “This morning, my 8-year-old son told me that
appropriate for the nurse to make prior to the he never wants to go to school again. What has
injection? happened?” In response, the nurse should
1. “Would you like the medicine injection in your encourage the mother to ask the child how he feels
right or left arm?” about which of the following? Select all that apply
2. “Would you like me to put the needle into your 1. His teacher.
arm fast or slow?” 2. His performance in school.
3. “I am going to hold your arm very tight to help 3. His friends.
you not to move.” 4. His bus ride to school.
4. “I know that you are a big girl and will be brave 5. His lunches he eats at school.
during the shot.”
20. The nurse is advising the parents of a school-age
16. A child is being assessed for readiness for child regarding an appropriate discipline for their
kindergarten by the school nurse. Which of the child who was caught stealing candy from a
following gross motor skills should the 5-year-old neighborhood store. Which of the following actions
child be expected to perform? should the nurse recommend the parents take?
1. Perform the broad jump 1. Spank the child on the buttocks.
2. Walk on tiptoes 2. Ground the child for one week.
3. Ride a tricycle 3. Make the child return the candy to the owner.
4. Skip using alternate feet 4. Prevent the child from eating dinner.
17. A school nurse suspects that a 17-year-old football 21. A nurse is assessing a 13-month-old child in the
player is contemplating suicide. Which of the pediatric clinic. During the assessment, the parents
following behaviors exhibited by the adolescent comment, “Even though our child is over a year of
might the nurse have observed? Select all that age, she still likes to go to bed with a bottle of
apply. The adolescent: formula. It calms her down so that she is able to fall
1. has given away his favorite football jersey. asleep.” Which of the following responses would be
2. recently has started dating a new girlfriend. most important for the nurse to make?
3. brags about his football team to his brother and 1. “I understand. Children this age often need
sister. something to soothe them when they are settling
4. talks about actors and actresses who have down to sleep.”
recently died. 2. “I am not surprised that your child still drinks
5. has stated that he has decided to play baseball in from a bottle before sleep, but does your child
the spring. drink from a cup when she eats her meals during
the day?”
18. A 10-month-old infant has been diagnosed with
3. “I understand. I would, however, recommend
acute otitis media. The baby has had symptoms,
that you put water in the bottle at bedtime rather
including a temperature of 104.4°F for 36 hours.
than formula.”
Which of the following actions would be
4. “I know how much babies love their formula, but
appropriate for the nurse to educate the parents to
once they reach one year of age they can start to
perform? Select all that apply
drink cow’s milk.”
1. Administer prescribed antibiotic via oral syringe.
2. Apply warm or cold compresses to the affected 22. A neonate is admitted to the high-risk nursery
area. with a diagnosis of meningomyelocele. Which
3. Administer over-the-counter cough suppressant of the following actions should the nurse perform
per published directions. at this time?
4. Cleanse the area with a dilute solution of 1. Position the neonate on his or her right side.
hydrogen peroxide. 2. Cover the lumbosacrum with a moist and sterile
5. Isolate the infant from other children until the dressing.
child has been on medication for 24 hr. 3. Assist with the insertion of a central line.
4. Contact respiratory therapy to intubate the
newborn.
23. A 6-month-old child has just been diagnosed with 27. A 13-month-old child, whose weight is 23 lb and
congenital hypothyroidism. Which of the following length is 30.5 in., is placed on ferrous sulfate 50 mg
signs/symptoms would the nurse expect the child to PO daily for iron-deficiency anemia. The pediatric
exhibit? dosage recommendation is 3 to 5 mg/kg/day
1. Developmental delay either once per day or in two divided doses. The
2. Strabismus medication is available as 125 mg/1 mL. Which of
3. Projectile vomiting the following actions by the nurse is appropriate at
4. Dyspnea this time?
1. Request an order change because the order is
24. A baby in the emergency department is in
unsafe as written.
respiratory distress. Which of the following blood
2. Request an order change to twice a day to
gas results would the nurse expect the child’s
improve absorption of the iron.
laboratory report to show?
3. Teach the mother how to draw up 0.4 mL of
1. pO2: 90 mm Hg
fluid into an oral syringe.
2. pCO2: 30 mm Hg
4. Teach the mother how to draw up 1.25 mL of
3. HCO3: 25 mEq/L
fluid into a medication dropper.
4. pH: 7.30
28. An HIV-positive, sexually active adolescent male is
25. A child with hypospadias is post-op surgical repair.
being seen during a clinic visit. The young man
For which of the following signs/symptoms should
states, “I met a friend who is also HIV positive. I
the nurse carefully monitor the child?
am finally free to be me.” Which of the following
1. Cloudy urine
responses is appropriate for the nurse to make?
2. Hypertension
1. “I am happy for you. You must be happy not to
3. Macular rash
have to worry about your disease anymore.”
4. Pulmonary edema
2. “This is good news, but I do want to remind you
26. A nurse is educating a breastfeeding mother to continue to wear condoms when having
regarding feeding her 12-month-old daughter who intercourse.”
has been diagnosed with mild dehydration from 3. “Congratulations. Do you know whether or not
diarrhea. The mother states that the child’s appetite your friend has any symptoms of AIDS?”
has not changed significantly during the illness. 4. “What a wonderful surprise. Did you meet your
Which of the following statements would be friend at an HIV awareness party?”
appropriate for the nurse to make to the mother
29. A nurse is assessing a 6-month-old infant in the
during the teaching session?
pediatric clinic. Which of the following abnormal
1. “Pump and dump your breast milk and replace
findings should the nurse report to the child’s
your daughter’s feedings with oral rehydration
primary health-care provider?
therapy (ORT).”
1. Exhibits a grasp reflex
2. “Feed your daughter oral rehydration therapy
2. Falls over from a sitting position
(ORT) after each breastfeeding to make sure she
3. Follows no commands
is getting enough protein.”
4. Drinks formula from a cup
3. “Have your daughter drink oral rehydration
therapy (ORT), but only if she refuses to 30. A child has been diagnosed with impetigo. Which
breastfeed.” of the following signs/symptoms would the nurse
4. “Give your daughter oral rehydration therapy expect to see?
(ORT) along with lean meats, cooked vegetables, 1. Encrusted vesicles
and breast milk.” 2. Red and scaly lesions
3. Painful abrasions
4. Alopecic scalp
31. A 17-year-old young woman is seen in the 35. A nurse is about to begin a physical examination of
dermatology clinic with severe acne. Which of the an infant who is sleeping in the mother’s arms.
following statements should the nurse include when Which of the following actions should the nurse
educating the young woman regarding her perform first?
diagnosis? 1. Auscultate the lung and heart sounds.
1. “You should wash your face twice daily with a 2. Palpate the fontanels.
dilute bleach solution.” 3. Place the infant on the examining table.
2. “You will need to manually remove any black 4. Percuss the abdomen.
heads that appear on your face.”
36. A nurse is questioning the parents regarding their
3. “Acne is caused by a virus for which there is no
4-year-old’s behaviors. The parents state, “Our child
cure.”
is great until night time when she cries because she
4. “Acne often worsens when cosmetics are worn.”
insists that there is an alligator under the bed. She
32. The parent of a 2-year-old child telephones the has never seen a real alligator, and we don’t know
pediatric clinic and states, “Our child has been where she got that crazy idea!” Which of the
exposed to another child with roseola. Is there following statements is appropriate for the nurse
anything we should know about the disease?” to make?
Which of the following information should the 1. “That is pretty unusual. Has she ever been to the
nurse convey to the parent regarding the disease? zoo? Maybe she saw an alligator there that
1. When the rash disappears, the parent should frightened her.”
expect the child’s temperature to rise. 2. “That is pretty unusual. Does she watch
2. When the child’s temperature rises, the parent television? Maybe there was a story in the news
should monitor the child carefully for febrile about a child being attacked by an alligator?”
seizures. 3. “Many children her age have night fears. If you
3. Once a child has had roseola, he or she is at high give into her fears, though, she will continue to
risk for recurrences of the disease. have night fears well into her school-age years.”
4. As long as the child’s rash is present, he or she is 4. “Many children her age have night fears. If you
highly contagious and must be kept on droplet look under her bed with her and give her a night
precautions. light, she should go to bed more easily.”
33. A 4-year-old with Down syndrome is being seen in 37. A child, who has been diagnosed with attention
the pediatric clinic. The nurse reminds the parents deficit hyperactivity disorder (ADHD), is being
to seek immediate care if the child exhibits which of prescribed a stimulant. The child should be
the following signs/symptoms? monitored carefully for which of the following
1. Upper respiratory illness serious side effects?
2. Pendulous abdomen 1. Jaundice
3. Elevated temperature 2. Arrhythmia
4. Protruding brow 3. Dyspnea
4. Anasarca
34. A 10-year-old, who has fallen while rollerblading, is
seen in the emergency room complaining of pain. 38. A 2-year-old child is suspected of having acute
The nurse notes large contusions on both legs and epiglottitis. Which of the following signs/symptoms
both arms. The mother states, “I know that he has would the nurse expect to see? Select all that apply
broken something!” The nurse examining the child 1. Vomiting
recommends to the primary health-care provider 2. Weight loss
that x-rays be taken. Which of the following is the 3. Tachycardia
best rationale for the nurse’s action? 4. Nasal flaring
1. The extent of the soft tissue injuries 5. Inspiratory stridor
2. The child’s complaints of pain
3. The mother’s statement
4. The accuracy of the diagnostic method
39. A nurse, who is caring for a chronically ill 6-year- 44. A nurse, caring for a 2-year-old child who has just
old child in a long-term care facility, has identified been diagnosed with type 1 diabetes mellitus, is
the following nursing diagnosis for the child: educating the child’s parents regarding the values of
Ineffective Coping as evidenced by detachment important diagnostic tests. The nurse should include
behaviors. When the child’s parents left the hospital which of the following information regarding their
after a visit, which of the following assessments did child’s illness in the teaching session?
the nurse observe? The child: 1. Hemoglobin A1C levels should be greater than
1. cried and begged the parents to stay. or equal to 5.5%.
2. waved good bye and asked the parents when 2. Preprandial blood glucose levels will likely be set
they would return. higher than those of older children.
3. hugged the nurse and ignored the parents. 3. Serum pH levels should be between 7.25 and
4. grabbed the legs of the parents and refused to let 7.35.
them go. 4. Daily urine dipstick findings should show mild
to moderate ketone levels.
40. A baby is born with esophageal atresia with
tracheoesophageal fistula. Which of the following 45. An emergency department nurse who is assessing a
signs/symptoms would the nurse expect to see? school-age child reports to the primary health-care
1. Dyspnea provider, “This child is exhibiting signs/symptoms
2. Coffee ground emesis of fluid overload.” Which of the following signs/
3. Bloody diarrhea symptoms did the nurse assess? Select all that
4. Lymphadenopathy apply.
1. Ascites
41. A nurse is taking a neonate, who was noted to have
2. Thready pulse
a grade 1 heart murmur during the newborn
3. Desquamation
assessment, to the parents’ room. It would be
4. Elevated specific gravity
especially important for the nurse to advise the
5. Adventitious lung sounds
parents to notify the nurse if the baby exhibits
which of the following signs/symptoms? The baby: 46. A child is seen in the emergency department for
1. refuses to suckle at the breast. suspected acute glomerular nephritis. To confirm
2. keeps his or her eyes tightly closed. the diagnosis, the nurse would expect to perform
3. spits up after each feed. which of the following actions?
4. points his or her toes inward. 1. Sterile catheterization
2. Serum antibody titers
42. An 8-year-old child is post-op ventriculoperitoneal
3. Urine cultures
shunt revision. The nurse documents the nursing
4. Patellar reflexes
diagnosis, Excessive Fluid Volume, after noting that
the child’s abdomen is distended. The nurse should 47. A one-month-old child is admitted to the
document that the finding is likely related to which emergency department with a diagnosis of pyloric
of the following physiological changes? stenosis. Which of the following laboratory values
1. Peritonitis would be consistent with the diagnosis?
2. Drainage of cerebral spinal fluid 1. Hematocrit 48%
3. Paralytic ileus 2. Potassium 5.2 mEq/L
4. Intraperitoneal hemorrhage 3. White blood cell count 15,000 cells/mm3
4. Platelet count 50,000 cell/mm3
43. The nurse is providing nutrition education to a
group of adolescent girls. Which of the following 48. A 2-year-old child with sickle cell anemia is
choices would best meet the mineral needs of admitted to the emergency department in a
adolescent girls? possible sequestration crisis. For which of the
1. Tossed salad following findings should the nurse carefully
2. Cheeseburger monitor the child?
3. Fruit smoothie 1. Severe pain
4. Stuffed peppers 2. Marked hypotension
3. Hyperthermia
4. Hyperkalemia
49. A 15-year-old child seen in the emergency 54. A nurse notifies the neonatal health-care provider
department with dyspnea is found to have high that a newly born baby likely has a clubfoot. The
levels of IgE in his bloodstream. As a means of nurse has noted which of the following abnormal
determining the etiology of the finding, the nurse findings?
should ask the child which of the following 1. Marked dorsiflexion of the big toe
questions? 2. All toes on the foot that are webbed.
1. “Are you allergic to anything?” 3. Foot with an unusually high arch and large heel
2. “Have you been exercising more than usual?” 4. Foot that is plantar flexed and turned inward
3. “Are you sexually active?”
55. A nurse is preparing to administer an intravenous
4. “Have you had any vomiting or diarrhea today?”
medication through an IV pump. The child has a
50. A nurse is educating a couple with a newborn saline lock in place. Please place the steps the nurse
regarding prevention of plagiocephaly. Which of the will perform in correct chronological order.
following actions should the nurse educate the 1. Wash hands.
parents to perform? 2. Set the infusion pump to the correct rate.
1. Keep the baby out of the sun for the first 3. Cleanse the saline lock with alcohol or Betadine.
6 months of life. 4. Document on the medication administration
2. Provide the baby with visually stimulating items record.
to look at. 5. Calculate the safe dosage for the child and
3. Monitor the numbers of stools and wet diapers compare it with the doctor’s order.
the baby has in 24 hours.
56. A nurse working in the pediatric clinic completes a
4. Place the baby on its stomach each day during
report to child protective services regarding a
supervised play.
4-year-old child who is seen for a routine physical
51. A mother calls the pediatric clinic and states, “My examination and who refuses to go to his mother
daughter had lice last week. I washed her hair with for comfort. In addition, the nurse assessed which
the lice shampoo, vacuumed, and washed all the of the following physical findings?
clothes, but the lice are back. What did I do 1. Bruises on his knees and elbows
wrong?” Which of the following additional 2. Bandaged laceration on his left calf
information should the nurse obtain? 3. Burn marks on his torso
1. Whether the child returned to school 4. Brown patches on his forehead
2. Whether the child has long or short hair
57. A child, birthed at 24 weeks’ gestation, is discharged
3. Whether the mother carefully combed out the
home at 8 weeks of age. To prevent a common, but
child’s hair after the shampooing
serious, respiratory illness in the baby, the public
4. Whether the mother rinsed off the shampoo
health nurse administers which of the following
before one hour had elapsed.
medications to the baby each month?
52. A nurse in the newborn nursery suspects that a 1. Pertussis immune globulin
neonate contracted rubella via vertical transmission. 2. Influenza immune globulin
Which of the following neonatal findings are 3. Synergis (palivizumab)
consistent with the nurse’s suspicions? Select all 4. Pulmozyme (dornase alfa)
that apply.
58. A child with cleft palate is post-op reconstruction
1. Cataracts
surgery. Which of the following interventions
2. Deafness
should the nurse perform?
3. Spina bifida
1. Maintain total parenteral nutrition for one week
4. Hyperbilirubinemia
following surgery.
5. Respiratory stridor
2. Place the child with a roommate who also is not
53. A child has been diagnosed with fragile X allowed to eat.
syndrome. Which of the following health-care 3. Feed the child without inserting any utensils into
referrals should the nurse encourage the parents to the mouth.
make? The nurse should encourage the parents to 4. Check the position of the device protecting the
consult with a(n): sutures each hour.
1. Orthopedic surgeon
2. Genetic counselor
3. Registered dietitian
4. Otolaryngologist
59. The laboratory data on a toddler with congestive 62. A 13-year-old child has just been diagnosed with
heart failure appears below. type 2 diabetes. Which of the following signs/
Date of Results
symptoms would the nurse expect the child to
Serum Test August 1 August 2 August 3 exhibit? Select all that apply.
1. Fatigue
Hematocrit 42% 43% 44%
2. Anorexia
Hemoglobin 14 G/dL 14 G/dL 15 G/dL
3. Excessive thirst
Potassium 3.6 mEq/L 4.0 mEq/L 4.2 mEq/L
4. Sweet-smelling breath
Sodium 139 mEq/L 142 mEq/L 143 mEq/L
5. Darkening of the skin of the neck
The child’s primary health-care provider has
63. A nurse is educating the parents of a newborn
ordered for the child to receive daily dosages of
regarding the child’s risk for dehydration. Which of
Lanoxin (digoxin) and Lasix (furosemide). On
the following information should the nurse include
August 3, immediately before the medications are
in the teaching session? Babies are at high risk for
due, the nurse assesses the child’s apical heart rate
dehydration because:
as 132 bpm. Which of the following actions should
1. they have a relatively small body surface area.
the nurse perform at this time?
2. they retain electrolytes in high concentrations.
1. Administer the medications, as ordered.
3. a high percentage of their weight is from fluid.
2. Administer the Lanoxin, but hold the Lasix, and
4. a low concentration of potassium is in their
inform the primary health-care provider.
blood.
3. Administer the Lasix, but hold the Lanoxin, and
inform the primary health-care provider. 64. A child is admitted to the pediatric unit with a
4. Hold both medications, and inform the primary diagnosis of nephrotic syndrome. Which of the
health-care provider. following signs/symptoms would the nurse expect
to see?
60. A 16-year-old child is seen in the pediatric clinic
1. Anasarca
with signs and symptoms of the flu. To prevent
2. Hyperproteinemia
further disease, the nurse educates the parents and
3. Hypertension
the teenager to refrain from performing which of
4. Anemia
the following treatment practices?
1. The teenager should consume no dairy products.
2. The teenager should spend no time in the sun or
under a sun lamp.
3. The teenager should perform no active range-of-
motion exercises.
4. The teenager should be administered no aspirin.
61. A young woman enters the school nurse’s office and
states, “I’ve decided to get my right nipple pierced.”
Which of the following comments by the nurse
would be most important?
1. “Before you have your nipple pierced, I would
like to talk about how you will need to clean the
area.”
2. “Do you realize that it will hurt a great deal to
have such a sensitive area pierced?”
3. “Have you gotten permission from your parents
to get your nipple pierced?”
4. “I am so glad that you have decided to get
pierced because, unlike a tattoo, it can be
removed.”
65. The parents of an infant in the emergency 66. A child, 3 years of age, has just been diagnosed with
department have just been advised that their child von Willebrand’s disease. Which of the following
has been diagnosed with intussusception. To help information should the nurse include in a teaching
the parents to understand the pathophysiology of session for the child’s parents?
the illness, a nurse provides them with which of the 1. Serve the child a diet that is rich in calcium.
following drawings? 2. Assess the child’s axillary temperature each
1. morning.
3. Avoid contact with the offending allergen.
4. Apply pressure and ice to all of the child’s injuries.
67. A 13-year-old girl is seen in the pediatric clinic with
painful, red joints and a macular rash over her nose
and cheeks. The nurse notifies the child’s primary
health-care provider and requests an order for
which of the following diagnostic blood tests?
1. Human chorionic gonadotropin (hCG)
2. Antinuclear antibody (ANA)
3. Partial thromboplastin time (PTT)
4. Alanine transaminase (ALT)
68. A nurse is providing an educational session for
2. parents on burn safety. Which of the following
information should be included in the educational
session?
1. Parents should conduct yearly fire drills for their
young children.
2. Hot water heaters should be set at no higher
than 140°F.
3. Batteries in household fire alarms should be
changed every 2 years.
4. No sunscreen should be put on a baby until the
3. baby is able to crawl.
69. A nurse working in the emergency department
would expect that the primary health-care provider
would order a tetanus booster for previously
immunized patients with which of the following
admitting complaints? Select all that apply.
1. Tick bite
2. Viral diarrhea
3. Third-degree burn
4. Bacterial meningitis
5. Deep puncture wound
70. A baby is admitted to the pediatric unit for repair of
a cleft lip. While performing the admission physical
4. assessment, the nurse notes that the baby has a
narrow distance between the inner and outer canthi
of the eyes, thin upper lip, and smooth philtrum.
The nurse reports to the primary health-care
provider that it is likely that the mother abused
which of the following substances during her
pregnancy?
1. Heroin
2. Cocaine
3. Nicotine
4. Alcohol
71. A nurse, during a well-baby check, is performing 74. A nurse is providing pain medication to a 5-year-
Ortolani’s sign. Which of the following actions is old child after abdominal surgery. Which of the
the nurse performing? following principles should provide the rationale for
1. Externally rotating the baby’s hips the nurse’s action?
2. Comparing the baby’s knee heights 1. Children are at high risk of becoming addicted
3. Checking the baby’s plantar reflexes to narcotics.
4. Monitoring the baby’s pedal pulses 2. Children are at high risk of developing
respiratory depression if given narcotics.
72. A primary health-care provider has ordered a
3. Children tolerate pain better than adults
medication for a child, 48 lb and 50 in. A reliable
tolerate pain.
medication reference states the safe pediatric dosage
4. Children can effectively use pain scales to
is 50 to 100 mg/kg/day in divided doses every 8 hr.
measure their pain.
Please calculate the safe dosage range of the
medication for this child. If rounding is needed, 75. A 5-year-old child has been diagnosed with
please round to the nearest whole number. pinworms (enterobiasis). Which of the following
statements by the parents is consistent with this
to mg every 8 hr.
diagnosis?
1. “My child has had black stools for the past
73. A 16-year-old female being examined in the
2 days.”
pediatric clinic has a body mass index (BMI) of
2. “My child cannot seem to stop scratching his
16.6 kg/m2. Which of the following questions/
bottom.”
comments would be important for the nurse to ask
3. “My child has had a temperature above 101°F
the young woman? (Please refer to the growth
all day.”
charts in the Appendix.)
4. “My child threw up yellow vomit all night long.”
1. “Do you eat snacks between meals?”
2. “How do you feel about your body?”
3. “Let’s talk about foods that are high in calories.”
4. “It’s important for you to start to exercise
each day.”
2. Fetal hypoxia during labor and delivery would place Client Need: Physiological Integrity: Pharmacological and
an unborn child at high risk for a cognitive deficit. Parenteral Therapies: Medication Administration
3. Neonatal febrile illness in the early neonatal period Cognitive Level: Application
would place the child at high risk for a cognitive deficit.
4. Maternal lead ingestion during pregnancy would place 15. ANSWER: 3
the child at risk of a cognitive deficit. A father’s ingestion Rationale:
has not been shown to be teratogenic. 1. Although it would be appropriate to provide the child
5. Cigarette smoking by the father would not place the with a choice, the child will likely not understand what
child at risk of a cognitive deficit. the word “injection” means.
2. Although it would be appropriate to provide the child
TEST-TAKING TIP: The brain is very sensitive to
with a choice, to ask the child regarding the speed of
environmental insults throughout the pregnancy as well
putting a needle into his or her arm is not appropriate.
as during the first few years after birth.
3. It would be appropriate to forewarn the child that his
Content Area: Pediatrics
or her arm will be held tight, and it would be
Integrated Processes: Nursing Process: Implementation;
appropriate to provide the child with help in order to
Teaching/Learning
remain still during the procedure.
Client Need: Physiological Integrity: Physiological
4. It would not be appropriate to pressure the child to be
Adaptation: Alteration in Body Systems
brave during the procedure. Children often cry during
Cognitive Level: Application
painful procedures into the school-age period and
13. ANSWER: 1, 2, 3, and 5 beyond.
Rationale: TEST-TAKING TIP: Language is an important consideration
1. Pain is a symptom the nurse would expect to see. when working with children. They are often unfamiliar
2. Edema is a symptom the nurse would expect to see. with medical terms or, in some cases, may completely
3. Bruising is a symptom the nurse would expect to see. misinterpret the terms. The nurse must use simple, clear
4. Bleeding would not be seen. language, especially when conversing with young
5. Reduced range of motion is a symptom the nurse children.
would expect to see. Content Area: Pediatrics—Preschool
TEST-TAKING TIP: Injuries to the musculoskeletal system Integrated Processes: Nursing Process: Implementation
usually result in the inflammatory response—edema, Client Need: Health Promotion and Maintenance:
pain, heat, redness. In addition, the nurse would note Developmental Stages and Transitions
ecchymosis and, in the case of a dislocation, limited Cognitive Level: Application
range of motion.
16. ANSWER: 4
Content Area: Pediatrics
Rationale:
Integrated Processes: Nursing Process: Assessment
1. Children usually are able to perform the broad jump at
Client Need: Physiological Integrity: Physiological
3 years of age.
Adaptation: Alteration in Body Systems
2. Children usually are able to walk on tiptoes at 3 years
Cognitive Level: Application
of age.
14. ANSWER: 3 3. Children usually are able to ride a tricycle at 3 years of
Rationale: age.
1. This action would be inappropriate. Three-year-old 4. Skipping using alternate feet is a task of 5-year-old
children are unable to swallow tablets without the children. It would be an indicator of readiness for the
potential of choking. gross motor skills taught in kindergarten.
2. This action would be inappropriate. It is unlikely that TEST-TAKING TIP: School nurses are responsible for the
the child would consume unmixed powder even if he or health and well-being of the children in their school. It is
she were given a favorite drink with which to swallow the important that children be expected to perform skills
powder. safely and, when they have yet to achieve skills expected
3. This action is appropriate. The nurse should crush the at their developmental level, that they be provided with
tablet, mix it with a teaspoon of applesauce, and give the opportunities to develop those skills. School nurses,
mixture to the child to swallow. therefore, often assess children’s abilities.
4. This action would be inappropriate. It is unlikely Content Area: Pediatrics—Preschool
that the child would consume an entire juice cup Integrated Processes: Nursing Process: Assessment
filled with fluid, even if it were his or her favorite Client Need: Health Promotion and Maintenance:
drink. Developmental Stages and Transitions
TEST-TAKING TIP: When preparing crushed medication Cognitive Level: Application
for children, it is important not to mix the medicine with
a large amount of liquid, gelatin, or applesauce because
17. ANSWER: 1 and 4
Rationale:
the child will likely refuse to consume the entire amount.
1. Giving away a favored object often precedes a suicide.
Content Area: Pediatrics—Medication
2. Dating is a normal activity of adolescents.
Integrated Processes: Nursing Process: Implementation
3. Seventeen-year-old football players often brag to others Content Area: Pediatrics—School Age
about their team. Integrated Processes: Nursing Process: Implementation
4. Talking about the death of others often precedes a Client Need: Health Promotion and Maintenance:
suicide. Developmental Stages and Transitions
5. Changing extracurricular activities is not uncommon in Cognitive Level: Application
adolescence.
20. ANSWER: 3
TEST-TAKING TIP: There are a number of behaviors
Rationale:
that may indicate that a young man or woman is
1. The nurse should not recommend spanking the child
contemplating suicide. If the nurse suspects that an
on the buttocks.
individual is considering suicide, it is important for the
2. The nurse should not recommend grounding the child
nurse to ask the individual.
for 1 week.
Content Area: Mental Health—Suicide
3. The nurse should recommend making the child return
Integrated Processes: Nursing Process: Assessment
the candy to the store owner.
Client Need: Psychosocial Integrity: Mental Health
4. The nurse should not recommend preventing the child
Concepts
from eating dinner.
Cognitive Level: Application
TEST-TAKING TIP: To help children learn the difference
18. ANSWER: 1 and 2 between right and wrong, it is important that they be
Rationale: disciplined for improper actions. Discipline, however,
1. The nurse should educate the parents regarding the should be consistent with the offense and meaningful.
safe administration of the antibiotics. Requiring the child to return the candy to the owner is
2. The nurse should educate the parents to place warm consistent with the offense and is a reprimand that will
or cold compresses on the affected area. be remembered by the child.
3. Cough suppressants should not be administered to Content Area: Pediatrics—School Age
children under 2 years of age, and they are not Integrated Processes: Nursing Process: Implementation
administered for otitis media. Client Need: Health Promotion and Maintenance:
4. Otitis media is an internal disorder. There is no way to Developmental Stages and Transitions
cleanse the area. Cognitive Level: Application
5. Isolation is not indicated for a diagnosis of AOM.
21. ANSWER: 3
TEST-TAKING TIP: The treatment of infants with AOM is
Rationale:
dependent upon the age and health status of the baby.
1. Although true, this is not the most important response
Because many ear infections are viral in origin, after the
for the nurse to make.
age of 2, practitioners are encouraged initially to provide
2. Although an important question to ask, this is not the
palliative care without antibiotics. Prior to that age,
most important response for the nurse to make.
antibiotics are often prescribed based on the infant’s
3. This is the most important response for the nurse to
clinical signs.
give. Only water should be in the bottle at bed time.
Content Area: Pediatrics
4. Although true, this is not the most important response
Integrated Processes: Nursing Process: Implementation
for the nurse to make.
Client Need: Physiological Integrity: Physiological
Adaptation: Alteration in Body Systems TEST-TAKING TIP: Babies who go to bed suckling on a
Cognitive Level: Application formula-filled bottle are at very high risk for developing
dental caries. The nurse should strongly recommend that
19. ANSWER: 1, 2, 3, and 4 the bottle contain only water in order to decrease the
Rationale: potential health hazard.
1. Fear of the teacher may be a cause of school refusal. Content Area: Pediatrics—Toddler
2. Performing poorly in school may be a cause of school Integrated Processes: Nursing Process: Implementation
refusal. Client Need: Health Promotion and Maintenance: Health
3. Bullying by classmates or a poor social experience Promotion/Disease Prevention
may be a cause of school refusal. Cognitive Level: Analysis
4. Bullying often occurs on the school bus and may be a
cause of school refusal. 22. ANSWER: 2
5. Dislike of food served in the cafeteria has not been Rationale:
identified as a cause of school refusal. 1. The neonate should be placed in the prone position.
2. The nurse should cover the lumbosacrum with a
TEST-TAKING TIP: School refusal is a common problem
moist, sterile dressing.
of the school-age period. It is important for the nurse to
3. It is unlikely that a central line will be inserted.
advise the parent to seek assistance from the school
4. It is unlikely that the newborn will need to be
officials to determine the cause of the refusal and to
intubated.
have them intervene when appropriate. In addition, it is
important to counsel the parents to make the child TEST-TAKING TIP: To prevent injury and/or infection of
return to school as soon as possible. the exposed sac, the nurse should cover the area with
sterile, moist dressings.
3. This is not an appropriate comment for the nurse to 3. This statement is incorrect. Acne is caused by a
make. bacteria.
4. This is not an appropriate comment for the nurse to 4. This statement is correct. Acne often gets worse when
make. cosmetics are worn.
TEST-TAKING TIP: It is possible to become infected with TEST-TAKING TIP: Acne is especially difficult for
more than one strain of HIV. Those who are infected adolescents because of how it can disfigure the face. It is
with more than one strain are at risk of developing AIDS important for the nurse to provide those suffering with
at a younger age. accurate information and empathy.
Content Area: Adolescent; Infectious Disease Content Area: Adolescent
Integrated Processes: Nursing Process: Implementation Integrated Processes: Nursing Process: Implementation
Client Need: Health Promotion and Maintenance: Client Need: Physiological Integrity: Physiological
High-Risk Behaviors Adaptation: Illness Management
Cognitive Level: Application Cognitive Level: Application
2. The child’s complaints of pain are important, but they Integrated Processes: Nursing Process: Implementation
are not the most important rationale for taking x-rays. Client Need: Health Promotion and Maintenance:
3. The mother’s statement is an important factor, but it is Developmental Stages and Transitions
not the best rationale for taking x-rays. Cognitive Level: Application
4. The only way to accurately diagnose a fracture is by
taking an x-ray. 37. ANSWER: 2
Rationale:
TEST-TAKING TIP: Whenever a child enters the health-
1. Jaundice is not a side effect of stimulant medications.
care system after a serious accident, an x-ray must be
2. The child should be carefully monitored for
performed to determine accurately whether he or she
arrhythmias.
has fractured a bone.
3. Dyspnea is not a side effect of stimulant medications.
Content Area: Pediatrics
4. Anasarca is not a side effect of stimulant medications.
Integrated Processes: Nursing Process: Analysis
Client Need: Physiological Integrity: Physiological TEST-TAKING TIP: Stimulants are medications that usually
Adaptation: Illness Management increase biological functions (e.g., heart rate, respiratory
Cognitive Level: Application rate, brain activity). In young children, however,
stimulants act in a more idiosyncratic way. Instead of
35. ANSWER: 1 increasing their activity, the medications actually help the
Rationale: children to concentrate and to behave less impulsively.
1. The nurse should auscultate the lungs and heart Content Area: Pediatrics—ADHD
sounds. Integrated Processes: Nursing Process: Assessment
2. The nurse should palpate the fontanels after assessing Client Need: Physiological Integrity: Pharmacological and
the lungs and heart sounds. Parenteral Therapies: Adverse Effects/Contraindications/
3. It is not necessary to remove the infant from the Interactions
mother’s arms. Cognitive Level: Application
4. The abdomen should be percussed later in the
examination. 38. ANSWER: 3, 4, and 5
Rationale:
TEST-TAKING TIP: Once a baby is disturbed, it is likely
1. Vomiting is not characteristic of epiglottitis.
that the baby will begin to cry. If a baby is quietly
2. Weight loss is not characteristic of epiglottitis.
sleeping, therefore, the nurse should first listen to the
3. Tachycardia is a symptom of epiglottitis.
baby’s lung and heart sounds.
4. Nasal flaring is a symptom of epiglottitis.
Content Area: Pediatrics
5. Inspiratory stridor is a symptom of epiglottitis.
Integrated Processes: Nursing Process: Implementation
Client Need: Health Promotion and Maintenance: TEST-TAKING TIP: When the epiglottis is markedly
Techniques of Physical Assessment swollen, as in the case of acute epiglottitis, the airway is
Cognitive Level: Application almost completely obstructed. The child, therefore,
exhibits signs/symptoms of respiratory distress, and the
36. ANSWER: 4 heart rate increases to compensate for the poor
Rationale: oxygenation.
1. It is not unusual for preschool children to believe that Content Area: Pediatrics—Respiratory
there are monsters or other scary things in their rooms at Integrated Processes: Nursing Process: Assessment
night. Client Need: Physiological Integrity: Physiological
2. It is not unusual for preschool children to believe that Adaptation: Alterations in Body Systems
there are monsters or other scary things in their rooms at Cognitive Level: Application
night.
3. It is true that many children her age have night fears, 39. ANSWER: 3
and it is appropriate to inspect the room before bedtime Rationale:
and to provide the child with a nightlight to reduce the 1. Children who cry and beg to have their parents stay
fears. after a visit are exhibiting signs of protest.
4. It is true that many children her age have night fears, 2. The nurse may observe an older, school-age child or
and it is appropriate to inspect the room before bedtime adolescent wave good-bye and ask the parents when they
and to provide the child with a nightlight to reduce the would return. These behaviors are less likely in a
fears. 6-year-old child.
3. Children who are exhibiting signs of detachment may
TEST-TAKING TIP: Preschool children are magical
hug their nurses and ignore their parents.
thinkers. They are unable to distinguish between fantasy
4. Children who grab the legs of their parents and refuse
and reality. As a result, they often truly believe that there
to let them go are exhibiting signs of protest.
are monsters or other scary things in their rooms at night.
It is appropriate for parents to try to allay those fears by TEST-TAKING TIP: Children who have been in the
inspecting under beds and in closets before the child’s hospital for long periods of time without frequent visits
bed time. from their parents often exhibit signs of detachment. The
Content Area: Pediatrics—Preschool children view the nurses as their primary caregivers and
sources of comfort rather than their parents.
Content Area: Pediatrics practitioner is not able manually to move the foot into
Integrated Processes: Nursing Process: Implementation proper position.
Client Need: Physiological Integrity: Physiological Content Area: Pediatrics
Adaptation: Alterations in Body Systems Integrated Processes: Nursing Process: Implementation
Cognitive Level: Application Client Need: Physiological Integrity: Physiological
Adaptation: Alterations in Body Systems
52. ANSWER: 1 and 2 Cognitive Level: Application
Rationale:
1. Cataracts are seen in babies with congenital rubella. 55. ANSWER: The order of nursing actions is: 5, 1, 3,
2. Deafness is seen in babies with congenital rubella. 2, 4.
3. Spina bifida is not characteristic of congenital 5. Calculate the safe dosage for the child and compare it
rubella. with the doctor’s order.
4. Hyperbilirubinemia is not characteristic of congenital 1. Wash hands.
rubella. 3. Cleanse the saline lock with alcohol or Betadine.
5. Respiratory stridor is not characteristic of congenital 2. Set the infusion pump to the correct rate.
rubella. 4. Document on the medication administration record.
TEST-TAKING TIP: Rubella during pregnancy is highly TEST-TAKING TIP: When confronted with a question that
teratogenic. In fact, if the mother contracts the illness requires the test taker to place items in chronological
during the first trimester, there is a 100% probability that order, he or she must realize that the question may
her fetus will be adversely affected. include only some of the required steps. The test taker
Content Area: Pediatrics must simply place those that have been provided into
Integrated Processes: Nursing Process: Assessment the correct order. Note that in the question, the nurse
Client Need: Physiological Integrity: Physiological should wash his or her hands following calculating
Adaptation: Alterations in Body Systems and comparing the dosage values because the hands
Cognitive Level: Application should be cleansed immediately before touching any
equipment.
53. ANSWER: 2
Content Area: Pediatrics
Rationale:
Integrated Processes: Nursing Process: Implementation
1. It is not appropriate for the nurse to encourage the
Client Need: Physiological Integrity: Pharmacological and
parents to consult with an orthopedic surgeon.
Parenteral Therapies: Medication Administration
2. It is appropriate for the nurse to encourage the
Cognitive Level: Application
parents to consult with a genetic counselor.
3. It is not appropriate for the nurse to encourage the 56. ANSWER: 3
parents to consult a registered dietitian. Rationale:
4. It is not appropriate for the nurse to encourage the 1. Bruises on the knees and elbows are often noted in
parents to consult an otolaryngologist. preschool children.
TEST-TAKING TIP: Fragile X syndrome is an X-linked 2. Bandaged lacerations are not unusual in preschool
genetic disease. The parents should be encouraged to children.
seek genetic counseling so that they will learn about the 3. Burn marks on a child’s torso are consistent with
etiology, signs, and symptoms of the disease as well as to child abuse.
provide them with the probability of passing the gene on 4. Brown patches on his forehead are likely a result of sun
to future children. exposure.
Content Area: Pediatrics TEST-TAKING TIP: Children who are cared for by loving
Integrated Processes: Nursing Process: Implementation parents seek comfort in their parents’ arms when they
Client Need: Safe and Effective Care Environment: are hurt and injured. Children who are abused often do
Management of Care: Referrals not. One of the many findings that is consistent with
Cognitive Level: Application child abuse is the presence of burn marks on a child’s
torso. Small round marks are likely caused by a lighted
54. ANSWER: 4
cigarette.
Rationale:
Content Area: Child Health, Abuse
1. Marked dorsiflexion is not characteristic of clubfoot.
Integrated Processes: Nursing Process: Implementation
2. Webbed toes are not characteristic of clubfoot.
Client Need: Psychosocial Integrity: Abuse/Neglect
3. A foot with an unusually high arch and large heel is not
Cognitive Level: Application
characteristic of clubfoot.
4. The nurse noted a foot that is plantar flexed and 57. ANSWER: 3
turned inward. Rationale:
TEST-TAKING TIP: At birth, many babies’ feet turn inward 1. Pertussis immune globulin is not administered on a
as a result of positioning in utero. When rotated monthly basis to preterm babies.
manually, however, the feet return to normal positions. If 2. Influenza immune globulin is not administered on a
the baby has a clubfoot, however, the health-care monthly basis to preterm babies.
3. Synergis (palivizumab) is often administered on a 3. The teenager may perform active range-of-motion
monthly basis to preterm babies. exercises.
4. Pulmozyme (dornase alfa) is a medication for children 4. The teenager should be administered no aspirin.
with cystic fibrosis. TEST-TAKING TIP: Reye syndrome is associated with the
TEST-TAKING TIP: Children who are born very preterm ingestion of aspirin during viral illnesses, most notably
are at high risk for bronchiolitis caused by the respiratory varicella (chicken pox) and the flu. To treat the body
syncytial virus. To prevent contracting the disease, the aches and fever associated with the flu, the teenager
babies are often prescribed monthly doses of Synergis. should be taught to take safe dosages of acetaminophen.
Content Area: Pediatrics—Respiratory Content Area: Pediatrics
Integrated Processes: Nursing Process: Implementation Integrated Processes: Nursing Process: Implementation;
Client Need: Physiological Integrity: Pharmacological and Teaching/Learning
Parenteral Therapies: Expected Actions/Outcomes Client Need: Physiological Integrity: Pharmacological and
Cognitive Level: Application Parenteral Therapies: Adverse Effects/Contraindications/
Side Effects/Interactions
58. ANSWER: 3 Cognitive Level: Application
Rationale:
1. Children following cleft palate surgery are able to 61. ANSWER: 1
consume soft foods. Rationale:
2. Children following cleft palate surgery are able to 1. This statement is the most appropriate comment for
consume soft foods. the nurse to make.
3. The nurse will feed the child who is post-op cleft 2. The nurse may make this statement, but it is not the
palate surgery without inserting any utensils into the most important for the nurse to make.
mouth. 3. The nurse may make this statement, but it is not the
4. No device is left in the mouth after cleft palate surgery. most important for the nurse to make.
TEST-TAKING TIP: Because eating utensils could damage 4. The nurse may make this statement, but it is not the
the cleft palate repair, the baby will be fed soft foods most important for the nurse to make.
until the surgery is healed. The nurse and parents should TEST-TAKING TIP: One of the most frequent
feed the child using a large spoon or other device that is complications of piercings is infection. To prevent
too large to insert into the mouth. infection, the teenager must be taught how to cleanse
Content Area: Pediatrics the area and to apply bactericidal medications.
Integrated Processes: Nursing Process: Implementation Content Area: Adolescent
Client Need: Physiological Integrity: Physiological Integrated Processes: Nursing Process: Implementation;
Adaptation: Illness Management Teaching/Learning
Cognitive Level: Application Client Need: Health Promotion and Maintenance: Health
Promotion/Disease Prevention
59. ANSWER: 1 Cognitive Level: Application
Rationale:
1. The nurse should administer the medications as 62. ANSWER: 1, 3, 4, and 5
ordered. Rationale:
2. The nurse should administer the medications as 1. Fatigue is a symptom of diabetes.
ordered. 2. Polyphagia is a symptom of diabetes.
3. The nurse should administer the medications as 3. Excessive thirst is a symptom of diabetes.
ordered. 4. Sweet-smelling breath is a symptom of diabetes.
4. The nurse should administer the medications as 5. Darkening of the skin of the neck (acanthosis
ordered. nigricans) is a symptom of type 2 diabetes.
TEST-TAKING TIP: The child’s heart rate is 120 bpm, and TEST-TAKING TIP: Most of the signs/symptoms of type 2
the child’s potassium levels are all within normal limits. diabetes are the same as those seen in type 1 diabetics.
The medications should be administered as ordered. The one exception to that is acanthosis nigricans, which
Content Area: Pediatrics—Cardiac is only seen in those with type 2 diabetes.
Integrated Processes: Nursing Process: Implementation Content Area: Pediatrics
Client Need: Physiological Integrity: Pharmacological and Integrated Processes: Nursing Process: Assessment
Parenteral Therapies: Medication Administration Client Need: Physiological Integrity: Physiological
Cognitive Level: Application Adaptation: Alterations in Body Systems
Cognitive Level: Application
60. ANSWER: 4
Rationale: 63. ANSWER: 3
1. The teenager may consume dairy products. Rationale:
2. The teenager may spend time in the sun if sunscreen is 1. Babies have a relatively large body surface area.
used. It is recommended that tanning lamps never be 2. Babies are unable to retain electrolytes in high
used. concentrations.
3. A high percentage of babies’ weight is from fluid.
4. Babies’ normal potassium level is the same as the older 3. A child with von Willebrand’s disease does not need to
child’s and the adult’s. avoid contact with allergens.
TEST-TAKING TIP: Up to 75% of the body of infants 4. A child with von Willebrand’s disease must have
and young children and 60% to 65% of the body of pressure and ice applied to all injuries.
preschoolers is comprised of fluid. Because the TEST-TAKING TIP: Von Willebrand’s disease is a
percentage of fluid is so high in infants and young hereditary bleeding disorder. To prevent excessive
children, they are especially at high risk for becoming bleeding, a child with the disease must have pressure
dehydrated during periods of illness. and ice applied to all injuries and receive DDAVP
Content Area: Pediatrics (desmopressin acetate) prior to any surgery or when
Integrated Processes: Nursing Process: Implementation; seriously injured.
Teaching/Learning Content Area: Pediatrics
Client Need: Physiological Integrity: Physiological Integrated Processes: Nursing Process: Implementation
Adaptation: Alterations in Body Systems Client Need: Physiological Integrity: Physiological
Cognitive Level: Application Adaptation: Illness Management
Cognitive Level: Application
64. ANSWER: 1
Rationale: 67. ANSWER: 2
1. The nurse would expect to see anasarca. Rationale:
2. The nurse would expect to see hypoproteinemia. 1. A human chorionic gonadotropin (hCG) assessment is
3. The nurse would expect to see a normal blood pressure. a pregnancy test.
4. The nurse would expect to see a high hematocrit 2. Antinuclear antibody (ANA) assessment is a screening
resulting from hemoconcentration. test for lupus.
TEST-TAKING TIP: The pathophysiology of nephrotic 3. Partial thromboplastin time (PTT) assessment tests the
syndrome results in the loss of large quantities of protein clotting time of blood.
from the blood. The hypoproteinemia results in a drop in 4. Alanine transaminase (ALT) assessment is a liver
the colloidal pressure in the vascular tree, resulting in a function test.
fluid shift into the child’s interstitial spaces, leading to TEST-TAKING TIP: The macular rash over the nose and
anasarca and hemoconcentration. cheeks is characteristic of lupus. In addition, the girl is
Content Area: Pediatrics exhibiting arthritic changes in her joints, which are also
Integrated Processes: Nursing Process: Implementation characteristic of lupus. It would be appropriate for the
Client Need: Physiological Integrity: Physiological nurse to request an order for an ANA test for this
Adaptation: Alterations in Body Systems patient.
Cognitive Level: Application Content Area: Pediatrics
Integrated Processes: Nursing Process: Implementation
65. ANSWER: 2 Client Need: Physiological Integrity: Reduction of Risk
Rationale: Potential: Diagnostic Tests
1. The image depicts a pyloric stenosis. Cognitive Level: Application
2. The image depicts an intussusception.
3. The image depicts esophageal atresia and 68. ANSWER: 1
tracheoesophageal fistula. Rationale:
4. The image depicts the colon of a child with 1. Parents should conduct yearly fire drills for their
Hirschsprung’s disease. young children.
TEST-TAKING TIP: Parents of children with serious 2. Hot water heater should be at no higher than 120°F.
illnesses are anxious and scared. When the illnesses 3. Batteries in household fire alarms should be changed
are described to them, they often have difficulty every year.
understanding the descriptions. When visual images are 4. Sunscreen may be applied to babies of any age, but no
available, they help to clarify the illnesses for the family baby should be in the direct sun until he or she is at least
members. 6 months of age.
Content Area: Pediatrics TEST-TAKING TIP: There are many reasons why young
Integrated Processes: Nursing Process: Implementation children become burned. Safe practices are very
Client Need: Physiological Integrity: Physiological important as a means of preventing burns.
Adaptation: Alterations in Body Systems Content Area: Child Health
Cognitive Level: Comprehension Integrated Processes: Nursing Process: Implementation;
Teaching/Learning
66. ANSWER: 4 Client Need: Health Promotion and Maintenance: Health
Rationale: Promotion/Disease Prevention
1. A child with von Willebrand’s disease does not need to Cognitive Level: Application
consume a special diet.
2. A child with von Willebrand’s disease does not need to
have his or her temperature assessed.
image as well as an intense fear of gaining weight. The Client Need: Physiological Integrity: Pharmacological and
nurse should query the young woman regarding her body Parenteral Therapies: Pharmacological Pain Management
image. Cognitive Level: Application
Content Area: Mental Health—Eating Disorders
Integrated Processes: Nursing Process: Implementation 75. ANSWER: 2
Client Need: Psychosocial Integrity: Mental Health Rationale:
Concepts 1. Children with pinworms do not experience black
Cognitive Level: Application stools.
2. Children with pinworms do scratch their anal area.
74. ANSWER: 4 3. Children with pinworms are not febrile.
Rationale: 4. Children with pinworms do not vomit.
1. Children are no more at high risk of becoming TEST-TAKING TIP: Once pinworm eggs hatch, they
addicted to narcotics than are adults. migrate out of the body via the anus. As a result, children
2. Children are no more at high risk of developing with pinworms do scratch the area to relieve the itching.
respiratory depression if given narcotics than are adults. In addition, the children often wet the bed because of
3. Children do not tolerate pain better than adults tolerate the stimulation caused by the migration of the worms.
pain. Content Area: Pediatrics
4. Children can effectively use pain scales to measure Integrated Processes: Nursing Process: Assessment
their pain. Client Need: Physiological Integrity: Physiological
TEST-TAKING TIP: There are excellent pain rating scales Adaptation: Alterations in Body Systems
that can be used for children of all ages. Cognitive Level: Application
Content Area: Pediatrics—Medication
Integrated Processes: Nursing Process: Analysis
505
F. What physiological characteristics should the child B. Which objective assessments are important in this
exhibit before going home? scenario?
1. The child hugs his mother and seeks security in 1. The child’s height, weight, and head circumference
her arms. were all at the 50th percentile at 1 year of age and
2. The mother hugs and consoles her son. are all at the 50th percentile at 2 years of age. (See
Growth Charts above and on p. 509.)
2. Laboratory values all within normal limits.
Chapter 3 3. Vital signs are all within normal limits.
A. Which subjective assessments are important in this 4. All other growth assessments are within normal
scenario? limits. It would be best if the child could be
1. The father states that there is a new baby in the assessed directly, but the father states that the child
house. is exhibiting appropriate growth and development.
2. The child is regressing—going back to the bottle 5. The child has two dental cavities.
after having weaned “months ago.” C. After analyzing the data that has been collected,
3. The child is having tantrums since the baby came what primary nursing diagnoses should the nurse
home. assign to this client?
4. The child is refusing to go “anywhere near 1. Interrupted Family Processes related to regression
a toilet.” of and tantrums by the child following the birth
5. The child states, “No! No! Me do! Me do!” of a new baby.
1 yr 21 lbs 29 in 45 cm
2 yrs 26.5 lbs 33¾ in 47.5 cm
2. Deficient Knowledge related to impaired dental appropriate toys, and continues to seek health
health of the child. promotion and disease prevention health care.
D. What interventions should the nurse plan F. What physiological characteristics should the child
and/or implement to meet this child’s and her exhibit before going home?
family’s needs? 1. Father who allows the child to assist with
1. Educate the father regarding reason for redressing after the examination.
regression of the child—normal response 2. Child hugs her father and seeks security in his
to birth of a new baby. arms.
2. Educate the father regarding negativity—related to 3. Father who hugs and consoles his daughter.
birth of a new baby plus normal growth and
development.
3. Educate the father regarding appropriate responses Chapter 4
to tantrums and other negative behavior—set A. Which subjective assessments are important in this
limits; ignore tantrums, then provide positive scenario?
reinforcement to appropriate behavior; time-outs. 1. The mother states, “My daughter’s temperature
4. Educate the father regarding importance of never has been between 100° and 101°F since
leaving the child alone with the baby—because yesterday.”
toddlers have poor impulse control, she may 2. The mother states that the only additional
seriously hurt the baby unintentionally. symptom is “her nose has been running a little
5. Educate the father regarding readiness for toilet bit.”
training and the need to refrain from attempting 3. The child states, “I know why I’m sick. I was bad
training until the child has become accepting of yesterday. I hit my sister!”
the new baby. 4. The child states that she is consuming fluids.
6. Educate the father regarding food fads and the 5. The child comments that she “love[s]”
decrease in growth during the toddler period— acetaminophen.
recommend providing healthy choices and paying B. Which objective assessments are important in this
less attention to quantity but rather to the quality scenario?
of the foods consumed. 1. Temperature of 100°F.
7. Provide a referral to a pedodontist or general 2. Other vital signs are within normal limits.
dentist who understands the normal growth and 3. Slightly enlarged cervical lymph nodes.
development of children’s teeth. 4. Slight rhinorrhea.
8. Educate the father regarding foods/behaviors that C. After analyzing the data that has been
put the child at high risk for tooth decay (e.g., collected, what primary nursing diagnosis
“sticky” foods, such as raisins and caramels; should the nurse assign to this mother-daughter
putting the child to bed with a bottle filled with dyad?
formula). 1. Deficient Knowledge related to the growth and
9. Educate the father and/or reinforce earlier development of the preschool child.
education regarding safety issues (e.g., gates, toys, D. What interventions should the nurse plan and/or
water, medicines). implement to meet this child’s and her family’s
E. What client outcomes should the nurse evaluate needs?
regarding the effectiveness of the nursing 1. Educate the mother regarding interventions
interventions? related to the child’s cold syndrome, that is:
1. Child who continues to develop and grow a. Keep the child home from preschool.
normally—regarding: a) biological growth, b. Provide the child with fluids throughout
b) gross motor development, c) fine motor the day.
development, d) language development, c. Administer a safe dose of acetaminophen for
e) psychosocial development, and f) cognitive elevated temperature.
development. 2. Educate the mother regarding poisoning potential
2. Father who states an understanding of normal related to acetaminophen and other medications,
growth and development and of normal responses that is:
related to the birth of a new baby. a. Keep all medications, including
3. Father who states that he will make an acetaminophen, in a locked cabinet.
appointment to visit a pediatric dentist. b. Only administer medication in the dosage and
4. Father who provides the child with an appropriate time intervals prescribed by the primary
and safe environment, provides her with safe and health-care provider.
3. Educate the child regarding the importance of: 5. The mother states that the child is the only
a. Staying home from school until she is no Chinese immigrant in her classroom.
longer sick. 6. The mother states that the child has complained
b. Drinking fluids. that some students in the upper reading group
c. Only taking medicine when her mother “said something” to her.
administers it to her. B. Which objective assessments are important in this
d. Frequent hand washing to prevent the spread scenario?
of the cold to others in the family. 1. None.
e. Covering her mouth and nose with her C. After analyzing the data that has been collected,
elbow or tissue when sneezing and/or what primary nursing diagnosis should the nurse
coughing. assign to this client?
4. In simple terms, advise the child, with the mother 1. Altered Coping related to feelings of inferiority.
in attendance: D. What interventions should the nurse plan and/or
a. That colds are spread by being close to implement to meet this child’s and her family’s
someone who has a cold. needs?
b. That hitting her sister may have been a “sad 1. Inform the mother that the child is exhibiting
choice” or “sad thing to do” but that it does not signs of school refusal and that it is important
make her a “bad girl” and her cold is not a that the child return to school the next day.
punishment for the “sad choice.” 2. Strongly encourage the parent to meet with the
5. In private, explain to the mother about the teacher and school principal regarding the
magical thinking of preschoolers and that, bullying by the students in the upper reading
when disciplining the child, it is important group.
to separate the child’s actions from the child 3. Strongly encourage the parent to meet with the
herself. teacher regarding supplementary learning
E. What client outcomes should the nurse evaluate experiences that the child could have to improve
regarding the effectiveness of the nursing the child’s reading level.
interventions? 4. Strongly encourage the mother to tell her
1. The child and mother communicate an daughter that she is a bright and capable young
understanding of the nurse’s education girl who does well in other school activities and in
regarding: activities outside of school. The mother should
a. School attendance. give the young girl specific examples of her
b. Fluid intake. abilities.
c. Medication administration. 5. Strongly encourage the mother to speak with her
d. Etiology of the illness. daughter regarding the problems at school and
2. The mother communicates an understanding of how the mother is working hard to make the
appropriate language to use when disciplining her school experience a more positive one.
daughter. 6. Encourage the mother, once they are identified, to
F. What physiological characteristics should the child inform the child regarding the actions that will be
exhibit before being discharged home? taken to improve the school experience.
1. Child covers her mouth and nose with her elbow 7. Provide the mother with strategies that she can
when she sneezes and coughs. teach her child to utilize when she is being bullied
by the other children, including avoiding contact
with the children, affirmatively telling the children
Chapter 5 to stop bullying, and informing the teacher when
A. Which subjective assessments are important in this the bullying occurs.
scenario? E. What client outcomes should the nurse evaluate
1. For the past 3 days, the child has complained of a regarding the effectiveness of the nursing
headache and stomachache. interventions?
2. The mother has kept the child home from school 1. The child returns to school the next day.
for the past 3 days. 2. The mother reports that the child expresses no
3. The mother states that the child’s symptoms reluctance to return to school.
resolve once the school day ends. 3. The mother reports that the child states that she is
4. The mother states that the child has complained being bullied no longer.
about being placed in the lowest reading group in 4. The mother reports that the child’s reading ability
her classroom. is improving.
F. What physiological characteristics should the child 2. The mother states that the child’s stools are
exhibit before being discharged home? “bright yellow and loose. She stools about
1. The child no longer reports headaches and/or three or four times a day. I’m still exclusively
stomachaches in the mornings before school breastfeeding her.”
begins. 3. The mother states that the child “has about
six really, really wet diapers a day. And when
she wakes up, her pajamas are sometimes
Chapter 6 even wet.”
A. Which subjective assessments are important in this B. What objective assessments indicate that the client is
scenario? a healthy child?
1. The child states that he frequently “blows off ” his 1. Entire review of systems is within normal limits.
homework. Head circumference, weight, and length are all at
2. The child states that in lieu of homework, he plays the 50th percentile.
video games and watches television. 2. Vital signs are all within normal limits.
3. The mother states that she and her husband have 3. Child’s verbalizations, “da da da,” are normal for
threatened to cancel camp for the child if he does child’s age.
not “do better in school.” 4. Child’s reflex responses are within normal
B. Which objective assessments are important in the limits.
scenario? 5. Child’s gross motor and fine motor development
1. All vital signs are within normal limits (WNL). are within normal limits.
2. Child is at the 50th percentile for both height and C. After analyzing the data that has been collected,
weight. what primary nursing diagnoses should the nurse
3. Normal physical examination. assign to this client?
C. After analyzing the data that has been collected, 1. Normal Health Maintenance and Normal Growth
what primary nursing diagnosis should the nurse and Development.
assign to this client? D. What interventions should the nurse plan and/or
1. Deficient Knowledge of parents related to implement to meet this child’s and her family’s
adolescent behavior, limit setting, and discipline. needs?
D. What interventions should the nurse plan and/or 1. Administer 6-month vaccinations.
implement to meet this child’s and his family’s a. Using appropriate method for drawing up and
needs? administering parenteral injections by locating
1. Educate the parent regarding adolescent behavior. each vastus lateralis and choosing the
2. Educate the parent regarding the need for limit appropriate length and gauge needle.
setting. b. Separating injection sites by at least 1 in. in
3. Educate the parent regarding disciplinary each thigh.
consequences that are appropriate and time c. Using appropriate method for oral vaccine
sensitive. administration.
4. Educate the child regarding the importance of 2. To minimize pain, either have the child suck on a
completing his assigned tasks. sucrose soothie or have the child breastfeed while
E. What client outcomes should the nurse evaluate immunizations are administered. Educate the
regarding the effectiveness of the nursing mother regarding rationale.
interventions? 3. Educate the mother regarding the method of
1. The child completes his homework prior to feeding solid foods.
engaging in leisure activities (i.e., video gaming a. Mix small amount of baby rice cereal with
and television watching). breast milk. To reduce potential for aspiration,
F. What physiological characteristics should the child offer the food while the baby is sitting up in an
exhibit before being discharged home? infant seat.
1. None. The child is physically healthy. b. Feed the child rice cereal two to three times
each day for 4 to 7 days to observe for allergic
response. If rash or other abnormal response
Chapter 7 occurs, notify the primary health-care
A. What subjective assessments indicate that the client provider.
is a healthy child? c. If no adverse response is noted, repeat the
1. The mother states, “She’s such an angel when she’s procedure with another cereal (e.g., barley
sleeping. And she is great fun when she is cereal) and then another until all cereals have
playing.” been offered.
d. Next, offer baby meats, vegetables, and fruits in D. What interventions should the nurse plan and/or
the same 4- to 7-day format. If adverse implement to meet this child’s and her family’s
reactions are noted, stop offering the food, and immediate needs?
notify the primary health-care provider. 1. After making sure that the mother has no
4. Reinforce the need to provide the baby with questions regarding the rationale for and potential
multiple forms of stimulation. complications from the endoscopy, determine that
E. What client outcomes should the nurse evaluate the mother and a witness have signed the
regarding the effectiveness of the nursing informed consent form.
interventions? 2. Allow the teenager to express concerns regarding
1. The baby will remain healthy. the endoscopy and the medications.
2. The baby’s growth and development will progress 3. Answer questions the teenager may have regarding
normally. the primary health-care provider’s orders.
3. The baby will develop no allergic reactions to 4. Inform the young woman that she will receive
foods. pain medication during the endoscopy.
4. The baby will return for a follow-up assessment at 5. Request the teenager’s assent for the procedures.
9 months of age. 6. Ask the teen if she would like her mother to stay
F. What physiological characteristics should the child with her during the procedures.
exhibit before being discharged home? 7. Provide therapeutic holding, as needed, during
1. The child should continue to exhibit normal the endoscopy.
physiological functioning. 8. The nurse recommends to the child’s health-care
G. What subjective characteristics should the child provider that a social work consult be ordered.
exhibit before being discharged home? E. What client outcomes should the nurse evaluate
1. The child should appear content in her mother’s regarding the effectiveness of the nursing
arms. interventions?
1. With her mother at her side, the teenager allows
the nurse to administer the medications with no
Chapter 8 physical or verbal protest.
A. What subjective assessments indicate that the client 2. With her mother at her side and with the nurse
is experiencing a health alteration? providing therapeutic holding, the teenager
1. The mother states that the teenager has “a very undergoes the endoscopy procedure with no
high fever, and she isn’t acting herself.” physical or verbal protest.
2. The teenager states, “I really feel awful.” 3. The teenager states that her pain level is below 3
3. The teenager states that she has been vomiting to on a 10-point scale.
lose weight. 4. The teenager’s vital signs return to normal.
4. The teenager asks the nurse not to tell her 5. The teenager does not vomit again.
mother that she has been engaging in high-risk F. What physiological characteristics should the child
behavior. exhibit before being discharged home?
5. When told that she needs a diagnostic procedure, 1. Normal blood pressure, normal temperature,
the teenager states, “Do you have to do all that? normal pulse, and normal respiratory rate.
I’m really okay.” 2. Pain level of 0 to 2 on a 10-point, numeric pain
B. What objective assessments indicate that the client is rating scale.
experiencing a health alteration? 3. No further episodes of blood-tinged vomitus.
1. Markedly elevated temperature, pulse, and G. What psychological characteristics should the child
respirations. and family exhibit before being discharged home?
2. Hypotension. 1. The teenager seeks comfort from her mother, and
3. Vomitus tinged with bright-red blood. her mother provides comfort, both verbally and
4. Objective assessment of pain. via touch.
C. After analyzing the data that has been collected, 2. The teenager consents to see a social worker
what primary nursing diagnosis should the nurse regarding her vomiting behavior.
assign to this client?
1. Physiological diagnosis: Risk for Injury related to
unknown pathology. Chapter 9
2. Psychosocial diagnosis: Risk for Altered Coping A. What subjective assessments indicate that the client
related to a history of self-induced vomiting, is experiencing a health alteration?
unknown pathology, and response to need for 1. The child is crying.
invasive procedure. 2. The child is complaining of neck pain.
• Dimensional analysis method: 2. The mother states that she “found an empty
15 mg 55 lb 1 kg
Children’s Tylenol bottle on his bedroom floor.”
= 375 mg every 6 hr 3. The mother states that she keeps the Tylenol
kg every 6 hr 2.2 lb
bottle in her purse.
• The primary health-care provider’s order of 400 mg 4. The mother estimates that the child consumed the
is higher than the calculated maximum safe dosage Tylenol 4 hr before the emergency department
for this child of 375 mg. visit.
• The nurse should request a safe order from the B. Which objective assessments are important in this
physician. scenario?
• The doctor changes the order to Vancomycin 1. The child is vomiting.
350 mg every 6 hr IV piggyback. 2. Vital signs are within normal limits.
• The nurse is now able to administer the safe dosage 3. CBC, ALT, and AST are all within normal limits.
of the antibiotic. 4. Serum acetaminophen concentration is 300 mcg/
2. Physician’s medication orders: ceftriaxone 1.25 g mL.
every 12 hr IV piggyback. C. After analyzing the data that has been collected,
• Recommended dosage of ceftriaxone in medication what primary nursing diagnosis should the nurse
reference: “children: 100 mg/kg/day intravenously assign to this client?
in equal doses every 12 hours.” The recommended 1. Risk for Injury (hepatotoxicity) related to acute
dosage is per weight. poisoning with Tylenol (acetaminophen).
• Ratio and proportion method: D. What interventions should the nurse plan and/or
• Convert pounds to kilograms: implement to meet this child’s and his family’s
1 kg/2.2 lb = x kg/55 lb needs?
1. Weigh the child.
x = 25 kg
2. Calculate the child’s DMV and compare with IV
• Calculate safe dosage: order.
100 mg/1 kg = x mg/25 kg 3. Begin IV infusion, after requesting the primary
health-care provider to provide a safe order.
x = 2,500 mg/day 4. Input values into the applicable nomogram to
• The calculated dose must be divided by two to confirm need for acetylcysteine.
make the time frame the same as the doctor’s 5. Employing the five rights of medication
order. administration, administer IV acetylcysteine after
calculating to make sure that it is a safe dosage.
x = 2,500/2
6. Employing the five rights of medication
x = 1,250 mg/12 hr administration, administer Zofran STAT, per
order.
• The calculated value must be divided by 1,000
7. Order repeat laboratory tests, and report findings
to make the units the same as the doctor’s
as soon as they are posted.
order.
8. Educate the mother regarding the poisoning
x = 1,250 mg/1,000 potential of preschool-age children.
x = 1.25 g/12 hr 9. Educate the mother regarding the importance of
keeping all medications, including vitamins, in a
• Dimensional analysis method: locked medicine cabinet.
100 mg 55 lb 1 kg 1 day 1g = 1.25 g/2 E. What client outcomes should the nurse evaluate
kg/day 2.2 lb 2 doses 1,000 mg doses regarding the effectiveness of the nursing
• The order is safe because the calculated interventions?
dosage and the doctor’s order are the same. 1. Assess whether the child stops vomiting within
• The nurse can safely administer the 30 min of the administration of Zofran.
medication every 12 hr as ordered. 2. Monitor for adverse responses to Zofran.
3. Assess IV site and infusion rate hourly.
4. Confirm that the acetylcysteine infused, as
Chapter 10 ordered.
A. Which subjective assessments are important in this 5. Monitor for adverse responses to acetylcysteine
scenario? infusion.
1. The mother states that her child “started vomiting 6. Monitor the child for jaundice and epigastric
about 1 hour ago.” pain.
7. Evaluate the mother’s responses to safety 3. Counsel the teenager regarding his obligations to
education. his girlfriend:
8. Compare the repeat laboratory results with a. To tell his girlfriend of his diagnosis.
normal values. b. To wear a condom each and every time he has
F. What physiological characteristics should the child sexual intercourse.
exhibit before being discharged home? c. To encourage his girlfriend to be tested for
1. All of the child’s laboratory values are within HIV because he has confessed that there are
normal limits. times when he does not wear a condom during
2. The child’s skin should show no signs of jaundice. intercourse.
3. The child should report no epigastric pain. 4. Counsel the teenager regarding the possible
worsening of his condition.
a. Low white blood cell count.
Chapter 11 b. Low CD4 count.
A. What subjective assessments indicate that the client c. Viral load of 1,000 copies/mL.
is experiencing a health alteration? d. Side effects of medication.
1. The patient’s comments indicate that he is i. Anemia, evidenced by fatigue and
becoming frustrated with his diagnosis and with abnormal hematocrit and hemoglobin
his medication regimen. levels.
2. The patient states that he is sexually active. ii. Hepatotoxicity, evidenced by rash and
3. The patient indicates that he inconsistently wears altered AST, ALT, and bilirubin levels.
a condom during intercourse. 5. Discuss with the teenager regarding a needed
4. The patient indicates that his energy level is below support system.
normal. a. His grandmother?
B. What objective assessments indicate that the client is b. Another family member?
experiencing a health alteration? c. A teacher at his school?
1. The adolescent patient has been HIV positive d. A mentor?
since birth. e. His girlfriend?
2. The patient, whose mother is deceased, lives with E. What client outcomes should the nurse evaluate
his grandmother. regarding the effectiveness of the nursing
3. The patient is currently on HAART. interventions? For the next clinic visit:
4. Vital signs: blood pressure 98/50 mm Hg; 1. If the teen fails to keep his next clinic visit, call
temperature 100.4°F; heart rate 110 bpm, him to remind him and to set up another
respiratory rate 20 rpm. appointment.
5. Maculopapular rash. 2. If the teen keeps his next clinic visit:
6. Abnormal CD4 count of 300 cells/mm3. a. Assess all laboratory data and compare with
7. Viral load of 1,000 copies/mL. previous findings.
8. Abnormal hematocrit of 28% and hemoglobin b. Assess his rash.
9 g/dL. c. Inquire whether his fatigue is improving or
9. Abnormal liver function tests of AST 200 IU/L worsening.
(normal 10 to 34 IU/L), ALT 250 IU/L (normal d. Ask whether he is following his medication
10 to 40 IU/L), and bilirubin 6 mg/dL (normal regimen and about other side effects that he
0 to 0.2 mg/dL). may be experiencing.
10. Abnormal white blood cell count of e. Ask about his girlfriend and:
3,500 cells/mm3. i. Whether he has told his girlfriend of his
C. After analyzing the data that has been collected, diagnosis.
what primary nursing diagnosis should the nurse ii. Whether he is wearing a condom each and
assign to this client? every time he is having intercourse.
1. Risk for Infection (opportunistic) related to iii. Whether his girlfriend has been tested for
current diagnosis. the disease.
D. What interventions should the nurse plan and/or f. Note whether his grandmother has
implement to meet this child’s and his family’s accompanied him to the clinic and/or
needs? whether he has identified another social
1. Strongly recommend that the teenager comply support.
with revised treatment regimen. F. What physiological characteristics should the child
2. Strongly recommend that the teenager return for exhibit before leaving the clinic?
follow-up laboratory examinations in 1 month. 1. None.
G. What subjective characteristics should the child 7. Confirm that the child is not immune
exhibit before leaving the clinic? compromised or that there are any other
1. The teenager states that he will: contraindications to the administration of the
a. Take his new medications each day. vaccines.
b. Report any worsening of current medication 8. Question the child and mother regarding
side effects and any side effects from the new behaviors the child exhibits during painful
medication. experiences. If the mother states that the child
c. Return to the clinic in 1 month for a follow-up needs to be restrained during injections, obtain
appointment. additional assistance.
d. Notify his girlfriend of his diagnosis, of her 9. Strongly encourage the child to utilize behaviors
risks if no condom is worn each time they to mitigate the pain while the vaccines are being
have intercourse, and of her need to be administered (e.g., counting to 10, utilizing
tested. guided imagery, clenching fists).
e. Advise his grandmother and/or another 10. Administer the injections in four different
confidant of his changing health status. muscles (i.e., two deltoid and two vastus
lateralis).
a. If appropriate, the injections could be
Chapter 12 administered at the same time by 4 different
A. What subjective assessments indicate that the client nurses.
is experiencing a health alteration? 11. Comfort and praise the child.
1. Mother states that the child is entering 12. Place an adhesive bandage on all injection
kindergarten in 2 months. sites.
B. What objective assessments indicate that the client is 13. Provide the child with a prize (e.g., sticker,
experiencing a health alteration? matchbox car, coloring book, picture book).
1. The child’s immunization record indicates that the 14. Document the administration of the injections
child has yet to receive five vaccines required by in the medical record.
the state in which the child lives. 15. Give the parent a list of signs and symptoms to
a. One DTaP vaccine report to the primary health-care provider if the
b. One IPV vaccine child should exhibit them.
c. One MMR vaccine 16. Give the parent a copy of the results of the
d. One VAR vaccine physical assessment and the immunization
e. One Hep A vaccine record.
C. After analyzing the data that has been collected, E. What client outcomes should the nurse evaluate
what primary nursing diagnosis should the nurse regarding the effectiveness of the nursing
assign to this client? interventions?
1. Ineffective Health Maintenance related to 1. All injections were administered using
incomplete vaccination series. correct technique and in anatomically
D. What interventions should the nurse plan and/or correct sites.
implement to meet this child’s and his or her family’s 2. All injection sites appear normal.
needs? 3. Mother states that she will report any side effects
1. Determine which vaccinations are available in exhibited by the child to the primary healthcare
combination forms. provider’s office.
2. If needed, elicit the assistance of up to three F. What physiological characteristics should the child
other nurses for the administration of the exhibit after treatment?
vaccines. 1. The child is composed when leaving the office.
3. With the other nurses, use the five rights of 2. The child is walking and moving all limbs
medication administration and aseptic technique normally.
to prepare injections of the vaccines needed to
complete the vaccine series.
4. Educate the mother and child regarding the
Chapter 13
injections that are required. A. What subjective assessments indicate that the client
5. Have the mother sign an informed consent form is experiencing a health alteration?
for the vaccine injections. 1. The mother states, “My daughter seems to be
6. Query the mother regarding any reasons why having trouble breathing.”
she feels the injections should not be 2. The child’s eyes are wide open, and she appears
administered at that time. anxious.
B. What objective assessments indicate that the client is 2. Monitor vital signs, especially rate and depth of
experiencing a health alteration? respirations.
1. The child is sitting erect in bed and gasping 3. Monitor blood gases.
for air. 4. Monitor urinary output.
2. Pulmonary wheeze heard on auscultation. 5. Monitor IV pump infusion.
3. The child’s fluid intake of 950 mL in 30 min 6. Assess serum electrolytes.
(child’s daily maintenance volume is 1,400 mL 7. Assess the child and mother for signs of fear or
for the entire day). anxiety.
a. Weight on admission is 18 kg. F. What physiological characteristics should the child
exhibit before being discharged home?
10 kg × 100 mL = 1,000 mL
1. Normal pulmonary auscultation: no rales, no
8 kg × 50 mL = 400 mL wheezes.
2. All physiological functions are within normal
total DMV = 1,400 mL
limits, including vital signs, blood gases, and
4.Rapid, bounding pulses. serum electrolytes.
5.Tachypnea. G. What subjective characteristics should the child
6.Elevated blood pressure. exhibit before being discharged home?
7.Blood gases indicate respiratory alkalosis, low 1. The child and parent state that they are unafraid
oxygen saturation, and low PO2. to return to the hospital for tonsillectomy in near
8. Using ROME, the nurse determines that the pH future.
and the pCO2 are in opposite directions—
Elevated pH and Low pCO2
9. High normal serum sodium related to the
Chapter 14
normal saline in the infusion. A. What subjective assessments indicate that the client
10. Low normal serum potassium related to the is experiencing a health alteration?
large quantity infused of IV fluid. 1. The mother describes an unhappy, irritable
C. After analyzing the data that has been collected, child.
what primary nursing diagnosis should the nurse 2. The mother states, “I think he is having problems
assign to this client? going to the bathroom.”
1. Excess Fluid Volume related to rapid infusion of a 3. The child states, “My belly hurts sometimes after I
large quantity of IV fluid. eat.”
D. What interventions should the nurse plan and/or B. What objective assessments indicate that the client is
implement to meet this child’s and her family’s experiencing a health alteration?
needs? 1. Weight percentile dropped from 55th percentile to
1. Clearly and calmly communicate to the child 45th percentile in the past 6 months.
and mother what has happened and what actions 2. Pale skin color.
are now being taken to rectify the problem. 3. High normal heart rate.
2. Administer oxygen as ordered. 4. Low red blood cell count, hematocrit, and
3. Raise the head of bed and maintain bedrest. hemoglobin.
4. Change IV infusion from gravity drip to IV 5. Positive IgA-tTG test.
pump. 6. Atrophy of intestinal villi on biopsy.
5. Calculate the safe dosage of Lasix and C. After analyzing the data that has been collected,
administer, if safe. what primary nursing diagnosis should the nurse
6. Monitor vital signs and oxygen saturations every assign to this client?
15 minutes, and report any further deviations 1. Imbalanced Nutrition: Less than Body
from normal. Requirements related to diagnosis of celiac
7. Give the child nothing by mouth. disease.
8. Monitor urinary output. D. What interventions should the nurse plan and/or
9. Order repeat blood gas for 1 hr. implement to meet this child’s and his family’s
10. Order repeat electrolytes for 12 hr. needs?
E. What client outcomes should the nurse evaluate 1. Educate the parents regarding the etiology and
regarding the effectiveness of the nursing physical characteristics of the disease.
interventions? 2. Allow the parents and child to communicate their
1. Auscultate the lungs for presence of abnormal concerns about the child’s physical and emotional
breath sounds. health.
4. The child’s intake and output are within normal ii. This child weighs 15.5 lb or 7.05 kg.
limits. iii. The safe dosage every 6 to 8 hr is equal to:
5. The child’s vital signs are within normal limits, 70.5 mg to 105.75 mg.
including blood pressure. b. Ampicillin 150 mg PO every 6 hr is within the
6. The child’s weight is consistent with admission safe dosage range for this child.
weight. i. The recommended dosage range of
7. The child’s laboratory data are all within normal ampicillin for children with AOM is: 80 to
limits. 90 mg/kg/day.
G. What subjective characteristics should the child ii. This child weighs 7.05 kg.
exhibit before being discharged home (from iii. The safe dosage every 6 hr is equal to:
hospital)? 141 mg to 158.63 mg.
1. The child is walking, talking, and playing c. Advise the mother regarding the milliliter
consistent with her growth and development. equivalent to medications.
d. Advise the mother that additional
acetaminophen should not be administered
Chapter 16 because of the potential for liver damage.
A. What subjective assessments indicate that the client e. Advise the mother of the importance of
is experiencing a health alteration? completing the ampicillin regimen.
Mother states that: 4. Demonstrate how to instill saline nasal drops.
1. The child has had a cold for two days. 5. Educate the mother regarding the need to make a
2. The child is having difficulty breathing through follow-up appointment.
her nose. 6. Educate the mother regarding administration of
3. The child is having “a bit of diarrhea.” oral rehydration therapy, and encourage upright
4. The child awoke in the middle of night with a positioning of the baby during bottle feedings.
fever. 7. Reinforce the need for the father to smoke outside
5. The child is irritable. of the home.
6. Mother states that child’s father smokes in the house. E. What client outcomes should the nurse evaluate
B. What objective assessments indicate that the client is regarding the effectiveness of the nursing
experiencing a health alteration? interventions?
1. The child is crying and shaking her head back and 1. The mother expresses understanding regarding
forth while in her mother’s arms. the etiology of the disease, medication
2. The child is repeatedly tugging at her right ear. administration, nose drop administration, child’s
3. Elevated temperature, heart rate, and respiratory diet, and behaviors that may place the child at
rate. high risk for future ear infections.
4. Rhinorrhea. 2. The mother expresses understanding of need to
5. Inflamed tympanic membranes. return to pediatrician’s office for a follow-up
6. The child is formula fed. appointment or if the child’s condition does not
C. After analyzing the data that has been collected, improve.
what primary nursing diagnoses should the nurse F. What physiological characteristics should the child
assign to this client? exhibit before being discharged home?
1. Infection related to physiological findings. 1. Child’s temperature drops to below 102°F
2. Risk for Deficient Fluid Volume related to nasal (may be taken axillary to prevent trauma to
congestion and “slight diarrhea.” rectum).
D. What interventions should the nurse plan and/or G. What subjective characteristics should the child
implement to meet this child’s and her family’s needs? exhibit before being discharged home?
1. Educate the mother regarding the etiology of the 1. The child’s crying subsides.
otitis media.
2. Calculate the safe dosage of the medications.
3. Educate the mother regarding the safe Chapter 17
administration of medication. A. What subjective assessments indicate that the client
a. Acetaminophen 80 mg PO every 6 hr is within is experiencing a health alteration?
the safe dosage range for this child. 1. Joint pain: joint pain is an unusual symptom in
i. The recommended dosage range of 8-year-old children. Migratory arthritis is one of
acetaminophen for children is: 10 to the five major manifestations (Jones criteria) of
15 mg/kg PO every 6 to 8 hr prn. rheumatic fever (RF).
F. What physiological characteristics should the child a. The recommended pediatric dosage of
exhibit before being discharged home? morphine sulfate for children 6 months to
1. Negative throat culture and normal temperature. 12 years of age is 0.1 to 0.2 mg/kg SC/IM/IV
2. P-R interval on the EKG that is approaching q2 to 4h prn.
normal. b. The nurse calculates the safe dosage range for
3. Maintenance of bedrest. this child as 1.8 mg to 3.6 mg IV q2 to 4 hr
4. Either the completion of the antibiotic course or prn. The ordered dosage is safe to administer.
taking prophylactic penicillin daily. 4. Assess pain every 30 minutes with Wong-Baker
Pain Scale.
a. If child’s pain is not reduced after the initial
morphine injection, the nurse should request
Chapter 18 the order be increased.
A. What subjective assessments indicate that the client 5. Obtain and send throat culture.
is experiencing a health alteration? 6. Administer penicillin G 600,000 units IV every
1. The child is crying. 6 hr.
2. The father states that the child has had vaso- a. The recommended pediatric dosage of
occlusive crises since he was 2 years old. penicillin G IV for infants and children is
3. The father states that the child is not drinking 100,000 to 400,000 units/kg/day IM/IV
well. divided q4 to 6h.
4. The father states that the child has yet to receive b. The nurse calculates the safe dosage range for
his yearly flu shot. this child as 450,000 units to 1,800,000 IV
B. What objective assessments indicate that the client is every 6 hr. The ordered dosage is safe to
experiencing a health alteration? administer.
1. The child has a history of sickle cell anemia 7. Administer oxygen at 2 L/min.
(SCA). 8. Monitor oxygen saturations.
2. The child chooses “hurts worse” on the Wong- 9. Monitor intake and output.
Baker Pain Scale. 10. Maintain the child on bedrest.
3. The child is febrile. 11. Provide the father and child with needed
4. The child’s elbows and knees are swollen, warm, emotional support.
and red. 12. Apply warmth to enflamed joints, as needed.
5. The child’s spleen is enlarged. 13. Provide the child with distractions/quiet activities
6. The child’s O2 saturation is 89%. (e.g., television, video games, books, puzzles).
7. The child’s laboratory report shows: E. What client outcomes should the nurse evaluate
a. RBC count: 3.0 million/mm3. regarding the effectiveness of the nursing
b. Hematocrit: 28%. interventions?
c. Hemoglobin: 9.1 g/dL. 1. The child’s pain level will decrease after
d. WBC: 15,500 cells/mm3. medication administration.
C. After analyzing the data that has been collected, 2. The child will stop crying.
what primary nursing diagnosis should the nurse 3. The child will drink fluids.
assign to this client? 4. The child’s temperature will drop.
1. Ineffective Peripheral Tissue Perfusion related to 5. The inflammation of the child’s joints will
clumping of sickled cells. diminish.
D. What interventions should the nurse plan and/or 6. The child will exhibit no signs of severe organ
implement to meet this child’s and his family’s involvement (e.g., no signs of stroke, heart failure,
needs? priapism).
1. Begin IV and infuse IV D5 ¼ NS at 90 mL/hr. F. What physiological characteristics should the child
a. The nurse calculates the child’s DMV as exhibit before being discharged home?
1,400 mL/24 hr or 58.3 mL/hr (10 kg × 1. The child is drinking one and one-half to two
100 mL + 8 kg × 50 mL = 1,400 mL/24 hr). times his DMV each day.
The rate of 90 mL/hr is needed to improve 2. The child’s CBC results are stable.
the child’s hydration. 3. The child’s joint involvement is minimal.
2. Provide and encourage the consumption of 4. Child reports that his pain level is at “no
favorite clear fluids, as tolerated. hurt” or “hurts little bit” on the Wong-Baker
3. Administer morphine 3 mg IV STAT, may repeat Pain Rating Scale without need for narcotic
every 2 hr, as needed. medications.
G. What subjective characteristics should the child 2. Mother states, “He needs immediate help. He
exhibit before being discharged home? must have pneumonia. Notify his pulmonologist
1. The child performs range of motion exercises with now!!!”
minimal to no complaints of pain. 3. Young man states, with marked difficulty,
“I don’t want any treatment. I am ready
to die.”
Chapter 19 B. Which objective assessments indicate that the client
A. What subjective assessments indicate that the client is experiencing a health alteration?
is experiencing a health alteration? 1. Gasping for breath.
1. The mother states that “dandruff ” cannot be 2. Rales bilaterally.
brushed from the child’s hair shafts. 3. Minimal intercostal retractions.
2. Daughter states that her head itches. 4. Poor aeration to the bases.
3. Mother states that there is evidence that the child 5. Marked muscular wasting.
has been scratching her neck and behind her ears. 6. Edema of the feet and lower legs.
B. What objective assessments indicate that the client is 7. Vitals: Temperature 102.4°F, heart rate 154 bpm,
experiencing a health alteration? respiratory rate 60 rpm.
1. The school nurse states that the child has lice. C. After analyzing the data that has been collected,
C. After analyzing the data that has been collected, what primary nursing diagnosis should the nurse
what primary nursing diagnosis should the nurse assign to this client?
assign to this client? 1. Compromised Family Coping related to fatal
1. Infection related to lice infestation. illness.
D. What interventions should the nurse plan and/or D. What interventions should the nurse plan and/or
implement to meet this child’s and her family’s needs? implement to meet this child’s and his family’s
1. Provide the mother with the health-care provider’s needs?
prescribed medication administration procedure 1. Elevate head of bed to 60 degrees.
for the child and for all family members who have 2. Administer oxygen via facemask at 2 L/min.
been in intimate contact with the child or with 3. Provide emotional support to the young man
products used by the child. by remaining at his side at all times and
2. Provide the mother with the procedure for caring acknowledging his readiness to die.
for all items that have been in contact with the 4. Request the assistance from another nurse to
child. provide emotional support to the patient’s mother
3. Provide emotional support for the mother, child, by remaining at her side and acknowledging her
and family. fear and anxiety over her son’s illness and her
E. What client outcomes should the nurse evaluate son’s readiness to die.
regarding the effectiveness of the nursing 5. Notify the chair of the ethics committee regarding
interventions? the need for a STAT meeting regarding the
1. Eradication of signs of lice infestation from the patient’s refusal (a minor) to give assent for
child and all members of the family, including no medical intervention and his mother’s demand
evidence of nits on the hair shafts or of itching of (his legal guardian) that aggressive care
the neck and/or behind the ears. interventions be begun.
F. What physiological characteristics should the child E. What client outcomes should the nurse evaluate
exhibit after treatment? regarding the effectiveness of the nursing
1. No evidence of nits on the hair shafts. interventions?
G. What subjective characteristics should the child 1. Satisfaction of the young man with the
exhibit after treatment? decisions made regarding his immediate
1. All complaints of itching have disappeared. and long-term care.
2. Satisfaction of the young man’s mother with the
decisions made regarding her son’s immediate and
Chapter 20 long-term care.
A. What subjective assessments indicate that the client F. What physiological characteristics should the child
is experiencing a health alteration? exhibit before being discharged from the emergency
1. As stated by the paramedic: department?
a. History of muscular dystrophy. 1. The child’s respiratory and heart rates slow.
b. Dyspnea. 2. The child’s core temperature remains stable or
c. Hyperthermia. drops.
G. What subjective characteristics should the child 6. Monitor hourly potassium levels, and report to
exhibit before being discharged from the emergency the primary health-care provider.
department? E. What client outcomes should the nurse evaluate
1. The young man and mother verbally express regarding the effectiveness of the nursing
satisfaction with the treatment plan developed by interventions?
the ethics committee and the child’s primary 1. Glasgow Coma score increasing to normal
health-care provider. of 15, with no signs of increased intracranial
Depending on the decision of the ethics committee and pressure.
the decision of the family, the young man may remain in 2. Vital signs returning to normal, including normal
the hospital and receive aggressive intervention, may respiratory rate and depth.
remain in the hospital on hospice care until his death, or 3. Blood glucose levels dropping: initial goal
may be discharged home on hospice care. 200 mg/dL
4. Potassium levels rising to normal of 3.5 to
5 mEq/L.
Chapter 21 5. Urine output within normal limits.
A. What subjective assessments indicate that the client 6. Ketones in urine dropping toward normal.
is experiencing a health alteration? 7. Weight returning to normal.
1. The school nurse states (learned via parents’ F. What physiological characteristics should the child
statements) that child collapsed in his classroom. exhibit before being discharged home?
2. The parents state that the child is a “good boy.” 1. Glasgow Coma score of 15.
3. The parents state that the child has had a cold for 2. Vital signs within normal limits.
the past 2 days. 3. Preprandial glucose tests between 90 and
4. The parents are attentive—requesting to see their 180 mg/dL.
son. 4. Serum potassium 3.5 to 5 mEq/L.
5. The parents state that he has been “drinking and 5. Urinary output within normal limits.
eating a lot lately.” 6. Urine ketones are absent.
B. What objective assessments indicate that the client is 7. Weight at or about 93 lb.
experiencing a health alteration? G. What psychological characteristics should the
1. Glasgow Coma score of 11, including making child and family exhibit before being discharged
verbal responses with inappropriate words. home?
2. Elevated respiratory rate—Kussmaul-type 1. The child reports an understanding of the need
breathing pattern. for home blood glucose monitoring, home urine
3. Elevated pulse rate. monitoring, insulin injections, diet changes, and
4. 8.1% weight loss since the child’s last well-child need for routine exercise.
check. 2. The child demonstrates the procedure for home
5. Markedly elevated glucose. blood glucose monitoring, urine monitoring, and
6. Markedly elevated hemoglobin A1C. rotation of injection sites.
7. Low potassium. 3. The parents demonstrate the procedure for home
8. Low pH. blood glucose monitoring, urine monitoring,
C. After analyzing the data that has been collected, rotation of injection sites, dietary needs,
what primary nursing diagnosis should the nurse administration of glucagon via injection, insulin
assign to this client? dosaging, and subcutaneous injections.
1. Risk for Injury related to marked hyperglycemia 4. The parents and child correctly report signs
and diabetic ketoacidosis. and symptoms of both hyperglycemia and
D. What interventions should the nurse plan and/or hypoglycemia.
implement to meet this child’s and his family’s needs? 5. The parents and child correctly report
1. Allow the parents to express anger, frustration, and treatment for both hyperglycemia and
guilt regarding the emergent condition of their son. hypoglycemia.
2. Have an IV catheter inserted STAT.
3. Begin infusion at 400 mL per hour to replace
fluids because the child is severely dehydrated.
Chapter 22
4. Perform Glasgow Coma assessment every 15 min, A. What subjective assessments indicate that the client
and report any deterioration of response. is experiencing a health alteration?
5. Monitor serum glucose levels every 15 min, and 1. The baby’s mother’s aunt is wheelchair bound.
report the results to the primary health-care 2. The baby’s mother’s diet during her pregnancy
provider. was poor.
B. What objective assessments indicate that the client is 15. Assess the bonding behaviors that the mother
experiencing a health alteration? exhibits when with her baby.
1. Spina bifida seen on ultrasound. 16. If appropriate, allow the mother to hold the baby
2. The mother had no prenatal care during her first prone on her lap and caress the baby.
trimester of pregnancy. E. What client outcomes should the nurse evaluate
3. Open sac at base of spine in lumbosacral region— regarding the effectiveness of the nursing
likely meningomyelocele in light of other signs interventions?
and symptoms. 1. The baby shows no signs of infection.
4. Constant dribbling of urine. 2. The baby’s head does not increase in
5. Constant oozing of feces. circumference or show any other signs of
6. Bilateral flaccid paralysis of both legs. hydrocephalus.
7. Asymmetry of leg folds—likely developmental 3. The baby’s mother exhibits signs of bonding
dysplasia of the hips, which commonly is seen in effectively with her baby (e.g., kissing and
babies with spina bifida. caressing the baby).
8. Head circumference of 37 cm, chest 4. The mother states a clear understanding both of
circumference of 32 cm—likely hydrocephalus, the baby’s diagnosis and the surgery.
which commonly is seen in babies with spina 5. The mother freely expresses concern over the
bifida. baby’s future well-being.
C. After analyzing the data that has been collected, F. What physiological characteristics should the child
what primary nursing diagnosis should the nurse exhibit before being discharged home?
assign to this client? 1. Intact lumbosacral area.
1. Risk for Infection related to presence of 2. Functioning VP shunt.
sacral sac. 3. Stable vital signs with no signs of infection.
D. What interventions should the nurse plan and/or 4. Retaining feedings and gaining weight.
implement to meet this child’s and his or her family’s G. What subjective characteristics should the child
needs? exhibit before being discharged home?
1. Meticulous handwashing and aseptic technique. 1. The child is responding appropriately to all
2. Monitor for signs of infection, including stimuli, including hunger, touch, and sound.
elevated WBC and redness or purulent
discharge at the site.
3. Monitor vital signs every 2 hr, especially
Chapter 23
temperature for both hyper- and hypothermia. A. Which subjective assessments are important in the
4. Maintain moist, sterile dressings over defect scenario?
using aseptic technique, and reinforce moist 1. Marked behavioral change noted by the child’s
dressings with dry, sterile dressing. teacher from:
5. Monitor sac for signs of rupture, CSF leakage, or a. Doing “very well on all of her assignments”
drying. and being “outgoing and talkative” to
6. Accompany the baby for ultrasound of site. b. Not doing “any homework all week” and
7. Maintain the baby in prone position. “sit[ting] alone in the corner during recess and
8. Change soiled diapers and underpads refus[ing] to play with her friends.”
immediately to prevent contamination of site. c. The mother confirming a change in
9. Monitor for signs of pressure points on behavior.
dependent surfaces. 2. The young girl states, “I really hate it when Uncle
10. Monitor for signs of hydrocephalus, including Jack visits.”
assessing daily for increasing head 3. When queried about whether her Uncle Jack hurt
circumference, bulging fontanels, separating her, the young girl cries and states, “I can’t say. I
sutures, bossing of forehead, and setting-sun will get into trouble.”
sign. 4. The child winces in pain when she sits.
11. Only use non-latex materials when caring for the B. Which objective assessments are important in the
baby. scenario?
12. Educate the mother regarding the 1. None: all vital signs are within normal limits.
pathophysiology of the baby’s defect. C. After analyzing the data that has been collected,
13. Educate the mother regarding the surgery that what primary nursing diagnosis should the nurse
the baby will have. assign to this client?
14. Allow the mother to express her feelings 1. Ineffective Coping/Injury related to suspected
regarding the baby’s defect. sexual abuse.
D. What interventions should the nurse plan and/or D. What interventions should the nurse plan and/or
implement to meet this child’s and her family’s needs? implement to meet this child’s and his family’s
1. Notify the parents of the nurse’s suspicions. needs?
2. Advise the parents to have their daughter seen by 1. Educate the parents and others regarding the
the primary health-care provider. child’s diagnosis.
3. Immediately report the suspicion of sexual 2. Allow the parents to express grief, anger, and/or
abuse to the local office of child protective frustration.
services. 3. Refer the child and family to educational
E. What client outcomes should the nurse evaluate resources specifically geared to autistic
regarding the effectiveness of the nursing children.
interventions? 4. Refer the child and family to the American
1. The parents state that they have had their Autism Society and/or American Autism
daughter assessed. Association.
2. A formal investigation is performed by the local 5. Strongly encourage the parents to establish
office of child protective services. a strict routine of daily activities for the
F. What physiological and/or psychological child.
characteristics should the child exhibit after the child 6. If the child ever needs a babysitter, try to employ
receives needed counseling? the same person each time.
1. The child’s behavior returns to normal. E. What client outcomes should the nurse evaluate
regarding the effectiveness of the nursing
interventions?
Chapter 24 1. At each well-child visit, evaluate and
A. What subjective assessments indicate that the client document the child’s physiological growth
is experiencing a health alteration? and development.
Based on observations by the day-care teacher and 2. At each well-child visit, assess and document the
parents: child’s social, language, behavioral, and cognitive
1. The child fails to give teacher eye contact. functioning.
2. The child “doesn’t seem very happy.” Teacher 3. At each well-child visit, interview the parents
rarely sees the child smile. to assess their individual and the family’s
3. The child avoids interacting with other children; coping.
child plays alone. F. What physiological characteristics should the child
4. The child engages in repetitive behaviors. exhibit before being discharged home?
5. The child does not initiate independent behaviors 1. None.
at home, including undressing and using
silverware during meals.
6. The child rarely speaks, and his responsiveness
Chapter 25
to engage in educational interactions has A. What subjective assessments indicate that the client
declined. is experiencing a health alteration?
7. None of the child’s behaviors can be explained by 1. A volunteer at the child’s day-care center reports a
parental behavior. The parents are educated and disparity between the vision test results of child’s
involved in all aspects of the child’s life. left and right eyes.
B. What objective assessments indicate that the client is 2. The mother states that she has noticed the child
experiencing a health alteration? moving her head to one side when looking at
1. The child failed two scales of the DDST: personal/ books.
social and language. (Not appropriate to B. What objective assessments indicate that the client is
administer IQ tests because the child is too experiencing a health alteration?
young.) 1. Slight strabismus noted on ophthalmic
2. All other data, including fine and gross motor examination.
development and all physiological parameters, are 2. Marked difference in visual ability between right
within normal limits. and left eye.
C. After analyzing the data that has been collected, C. After analyzing the data that has been collected,
what primary nursing diagnosis should the nurse what primary nursing diagnosis should the nurse
assign to this client? assign to this client?
1. Impaired Social Interaction/Impaired Verbal 1. Risk for Disproportionate Growth related to the
Communication. diagnosis of amblyopia.
D. What interventions should the nurse plan and/or that because of the child’s age, she may
implement to meet this child’s and her family’s need assistance when administering the
needs? medication.
1. Inform the mother that the child is primarily v. Observe a return demonstration.
using only her right eye to see. b. The intervention will require the child to use
2. Advise the mother that if the child continues to her weak eye to see. Even though she will see
use the dominant eye that she will eventually poorly for a while, the vision in the amblyopic
become blind in the left eye. eye will slowly improve.
3. Educate the mother regarding the therapy E. What client outcomes should the nurse evaluate
prescribed by the ophthalmologist. regarding the effectiveness of the nursing
a. One atropine drop in the right eye each interventions?
morning, which will blur the image seen 1. The mother communicates an understanding of
by that eye. Demonstrate procedure as the child’s condition.
follows: 2. During return demonstration, the mother uses
i. Wash hands well before administering the appropriate technique when instilling eye drops
drop. into her daughter’s right eye.
ii. Maintain drops at room temperature. 3. The mother makes an appointment for a return
iii. Never allow the dropper to touch the eye. visit in 1 month.
If it does, the mother should be advised to F. What physiological characteristics should the child
request a new prescription from the exhibit before being discharged home?
ophthalmologist. 1. None.
iv. Offer suggestions for distractions that G. What psychological characteristics should the
the mother could use during instillation child and family exhibit before being discharged
of the drop (e.g., watching television, home?
playing handheld video games, singing 1. The child allows her mother to instill one eye
songs). In addition, advise the mother drop into her right eye with minimal complaint.
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Chapter 2 Chapter 12
Fig 2.3. Photo courtesy of the Back to Sleep campaign, Table 12.1, Figs 1–6 and 8–9. Courtesy CDC.
Eunice Kennedy Shriver National Institute of Child Table 12.1, Fig 7. Courtesy CDC/J.D. Millar.
Health and Human Development, National Institutes
Chapter 16
of Health and Human Services (www.nichd.nih.gov/
sids). Fig 16.3. From Dillon, P.M. (2007) Nursing health
Review Question 9. Modified from CDC Clinical assessment: A critical thinking, case studies
Growth Charts (www.cdc.gov/growthcharts/clinical approach, 2nd ed. Philadelphia: F.A. Davis.
_charts.htm).
Chapter 17
Review Question 9 Answer. Modified from CDC
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clinical_charts.htm). (2014). Pediatric nursing: The critical components of
nursing care. F.A. Davis.
Chapter 6
Fig 17.2. Rudd, K., & Kocisko, D. (2014). Pediatric
Fig 6.1. Colyar, M.R. (2011). Assessment of the nursing: The critical components of nursing care.
school-age child and adolescent. Philadelphia: F.A. Davis.
F.A. Davis. Fig 17.3. Centers for Disease Control and Prevention,
Fig 6.2. Colyar, M.R. (2011). Assessment of the Department of Health and Human Services, Joe
school-age child and adolescent. Philadelphia: Miller, VD. (1976.). Retrieved from: http://phil.cdc
F.A. Davis. .gov/Phil/details.asp, ID #6784
Fig 6.3. Colyar, M.R. (2011). Assessment of the school- Table 17.1, Figs 1–10. Modiified from Ward, S.L., &
age child and adolescent. Philadelphia: F.A. Davis. Hisley, S.M. (2009). Maternal-child nursing care:
Review Question 2. Modified from Colyar, M.R. Optimizing outcomes for mothers, children, and
(2011). Assessment of the school-age child and families. Philadelphia: F.A. Davis.
adolescent. Philadelphia: F.A. Davis.
Chapter 19
Chapter 7
Fig 19.1. From Dillon, P.M. (2007). Nursing health
Review Question 9. Modified from CDC Clinical assessment: A critical thinking, case studies
Growth Charts (www.cdc.gov/growthcharts/clinical approach, 2nd ed. Philadelphia: F.A. Davis.
_charts.htm). Fig 19.2. Courtesy CDC/Dr. Herman Miranda, Univ. of
Trujillo, Peru; A. Chambers.
Chapter 9
Fig 19.3. Courtesy CDC/Dr. Thomas F. Sellers/Emory
Fig 9.1. From Behrman, R., Kleigman, R., & Arvin, University.
A.M. (1996). Nelson textbook of pediatrics. Elsevier. Fig 19.4. Courtesy CDC/Bruno Coignard, M.D.; Jeff
Box 9.1, Figs 1 and 2. Modified from Behrman, R., Hageman, M.H.S.
Kleigman, R., & Arvin, A.M. (1996). Nelson Fig 19.5. Courtesy CDC/Dr. Lucille K. Georg.
textbook of pediatrics. Elsevier. Fig 19.6. Courtesy CDC/Frank Collins, Ph.D.
Review Question 9. From Behrman, R., Kleigman, R., Fig 19.7. Courtesy CDC/Susan Lindsley.
& Arvin, A.M. (1996). Nelson textbook of pediatrics.
Chapter 20
Elsevier.
Fig 20.4. Rudd, K., & Kocisko, D. (2014). Pediatric
Chapter 10
nursing: The critical components of nursing care.
Fig 10.1. Berg, M.D., Schexnayder, S.M., Chameides, L., F.A. Davis.
Terry, M., Donoghue, A., Hickey, R.W., ... & Fig 20.6. Rudd, K., & Kocisko, D. (2014). Pediatric
Hazinski, M.F. (2010). 2010 American Heart nursing: The critical components of nursing care.
Association guidelines for cardiopulmonary F.A. Davis.
resuscitation and emergency cardiovascular care Fig 20.7. Rudd, K., & Kocisko, D. (2014). Pediatric
science, Part 13: Pediatric basic life support. nursing: The critical components of nursing care.
Circulation, 122, S862–S875. F.A. Davis.
545
Note: Page numbers followed by b indicate boxes, f indicate figures, and t indicate tables.
547
Audiometric tests, 50, 97 Body structures, assessment of, 94–100 Car seats, 19, 36, 49, 64
Auscultation, of abdomen, 98 Body surface area (BSA), 129, 130, 223 Carbon monoxide detectors, 37
Autism spectrum disorders, 459–460 Boils, 346–347 Cardiac catheterization, 304
Automated external defibrillator (AED), 157, Bone bend, 366t Cardiac defects, 299–304, 300t–303t
159 Bone fractures, 365–370 Cardiac muscle, 325
Automobile accidents, 79, 164 Bone marrow, 329 Cardiac output (CO), 305
Autonomy vs. shame and doubt, 31 Bone marrow transplants, 330 Cardiomegaly, 305b
Axillary temperature, 13 Bones, 363 Cardiopulmonary arrest, 157
Botox, 468 Cardiopulmonary resuscitation (CPR), 159–
Bottle hygiene, 16 161, 160f
B Bow legs, 100 Cardiovascular illnesses, 299–319
B cell, 179, 180, 323t Bowel, intussusception, 237, 251–252, 251f cardiac defects, 299–304, 300t–303t
Babinski reflex, 14t, 101t, 419 Bradycardia, 92 congestive heart failure, 299, 304–307,
Baby care skills, 18 Brain, 407 305b
Baby teeth, 13 Brain development, 77 Kawasaki disease, 309–311
BAL in oil (dimercaprol), 169 Brain growth, 60 overview of, 299
Bar mitzvah, 1, 2 Brain injuries, 77, 416–417 rheumatic fever, 307–309
Barlow’s sign, 100, 372b Brain stem, 407 Cardiovascular system, 299
Bases, 221 Brain tumors, 421–422 Caregiver role strain, 4
Basic life support algorithm, 158f Breast development, 75f, 98 Casts, 365, 369
Basophils, 323t Breast milk, 16, 180, 239, 322 Catabolism, 389, 393
Bat mitzvah, 1, 2 Breast self-examination, 98 Catheters, IV, insertion of, 135–136
Bathing, infants, 18 Breastfeeding, 16, 239, 279 CCR5 antagonists, 183t
Bedtime routines, 33, 48 Breathing, assessing for, 158 Celiac crisis, 252
Bed-wetting, 263–264 Bris, 1 Celiac disease, 237, 252–253
Bicycle safety, 64 Bronchi, 277 Cellulitis, 341, 345–346, 345f
Bile, 238 Bronchiolitis, 277, 284–285 Centers for Disease Control and Prevention
Binge drinking, 436 Brudzinski sign, 407 (CDC)
Binge eating disorder, 435–436 Bruising, 100 growth charts of, 9
Binocular vision, 95 BSA dosages, 130–131, 131f, 132b–133b on infectious disease, 195–196
Biological development Buckle fracture, 366t on HIV testing, 181
adolescents, 73–76 Bulimia nervosa, 435 on MRSA, 346
benchmarks for, 9 Bullying, 66 Central nervous system, 325, 407
defined, 11 Burns Cerebellum, 407
infants, 12–13 classification of, 351–352, 352f, 352t Cerebral palsy (CP), 407, 415–416
preschoolers, 45–46 diagnosis of, 351–352 Cerebral spinal fluid (CSF), 407, 413
school-age children, 59–61 etiology, 351 Cerebrum, 407
toddlers, 29–31 extent of, 353f CF. See Cystic fibrosis (CF)
Birth practices, 2 incidence of, 351 Chelation therapy, 157, 168–169
Blacks, 3 pathophysiology, 351 Chemet (succimer), 169
Bladder, 261 prevention of, 49, 50, 65, 352, 353–354 Chemotherapy, 329–330
Bladder exstrophy, 261, 262 safety issues, 19, 36–37 Chest, assessment of, 98
Bleeding, in hemophilia, 327–328 threats for, 18, 36, 50 Chest circumference, 93–94
Blended family, 1, 2 treatment of, 352 Chest physical therapy (CPT), 285
Blood, in vomit, 240t Burr hole, 410 CHF. See Congestive heart failure (CHF)
Blood gas analysis, 277 Butterfly rash, 184f Chickenpox, 206t–207t
Blood glucose testing, 394, 397 Buttocks, assessment of, 99 Child
Blood lead levels (BLLs), 168, 169 as member of family, 1–8
Blood pressure parent-child relationships, 4
adolescents, 76 C Child abuse/neglect, 20, 37, 51, 66, 364, 438–
assessment of, 93 CAB (chest compression, airway, breathing), 441, 452
infants, 13 157, 159 Childproofing home, 18, 35–36, 50, 66
preschoolers, 47 Calcium (Ca), 78, 168, 223, 224 Children
school-age children, 60 Calcium disodium versenate, 169 See also Adolescents; Infants; Preschoolers;
toddlers, 30 Caloric requirements, 78 School-age children; Toddlers
Blood products, administration of, CaNa2EDTA, 169 CPR for, 160
138–139 Cancer fluid composition of, 222t
Blood transfusions, 138–139, 326 brain tumors, 421–422 transporting, 120
Bodily injury, 115 leukemia, 321, 328–331 Children’s Glasgow Scale, 408, 409t
Body composition, 222 neuroblastoma, 422–432 Child-SCAT3, 417
Body mass index (BMI) retinoblastoma, 467, 470–471, 470f Chloride (Cl), 223
adolescents, 75 Wilms’ tumor, 261, 267–268 Choking hazards, 17, 18, 33, 36, 50–51
calculation of, 30, 94 Candida albicans, 341, 342, 343 Chordee, 261
preschoolers, 45 Candidiasis, 341, 342–343, 343f Choroid plexus, 413
school-age children, 60 Captopril (Capoten), 306 Christianity, 2
toddlers, 30 Car safety, 19, 36, 49, 64, 79 Christmas disease, 327
Glycosylated hemoglobin, 394 Health-care setting, nursing care in, 113–128 procedures during, 121–122
Glycosuria, 394 Healthcare-acquired MRSA (HA-MRSA), 346 regression during, 118
Gower’s sign, 363, 377, 378f Health-promotion strategies, 9 safety during, 119–121
Grandparent-led family, 2 Hearing separation during, 114–115
Granulocytes, 323t infants, 13 stressors of, 113–114
Grasp reflex, 14t, 101t screening tests, 50, 67, 81, 97 Hot water heaters, 19
Greenstick fracture, 365t Hearing deficit, 471–473 Human immunodeficiency virus (HIV),
Grief counseling, 5 Heart, 299 180–183
Grieving, 163b assessment of, 98 Human papillomavirus (HPV), 208t–209t
Gross motor development congestive heart failure, 299, 304–307 Human papillomavirus (HPV) vaccine, 197
adolescents, 76 defects, 299–304, 300t–303t Hydrocarbons, 167t
assessment of, 92 fetal development of, 299–300 Hydrocephalus, 407, 411, 413–414
defined, 11 murmurs, 92 Hymen, 99
infants, 13, 14t Heart rate Hypercalcemia, 221, 224
milestones, 14t adolescents, 76 Hyperglycemia, 395, 396
preschoolers, 47 apical, 30, 92, 306 Hyperkalemia, 221, 224
school-age children, 61 assessment of, 92, 98 Hypernatremia, 221, 224
toddlers, 31 infants, 13 Hypernatremic dehydration, 221, 225
Gross Motor Function Classification System preschoolers, 47 Hyperopia, 467
(GMFCS), 407 school-age children, 60 Hyperproteinuria, 261, 266
Group A strep, 280, 309 toddlers, 30 Hyperreflexia, 221, 224
Growth and development Heavy metal poisoning, 167–170 Hypertelorism, 89, 95b
adolescents, 73–88 Height Hypertension, 305b
assessment of, 92, 93–94 adolescence, 73 Hypertonic dehydration, 221, 225
infancy, 11–28 infants, 12 Hypertrophic pyloric stenosis, 250–251
pattern of, 12 measurement of, 94 Hypocalcemia, 221, 224
preschoolers, 45–57 preschoolers, 45 Hypoglycemia, 394, 396
school-age children, 59–72 school-age children, 60 Hypokalemia, 221, 224, 306
screening tests, 452 toddlers, 30 Hyponatremia, 221, 224
toddlerhood, 29–44 Heimlich maneuver, 161, 161f Hyponatremic dehydration, 221, 225
Growth charts, 9, 12, 75, 94 Hemarthrosis, 321, 327 Hypoproteinuria, 261, 266
Growth hormone deficiency (GHD), 389, Hematocrit (Hct), 323t Hyporeflexia, 221, 224
392–393 Hematologic illnesses, 321–339 Hypospadias, 261, 262–263, 262f
Gums, 96 acute lymphoblastic leukemia, 321, 328–331 Hypotelorism, 89, 95b
hemophilia, 321, 327–328 Hypotension, 93
iron-deficiency anemia, 321, 322, 324 Hypothermia, 170
H overview of, 321–322 Hypotonic dehydration, 221, 225
H. influenzae type b (Hib), 279 sickle cell disease, 321, 324–327 Hypovolemic shock, 157, 163
HAART (highly active antiretroviral therapy), Hematology, 321
182 Hemoconcentration, 261, 266
Hair, assessment of, 94 Hemoglobin, 322, 323t, 325 I
Haj, 1, 3 Hemoglobin A1C, 394 Ibuprofen, 345
Halal, 1, 3 Hemophilia, 321, 327–328 Identity vs. role confusion, 76–77
Hand hygiene, 195 Hemophilus influenzae type b (Hib), 197, 419 IgA, 180
Hard palate, 96 Hepatitis A, 208t–209t IgE, 180, 184
Head, assessment of, 94 Hepatitis A vaccine, 197 IgG, 180
Head circumference, 11, 12, 12f, 30, 46, 93–94 Hepatitis B, 198t–199t IgM, 180
Head injuries, 416–417 Hepatitis B vaccine, 20t, 196 Ileum, 238
Head lag, 89, 94 Hepatitis C, 210t–211t Ileus, 237
Health history, 91 Hepatotoxicity, 165 Imaginary play, 47, 48–49
Health maintenance, 80 Heterosexuality, 77 Immune globulin, 310
Health promotion Hide and seek game, 31 Immune response, 179–180
adolescents, 77–79 Hinduism, 3 Immune system
defined, 11 Hirschsprung’s disease, 237, 248–249 overview of, 179
infants, 16–17 Hirsutism, 89, 94 physiology of, 179–180
preschoolers, 47–48 Hispanics, 4 Immunity
school-age children, 63–64 Histamine, 184 active, 179, 180
toddlers, 32–35 HIV. See Human immunodeficiency virus passive, 179, 180
Health screenings (HIV) Immunizations
See also Screening tests Hospitalization adolescents, 81
for adolescents, 81, 81f dying child and, 119 immunity acquired from, 180
for preschoolers, 50 infection control and, 121 infants, 19–20, 20t
for school-age children, 66–67 nursing care during, 113–128 for infectious diseases, 196–197
for toddlers, 37 pain management during, 115–117, 117t preschoolers, 50
Health-care professionals, when to see, 19b play during, 118 schedules, 196
Pinworms, 237, 241–242, 241b, 242f medication administration to, 140 Receptive language development, 13
PKU. See Phenylketonuria (PKU) nutrition for, 47–48 Rectal temperature, 13, 47, 92
Plagiocephaly, 11, 17 overview of, 45 Rectum, 238
Platelets, 323t pain management in, 117t medication administration via, 145
Play parent education for, 47–51 Red blood cells (RBCs), 322, 323t, 325f
associative, 45, 48, 64 physical assessment of, 90 Red reflex, 89, 94, 468
cooperative, 64 play and toys for, 48–49 REEDA Assessment, 237
during hospitalization, 118 safety issues for, 49–51 Refeeding syndrome, 433
imaginary, 47, 48–49 senses, 47 Reflexes, 14t, 101t–103t
infants, 17, 17t sleep for, 48 Regression, 118
parallel, 29, 34 supervision of, 49 Religion, 2–3
preschoolers, 48–49 vital signs, 47 Renal system, 223
school-age children, 64 Prescription medications, poisoning by, Renin, 266
toddlers, 34 165 Renin-angiotensin system (RAS), 221, 223
using, during physical assessment, 90 Preterm babies, 322 Respiration, 222
Playrooms, hospital, 118 Preventive health care, for toddlers, 37 Respiratory acidosis, 227, 228
Pliocytic astrocytoma (PA), 421 Primary health-care provider, medication Respiratory alkalosis, 227–228, 228–229
Pneumococcal conjugate vaccine (PCV), 197, orders by, 129 Respiratory illnesses, 277–297
279 Primary teeth, 13, 96f asthma, 277, 287–289
PO medication administration, 139–140 Prodrome, 195 bronchiolitis, 277, 284–285
Pocket Concussion Recognition Tool, 417 Protease inhibitors (PIs), 183t croup, 282–283
Poison control center (PCC), 166 Protective equipment, 195–196 cystic fibrosis (CF), 277, 285–287
Poisoning Protest, 113, 114b diagnostic tests for, 277–278
acute, 165–167 Pseudostrabismus, 11, 13 epiglottitis, 277, 282–283
care for common, 167t Psychological assessment, 100 otitis media, 277, 278–280
chronic heavy metal, 167–170 Psychosocial development, 9 overview of, 277–278
lead, 19, 167–170, 451 adolescents, 76–77 pharyngitis, 277, 280–282
prevention of, 49, 50, 65, 79 defined, 11 Respiratory medications, administration of,
threats for, 18, 37 infants, 15 144–145, 145f
Polio vaccine, 197 preschoolers, 46–47 Respiratory rate
Poliomyelitis, 202t–203t school-age children, 62 adolescents, 76
Polycythemia, 305b toddlers, 31–32 assessment of, 92–93
Polyhydramnios, 237, 246 Psychosocial disorders, 433–450 infants, 13
Postconventional morality, 77 attention deficit hyperactivity disorder, preschoolers, 47
Posterior fontanel, 12, 12f, 94 433–434 school-age children, 60
Postexposure prophylaxis, for HIV, 182 child abuse/neglect, 438–441 toddlers, 30
Posture, 91t eating disorders, 434–436 Respiratory syncytial virus (RSV), 284
Posturing, 305b overview of, 433 Respiratory system, 277–278, 278f
decerebrate, 407, 419, 419f substance abuse, 436–437 Responsiveness, 91t
decorticate, 407, 419, 419f suicide, 437–438 Restraint, physical, 120–121, 121f
tripod, 282, 287 Puberty Reticulocytes, 323t
Potassium (K), 223, 224, 306 beginning of, 61 Retina, 94
Potassium chloride (KCl), 226 changes during, 73–75 Retinoblastoma, 467, 470–471, 470f
Precocious development, 59, 61 precocious, 389, 392 Retroviruses, 181
Precocious puberty, 389, 392 Pubic hair, 74f Reversibility, 59, 62
Prefrontal cortex, 433 Pulmicort (budesonide), 288 Reye syndrome, 197, 308, 407, 418–419
Prehypertensive, 89, 93 Pulmonary function tests, 277 Rheumatic fever, 280, 307–309
Prenatal screening, 452, 453, 455f Pulmonic stenosis, 303t RICE (rest, ice, compression, elevation), 364,
Preoperational thought, 32, 47 Pulmozyme, 286 368
Pre-pubertal stage, 75 Pulse, 92 Rice cereal, 16
Preschoolers altered, 305b Rifampin (Rifadin), 347t
dentition in, 47 assessment of, 158–159 Ringworm, 347–348, 347f
development Pulse oximetry, 93, 277 Risk for complicated grieving, 163b
biological, 45–46 Pupils, 95 Risk-taking behavior, 77, 80
cognitive, 47 Pustules, 346–347 Ritalin (methylphenidate), 434
language, 47 Pyloric stenosis, 237, 250–251 Rituals, 31, 32, 33, 48
moral, 47 Pyloromyotomy, 237 ROME (respiratory opposite/ metabolic equal),
motor, 47 228
psychosocial, 46–47 Rooting reflex, 14t, 102t
discipline of, 50 R Roseola (sixth disease), 212t–213t
disease prevention in, 49–51 Racial groups, 3–4 Rotavirus, 238
health promotion in, 47–48 RAS. See Renin-angiotensin system (RAS) Rotavirus vaccine, 196, 239
health screenings for, 50 Rash Rubella (German measles), 204t–205t
IM injections to, 141–143 diaper, 341–342, 343f Rubeola (measles), 204t–205t
immunizations for, 50 maculopapular, 341, 342 Rule of 9s, 351
loss of control issues for, 115t vesicular, 341, 344 Russell’s sign, 433
Sunscreen, 37, 79, 352 Tinea infections, 347–348, 347f Tympanic membrane, 97
Supplements. See Nutritional supplements Tobi (tobramycin), 286 Type 1 diabetes mellitus, 393–396
Support systems, 5 Toddlerhood, 29–44 Type 2 diabetes mellitus, 396–397
Swimming safety, 65, 79 Toddlers
Synthesis, of vitamins, 238 dentition in, 30
Synthroid (levothyroxine), 391 development U
Syrup of ipecac, 166 biological, 29–31 Undescended testes. See Cryptorchidism
Systemic lupus erythematosus (SLE), 179, cognitive, 32 Upper airway, 277, 278f
183–184 language, 31, 32 Ureters, 261
Systolic blood pressure, 93 moral, 32 Urethra, 261
motor, 31 Urinary incontinence, 263–264
psychosocial, 31–32 Urination
T discipline of, 34–35 assessment of output, 99
T cell, 179, 180, 323t disease prevention in, 35–37 minimum outputs, 100t
Tachycardia, 92, 305b health promotion in, 32–35
Tachypnea, 305b IM injections to, 141–143
Talking. See Language development immunizations for, 37 V
Tanner scale, 59, 61, 73–75, 74f, 98, 99 loss of control issues for, 115t Vaccines. See Immunizations
Tantrums, 29, 33, 34–35, 50 medication administration to, 140 Vaginal discharge, 100
Tape test, for pinworms, 241, 242f pain management in, 117t Varicella (chickenpox), 206t–207t
Taste, 31, 47 parent education for, 31–37 Varicella (VAR) vaccine, 197
Tattoos, 80 physical assessment of, 90 Vaso-occlusive crisis, 321, 325, 326
Tdap (tetanus, diphtheria, acellular pertussis) play and toys for, 34 Vastus lateralis injection site, 141f, 142
vaccine, 196–197 safety issues for, 35–37 Vegans, 78
Teenagers. See Adolescence senses in, 31 Vegetarianism, 78
Teeth sleep needs of, 33 Ventricular septal defect (VSD), 300, 301t
See also Dental care tantrums by, 29, 33, 34–35 Ventriculoperitoneal (VP) shunting, 407, 413–
development of, 96f toilet training, 33–34, 37 414, 414f
impacted, 76 vital signs, 30 Ventrogluteal injection site, 142, 142f
loss of primary, 59, 60 walking by, 30f, 31 Vertebrae, 407
primary, 13, 96f Toilet training, 33–34, 37 Vertically acquired passive immunity, 179,
secondary, 96f Tongue, 96, 277 180
toddlers, 30 Tonic neck reflex, 14t, 102t Vesicant, 321, 329
wisdom, 76 Tonic-clonic seizure, 407, 418 Vesicular rash, 341, 344
Tegretol (carbamazepine), 408 Tonsillectomy, 280, 281, 281b Violence, 79, 164
Telegraphic speech, 29, 31 Tonsillitis, 280–282 Viruses
Temperature Tonsils, 96–97 HIV, 180–183
adolescents, 76 Torus fracture, 366t retroviruses, 181
assessment of, 92 Total brain injuries (TBIs), 416–417 Vision
axillary/armpit method of taking, 13 Toys binocular, 95
infants, 12–13 during hospitalization, 118 color, 95
normal range, 12 infants, 17, 17t infants, 13, 95
preschoolers, 47 preschoolers, 48–49 preschoolers, 47, 95
rectal method of taking, 13, 47, 92 school-age children, 64 school-age children, 60, 67
school-age children, 60 toddlers, 34 screening tests, 50, 60, 67, 81, 94–95, 467
toddlers, 30 Trachea, 277 toddlers, 31
Tendons, 363 Tracheoesophageal fistula, 237 Vital signs
Testes, 74f Traction, 365, 367, 367f, 368f, 369 adolescents, 76
cryptorchidism, 261–262 Traditional family, 1 assessment of, 92–93
Testosterone, 73 Transepidermal diffusion, 222 infants, 12–13
Tetanus, 200t–201t Transition object, 29, 31 preschoolers, 47
Tetany, 221 Transposition of the great vessels (TGV), 302t school-age children, 60
Tetracycline doxycycline (Vibramycin), 347t Trauma, 157, 163–165 toddlers, 30
Tetralogy of Fallot (ToF), 302t Travel safety, 19, 36, 49 Vitamin B12, 238
Therapeutic holding, 113, 120 Tricuspid atresia (TA), 302t Vitamin C, 168, 324
Third-degree burns, 352f, 352t Trimethoprim-sulfamethoxazole (Bactrim), Vitamin D, 17, 78
Thirst, 222 347t Vitamin K, 238
Thrill, 89, 98 Trisomy 21, 329, 451, 454–456, 454f Vitamin supplements, 33
Throat, 277 Trunk incurvation reflex, 103t Vitamins, synthesis of, 238
assessment of, 95–96, 96–97 Trust vs. mistrust, 15 Vomiting, 222, 238, 240–241, 240t, 306
Thrombocytes, 323t Tumors Von Willebrand disease, 327
Thrush, 341, 342, 343 brain, 421–422
Thyroid gland, 390–391 neuroblastomas, 422–432
Thyroid-stimulating hormone (TSH), 389, 390 retinoblastomas, 467, 470–471, 470f W
Thyroxine (T4), 389, 390 Wilms’, 261, 267–268 Waddell’s triad, 157, 164
Time out, 35 Tylenol, 165, 167t Walking, by toddlers, 30f, 31