Ch. 71 Fundamentals of Pediatric Nursing

Question 1

________ a scaly scalp condition in infants that is also known as cradle cap.

Answer 1

Seborrhea

Question 2

One site for venipuncture in infants is the femoral or _________ area.

Answer 2

Thigh

Question 3

Catheterization can introduce _________ into the bladder, causing urinary tract infections.

Answer 3

Bacteria

Question 4

Pediatrics requires knowledge of developmental _____ to help determine developmental delays in children.

Answer 4

Milestones

Question 5

What are the signs of pediatric respiratory distress?

Answer 5

The following are signs of pediatric respiratory distress:
* Restlessness, apprehension, panic
* Tachycardia
* Tachypnea
* Nasal flaring
* Wheezing
* Stridor
* Change in color (e.g., pallor, cyanosis)
* Expiratory grunt
* Retractions: substernal, subcostal, intercostal, suprasternal, and supraclavicular
* Gasping and shallow, labored breaths
* Head bobbing

Question 6

Observe child for dryness, because the oxygen is not humidified.

Answer 6

Isolette

Question 7

Monitor placement so that gas does not blow directly onto the baby’s face.

Answer 7

Hood

Question 8

Make sure nares are clear of mucus.

Answer 8

Nasal Cannula

Question 9

Change linen and clothing frequently.

Answer 9

Tent

Question 10

Write the correct sequence that occurs when a blood sample is to be taken from the jugular vein of a very young child.

1. Restrain the child with the head extended over the table’s edge.
2. Note any signs of swelling or bleeding.
3. Assist the healthcare provider by holding the child.
4. Pad the table edge and hold the child perfectly still

Answer 10

3 Assist the healthcare provider by holding the child.

1 Restrain the child with the head extended over the table’s edge.

4 Pad the table edge and hold the child perfectly still

2 Note any signs of swelling or bleeding.

Question 11

What is is the goal of pediatric nursing?

Answer 11

The goal of pediatric nursing is to prevent disease, disorders, and disability in the child. Preventive healthcare helps to monitor growth rates and achievement of developmental milestones and provides opportunities for early detection of health problems.

Question 12

Why is immunization needed?

Answer 12

Immunization provides people with temporary or permanent protection against certain diseases. Immunization schedules start shortly after birth and continue at various stages of growth on a regular basis. The requirements of immunization change as the availability of vaccines increases.

Question 13

What cross-cultural considerations should the nurse keep in mind when communicating with children at the healthcare facility?

Answer 13

When communicating with children and families from a culture that is different from that of most clients or nurses, the nurse should allow the child to be with other children. The nurse can make children feel comfortable and relaxed by using pictures of common items to help them to commu- nicate their needs, thereby making them feel less isolated. The family caregivers could translate for the child.

Question 14

What is gavage feeding?

Answer 14

Gavage feeding is feeding through a gavage (gastrostomy) button. The gavage button is relatively flat on the abdominal wall and connects to a tube that leads into the stomach. A syringe or tube-feeding bag is attached to an adapter and is primed with the tube feeding. The adapter is then attached to the button, and the tube feeding is administered. Bolus feeding is administered over 30 minutes, using only gravity. Infusion pumps are used for continuous feedings.

Question 15

A parent arrives at the healthcare facility with their 1-month-old infant for a checkup.

a. What should the nurse observe generally when caring for this child?

Answer 15

A nurse caring for an infant should observe the following:

• Whether family caregivers hold or cuddle the infant
• Cleanliness of the infant
• Infant’s response to painful stimuli
• Infant’s appearance of health or illness

Question 16

What specific observations should the nurse make?

Answer 16

A nurse caring for an infant should specifically make note of the following:

• Movement of extremities
• Activity and alertness
• Skin color, warmth, texture * Infant’s cry
• Respiratory status
• Fontanels
• Developmental milestones

Question 17

A nurse is to care for a 3-year-old child who is admitted to the healthcare facility.

a. How can the nurse help the family and the child during their hospital experience?

Answer 17

A. The nurse can arrange for the caregiver to remain with the child during the hospital experience. This helps to reduce the stress on the child and the caregiver. If the caregiver is unable to remain with the child, the nurse can provide a toy or a doll to the child and assure the child that the caregiver will return. The object becomes a physical reminder that the family caregiver will return. In this way, the nurse can help to reduce anxiety in the child.

Question 18

What factors affect the reactions of family caregivers?

Answer 18

The nurse caring for the child should be aware that the following factors affect the reactions of the family caregivers when in the healthcare facility:
* The seriousness of the child’s illness
* The immediate threat to the child’s life
* The situation of the family
* Ego resources of the family caregivers
* The family’s former experiences with illness
and hospitalization
* The family’s style of coping with stress
* The caregivers’ beliefs and values

Question 19

A nurse is caring for a toddler at the healthcare clinic during one of their well-child visits.

a. What should the nurse document during the well-child checkup?

Answer 19

During the well-child check-up of a toddler, the nurse should document the following:

• Age of weaning from breast or bottle to cup
• Ages at which toilet training was started and
  completed
• Language development
• Play patterns and activities
• Sleep patterns

Question 20

What teaching should the nurse provide the family caregivers?

Answer 20

The nurse should encourage caregivers to begin dental checkups for toddlers as early as
12 months of age. The nurse should stress the need for safety, because toddlers are very mobile
but lack the judgment to protect themselves.

Question 21

What observations should the nurse make during the visit?

Answer 21

The nurse should observe caregiver–toddler
interation and discuss with the family caregivers their child’s behavior patterns and the type of discipline they use at home.

Question 22

Which should the nurse do when applying the clove hitch restraint to a child?

a. Apply the restraint directly to the arm.
b. Check the extremity every 2 hr.
c. Take off the restraint every 4 hr.
d. Tie a knot when applying the device.

Answer 22

Answer: d

Rationale: The nurse should tie a knot when applying the device so that it does not become too tight. The nurse should not apply a restraint directly on the arm but should apply padding under the restraint to reduce skin irritation. The nurse should check the extremity hourly, and not every 2 hours, for circulation and signs of skin breakdown. The nurse should remove the restraint every 2 hours and allow the child to exercise the extremity.

Question 23

A nurse is caring for an 8-year-old child with diarrhea. Which intervention should the nurse perform when caring for the child?

a. Observe the feet for signs of edema.
b. Observe the child for skin excoriation.
c. Measure a rectal temperature for accuracy.
d. Provide plenty of solids to prevent dehydration.

Answer 23

Answer: b

Rationale: The nurse should observe the child for skin excoriation when caring for the child with diarrhea. The nurse should observe the child for signs of dehydration and not edema. Rectal temperature should not be taken for a child with diarrhea; a tympanic or oral temperature should be taken. A child with diarrhea should be given plenty of liquids that can be easily absorbed by the system to overcome dehydration.

Question 24

A child has been admitted to the healthcare facility for surgery. The nurse observes that the child is inactive, miserable, and clutching her blanket. The nurse understands that the child is in which stage of anxiety?

a. Despair
b. Denial
c. Detachment
d. Protest

Answer 24

Answer: a

Rationale: The nurse understands that the child is in the despair phase of separation anxiety. A child in the denial or detachment phase of separation anxiety pretends to reject family caregivers, when actually the need for caregivers is more intense than ever. A child who cries and reacts aggres- sively, demanding her family caregivers, is in the protest phase of separation anxiety.

Question 25

Which should the nurse do when measuring the blood pressure of a child?

a. Ensure that the width of the cuff is half the width of the child’s arm.
b. Ensure that the bladder of the cuff encircles the arm without overlapping.
c. Know that thigh pressure is approximately 10 mm Hg higher than arm pressure.
d. Know that radial blood pressure is 20 mm Hg lower than that of the brachial artery.

Answer 25

Answer: b

Rationale: The nurse should ensure that bladder of the cuff encircles the child’s arm without overlapping. The nurse should ensure that the width of the cuff is approximately two-thirds of the upper arm, and not half the width of the child’s arm. The nurse must know that thigh pressure is approximately 20 mm Hg higher and not 10 mm Hg higher than arm pressure. The nurse must know that radial blood pressure is 10 mm Hg lower and not 20 mm Hg lower than that of the brachial artery.

Question 26

A nurse is caring for a child with an oral temperature of 103 °F. Which intervention should the nurse follow when providing a sponge bath to the client?

a. Check the child’s temperature every 30 min.
b. Add alcohol or ice for the tepid sponge bath.
c. Maintain the water temperature at 70 °F-85 °F.
d. Stop the sponge bath if the child shows signs of chilling.

Answer 26

Answer: d

Rationale: When caring for a child with an oral temperature of 103°F, the nurse should stop the sponge bath if the child shows signs of chilling. The nurse should check the child’s temperature every 10 to 15 minutes, not every 30 minutes. The nurse should not add alcohol or ice to the sponge bath, because this could lead to hypothermia. Alcohol fumes are irritating and may be inhaled or absorbed through the skin. The nurse should maintain the temperature of the water at 85°F to 95°F, not 70°F to 85°F.

Question 27

Which intervention should the nurse perform with regard to an infant’s bath?

a. Provide a tub bath every day.
b. Wash the eyes after washing the face.
c. Provide daily shampoo to prevent cradle cap.
d. Probe the outer ear canals of the infant.

Answer 27

Answer: c

Rationale: The nurse should provide a daily shampoo to prevent cradle cap. Some children need a shampoo daily to prevent seborrhea, a scaly scalp condition known as cradle cap. The nurse need not provide a tub bath every day; instead, the nurse should wash the child’s face, hands, and diaper area daily. The nurse should clean the eyes first with clear water from the inner to the outer canthus, using a separate cotton ball for each eye, and then wash the rest of the baby’s face. The nurse should not probe the outer ear canals of the infant.

Question 28

A 10-year-old child has just been brought to the nursing unit after abdominal surgery.

Which of the following nursing interventions must the nurse perform for the child? Select all that apply.

a. Assist the child to a side position.
b. Check for return of peristalsis.
c. Evaluate pain and discomfort.
d. Ask the child not to move from bed.
e. Prevent the child from deep breathing.

Answer 28

Answer: a, b, and c
Rationale: The nurse should assist the child to a side position to prevent aspiration. The nurse should check for return of peristalsis; if bowel sounds are absent, the nurse should consult the supervisor regarding administration of fluids or ice, to prevent gas pains. The nurse should encourage the child to move her toes, ankles, and legs (if permitted) to prevent thrombophlebitis. The nurse must ask the child to breathe deeply to prevent postoperative respiratory complications. The abdominal incisional site should be supported with a bath blanket or pillow during the process.

Question 29

Which of the following interventions should the nurse consider when administering medications to a child?

Select all that apply.

a. Tell the child that she has been “good.”
b. Reassure the child that an injection will not hurt.
c. Reassure the child that crying is okay.
d. Keep the time of administration to a minimum.
e. Ensure accuracy in medication administration.

Answer 29

Answer: c, d, and e

Rationale: When administering medication to a child, the nurse should reassure the child that crying is okay, keep the time of administration to a minimum, and ensure accuracy in medication administration. The nurse should not tell the child that she has been “good” or reassure the child that an injection will not hurt; this would mean that the nurse may have to lie to the child.

Question 30

A nurse in the pediatric unit of the healthcare facility may be required to assist in resuscitating a child. Which should the nurse know if required to assist in the procedure?

a. Emergency drugs are calculated according to a child’s age.
b. Drugs are administered based on the circumference of the child’s head.
c. A Broselow tape is used to measure the circumference of the child’s chest.
d. The Broselow system of length may be substituted for weight.

Answer 30

Answer: d

Rationale: The nurse should know that the Broselow system of length may be substituted for weight in an emergency. Emergency drugs are calculated according to a child’s body weight and not by age or the circumference of the child’s head. The Broselow tape is a color-coded system that facilitates the use of correct pediatric drug calculations; it is not used to measure the circumference of the child’s chest.

Question 31

A nurse is evaluating the respiratory status of a child. Which symptoms) may indicate pediatric respiratory distress? Select all that apply.

a. Head bobbing
b. Fever
c. Nasal flaring
d. Wheezing
e. Running nose

Answer 31

Answer: a, c, and d

Rationale: Head bobbing, nasal flaring, and wheezing may indicate pediatric respiratory distress. Fever and a running nose are not indicative of a respiratory problem; they could indicate the flu.