Chapter 22 : Pediatric Nursing interventions and skills Flashcards
- A 16-year-old girl comes to the pediatric clinic for information on birth control. The nurse knows that before
this young woman can be examined, consent must be obtained from which source?
a. Herself
b. Her mother
c. Court order
d. Legal guardian
ANS: A
Contraceptive advice is one of the conditions that is considered medically emancipated. The adolescent is able
to provide her own informed consent.
- The nurse needs to take the blood pressure of a preschool boy for the first time. What action would be best
in gaining his cooperation?
a. Tell him that this procedure will help him get well faster.
b. Take his blood pressure when a parent is there to comfort him.
c. Explain to him how the blood flows through the arm and why the blood pressure is important.
d. Permit him to handle the equipment and see the cuff inflate and deflate before putting the cuff in
place.
ANS: D
A preschooler is at the stage of preoperational thought. The nurse needs to explain the procedure in simple
terms and allow the child to see how the equipment works. This will help allay fears of bodily harm. Blood
pressure measurement is used for assessment, not therapy, and will not help him get well faster. Although the
parent will be able to support the child, he may still be uncooperative. Also, the assessment of blood pressure
may be needed before the parent is available. Explaining to a preschooler how the blood flows through the
artery and why the blood pressure is important is too complex.
- A 4-year-old girl is admitted to outpatient surgery for removal of a cyst on her back. Her mother puts the
hospital gown on her, but the child is crying because she wants to leave on her underpants. What is the most
appropriate nursing action at this time??
a. Allow her to wear her underpants.
b. Discuss with her mother why this is important to the child.
c. Ask her mother to explain to her why she cannot wear them.
d. Explain in a kind, matter-of-fact manner that this is hospital policy.
ANS: A
It is appropriate for the child to leave her underpants on. If necessary, the underpants can be removed after she
has received the initial medications for anesthesia. This allows her some measure of control in this procedure. The mother should not be required to make the child more upset. The child is too young to understand what
hospital policy means.
- Using knowledge of child development, what approach is best when preparing a toddler for a procedure?
a. Avoid asking the child to make choices.
b. Plan for a teaching session to last about 20 minutes.
c. Demonstrate on a doll how the procedure will be done.
d. Show the necessary equipment without allowing child to handle it.
ANS: C
Prepare toddlers for procedures by using play. Demonstrate on a doll but avoid the childs favorite doll because
the toddler may think the doll is really feeling the procedure. In preparing a toddler for a procedure, the child is
allowed to participate in care and help whenever possible. Teaching sessions for toddlers should be about 5 to
10 minutes. Use a small replica of the equipment and allow the child to handle it.
- The nurse is preparing a 9-year-old boy before obtaining a blood specimen by venipuncture. The child tells
the nurse he does not want to lose his blood. What approach is best by the nurse?
a. Explain that it will not be painful.
b. Suggest to him that he not worry about losing just a little bit of blood.
c. Discuss with him how his body is always in the process of making blood.
d. Tell the child that he will not even need a Band-Aid afterward because it is a simple procedure.
ANS: C
School-age children can understand that blood can be replaced. Explain the procedure to him using correct
scientific and medical terminology. The venipuncture will be uncomfortable. It is inappropriate to tell him it
will not hurt. Even though the nurse considers it a simple procedure, the boy is concerned. Telling him not to
worry will not allay his fears.
- A bone marrow biopsy will be performed on a 7-year-old girl. She wants her mother to hold her during the
procedure. How should the nurse respond?
a. Holding your child is unsafe.
b. Holding may help your child relax.
c. Hospital policy prohibits this interaction.
d. Holding your child is unnecessary given the childs age.
ANS: B
The mothers preference for assisting, observing, or waiting outside the room should be assessed, as well as the
childs preference for parental presence. The childs choice should be respected. This will most likely help the
child through the procedure. If the mother and child agree, then the mother is welcome to stay. Her familiarity
with the procedure should be assessed and potential safety risks identified (mother may sit in chair). Hospital
policies should be reviewed to ensure that they incorporate family-centered care.
- A 6-year-old child needs to drink 1 L of GoLYTELY in preparation for a computed tomography scan of the
abdomen. To encourage the child to drink, what should the nurse do?
a. Give him a large cup with ice so it tastes better.
b. Restrict him to his room until he drinks the GoLYTELY.
c. Use little cups and make a game to reward him for each cup he drinks.
d. Tell him that if he does not finish drinking by a set time, the practitioner will be angry.
ANS: C
One liter of GoLYTELY is difficult for many children to drink. By using small cups, the child will find the
amount less overwhelming. Then a game can be made in which some type of reward (sticker, reading another
page of a book) is given for each cup. A large cup of ice would make it more difficult because the child would
see it as too much and ice adds additional fluid to be consumed. Negative reinforcement may work if the child
wishes to be out of his room. A practitioner may or may not be angry if he does not finish drinking by a set
time; this is a threat that may or may not be true. If the child is having difficulty drinking, this would most
likely not be effective.
- A toddler is being sent to the operating room for surgery at 9 AM. As the nurse prepares the child, what is
the priority intervention?
a. Administering preoperative antibiotic
b. Verifying that the child and procedure are correct
c. Ensuring that the toddler has been NPO since midnight
d. Informing the parents where they can wait during the procedure
ANS: B
The most important intervention is to ensure that the correct child is going to the operating room for the
identified procedure. It is the nurses responsibility to verify identification of the child and what procedure is to
be done. If an antibiotic is ordered, administering it is important, but correct identification is a priority. Clear
liquids can be given up to 2 hours before surgery. If the child was NPO (taking nothing by mouth) since
midnight, intravenous fluids should be administered. Parents should be encouraged to accompany the child to
the preoperative area. Many institutions allow parents to be present during induction.
- A 5-year-old child returns from the pediatric intensive care unit after abdominal surgery. The orders state to
monitor vital signs every 2 hours. On assessment, the nurse observes that the childs heart rate is 20 beats/min
less than it was preoperatively. What should be the nurses next action?
a. Follow the orders and check in 2 hours.
b. Ask the parents if this is the childs usual heart rate.
c. Recheck the pulse and blood pressure in 15 minutes.
d. Notify the surgeon that the child is probably going into shock.
ANS: C
In a 5-year-old child, this is a significant change in vital signs. The nurse should assess the child to see if his
condition mirrors a drop in heart rate. The assessment and vital signs should be redone in 15 minutes to
determine whether the childs condition is stable. When a disparity in vital signs or other assessment data is
observed, the nurse should reassess sooner. Most parents will not know their childs heart rate. It is important to
determine how the child is recovering from surgery. The nurse should collect additional information before
notifying the surgeon. This includes blood pressure, respiratory rate, and pain status.
child continually forgets to take the medicine unless reminded. What nursing action is most appropriate to
promote adherence to the medication regimen?
a. Establish a contract with her, including rewards.
b. Suggest time-outs when she forgets her medicine.
c. Discuss with her mother the damaging effects of her rescuing the child.
d. Ask the child to bring her medicine containers to each appointment so they can be counted.
ANS: A
Many factors can contribute to the childs not taking the medication. The nurse should resolve those issues such
as unpleasant side effects, difficulty taking medicine, and time constraints before school. If these factors do not
contribute to the issue, then behavioral contracting is usually an effective method to shape behaviors in
children. Time-outs provide negative reinforcement. If part of a contract, negative consequences can work, but
they need to be structured. Discussing with her mother the damaging effects of her rescuing the child is not the
most appropriate action to encourage compliance. For a school-age child, parents should refrain from nagging
and rescuing the child. This child is old enough to partially assume responsibility for her own care. If the child
brings her medicine containers to each appointment so they can be counted, this will help determine if the
medications are being taken, but it will not provide information about whether the child is taking them by
herself.
