Exam 3 Flashcards
What statements are true about fetal lung fluid (choose all that apply):
1) About 65% is absorbed by time of birth
2) It restricts alveoli
3) Remainder is expelled in the birthing process
1) and 3) are correct
All of the following statements are true about surfactant in newborns EXCEPT:
1) It reduces surface tension within the alveoli
2) It starts to develop around 32-34 weeks gestation
3) Secretions increase during labor and immediately after birth
2) is the exception, surfactant does not develop at 32-34 weeks, it develops starting around 24-25 weeks of gestation
Which explanation of the vitamin K injection for newborns by the nurse is correct?
1) Necessary for production of clotting factors
2) Necessary for the production of platelets
3) Necessary for the production of red blood cells
1) is correct, vitamin K helps synthesize clotting factors within the liver
What is a common sign of newborn hypothermia?
1) Shivering
2) Acrocyanosis
3) Hyperglycemia
2) acrocyanosis, the body is pulling warm blood away from the extremities to the trunk to stay warm
All of the following are risk factors for newborn hypoglycemia except:
1) Paternal diabetes
2) SGA, LGA, IUGR
3) Cold stress or birth stress
1) Paternal diabetes is the exception, maternal diabetes could cause newborn hypoglycemia but not paternal (of the father)
Placing a war blanket or sheet on the scale prior to weighing a newborn prevents which type of heat loss?
1) Convection
2) Radiation
3) Conduction
4) Evaporation
1) Conduction is correct, the surface of the skin in contact with a cool surface will conduct, or transfer heat away to the cooler area
- Convection = loss of heat to cool air
- Radiation = loss of heat to a cool object nearby, but not in contact
- Evaporation = moisture heat loss from skin
A nurse in the newborn nursery receives handoff report in the morning. Which newborn should the nurse assess first?
1) Newobrn with axillary temp of 96.2F
2) Newborn with a glucose of 52 mg/dL
3) Newborn with RR of 58 breaths/minute
1) should be assessed first, the newborn with a low temperature is displaying a sign of infection or heat loss
- normal: 97.5-99.7 F (Axillary)
Which of the following statements is true about non-shivering thermogensis (NST)?
1) It increases heat production by 50%
2) It is a tertiary source of heat production in newborns
3) It metabolizes brown fat present in newborns to produce heat
3) It metabolizes brown fat is correct
- It is the primary source of heat production
- It increases heat production by 100%
First time parents are concerned that their 3-day-old infant skin is looking “yellow”. The nurse’s explaination of physiologic jaundice should include:
1) Physiological jaundice occurs during the first 24 hours of life and bilirubin levels falls on their own
2) Physiological jaundice is common and bilirubin levels peak between days 2 and 4 of life
3) Physiologic jaundice may be caused by ABO imcompatability between mother and infant
2) is the correct answer, physiologic jaundice is common, peaks after 2-4 days and slowly returns to normal by days 10-12
- Physiologic jaundice does not occur during the first 24 hours, if it occurs in the first day, this is an indication of pathologic jaundice
- ABO incompatability can cause jaundice, but it would not be physiologic, it would be pathologic jaundice
A prime indicator of neonatal spesis is:
1) Fever
2) Hypothermia
3) Hyperglycemia
2) hypothermia is correct, low temperature is a more accurate indicator of infection in newborns
- Fever is less of an indicator of spesis compared to hypothermia, but still can be an indicator of infection
- Hyperglycemia is not an indicator, hypoglycemia is more likely to be an indicator of spesis
Which of the following would be concerning in a newborn:
1) Not voiding within first 12 hours
2) A thick, tarry green-black stool at 24 hours
3) A blood glucose of 35
3) is correct, BG of 35 is low, it should be above 40 mg/dL
When are interventions always required for an APGAR score:
1) 7
2) 6 or below
3) 8-10
3) 6 or below always requires intervention
What does a ballard assessment determine?
1) normal reflexes
2) gestational age
3) gestational size
2) ballard assessment determines gestational age
- it is composed of looking at the external physical characteristics and neurologic characteristics
Nightmares and animism are devlopmentally typical in which age group:
1) Toddler
2) Pre-school
3) School-age
2) they are typically common in pre-school age children
What method would be considered most accurate and is recommended for screening temperature in infants under 1 month of age?
1) Rectal
2) Temporal
3) Tympanic
4) Axillary
1) Axilliary is the most accurate
When palpating the abdomen abdomen of a 7-year-old who is complaining of pain, what is the most appropriate nursing action?
1) Palpate most painful area first
2) Palpate least painful area first
3) Palpate for rebound tenderness
4) Percuss instead of palpate
2) Palpate least painful area first
How would you start a visit with a two year old?
1) Engage first with the patient’s caregiver
2) Jump right in and take a temperature
3) Pick up toddler and bring them to the exam table
1) Engage with patient’s caregiver first
What heart sound is produced by vibrations within the heart chambers or in the major arteries from the back-and-forth flow of blood?
1) S1, S2
2) S3, S4
3) Murmur
4) Physiologic splitting
3) murmur
The nurse palpated the anterior fontanel of a 14-month-old infant and found that it was closed. What dose this finding indicate?
1) This is a normal finding
2) This finding indicates premature closure of cranial sutures.
3) This is abnormal and the child should have a developmental evaluation.
1) This is a normal finding
Which measurement is not indicated for a 4-year-old well-child examination?
1) Blood pressure
2) Weight
3) Height
4) Head circumference
4) Head circumference, head circumference is only 0-36 months
What is the main event during birth that causes transition for the baby to extrauterine life?
Disruption of the placental circulation system
**What does fetal lung fluid do and how much is absorbed by birth?
- Fetal lung fluid helps to expand the alveoli and aids in lung development
- 65% is absorbed by birth (80-10 mL) remain
**What is surfactant and what does it do?
When does it begin to develop?
- Surfactant: a detergent-like lipoprotein that reduces surface tension in the alveoli of the lungs helping to keep them open
- It is detectable by 24-25 weeks
**What happens without surfactant? When does it increase and what is one condition that can delay production?
- Without surfactant the alveoli would collapse on exhale
- It increases during labor and just after birth
- Diabetes can delay surfactant production
What are the four triggers for newborn respiration? Describe them.
1) Chemical: decreased pH, increased CO2, changes trigger chemoreceptors and medulla (respiratory center)
2) Mechanical: chest is compressed during birth expelling fluid; the recoil after compression allows for first breath
3) Thermal: skin senses drop in environmental temperature, triggers respiratory center
4) Sensory: touch, light, sound, small, and discomfort stimulate respiratory center
What are the 4 factors that contribute to newborn heat loss?
1) Thin skin with blood vessels close to the surface
2) Little subcutaenous (white) fat
3) 3x greater surface area to body mass
4) Rate of heat loss 4x greater than adults
True or false: convection heat loss occurs when nearby cooler objects not touching the infant cool the infant by taking heat away
False: this would be radiation heat loss, convection is heat loss due to cooler circulating air
**What are the four types of infant heat loss?
1) Evaporation
2) Conduction
3) Convection
4) Radiation
**What is evaporation heat loss and how can you prevent it?
Evaporation: heat loss due to water or moisture converted to vapor cooling the infant
Prevention:
- keep infant dry
- minimize bath exposure
- remove wet diapers
What is conduction heat loss and how can you prevent it?
Conduction: heat loss due to the infant directly touching a cool surface
Prevention:
- place down a towel or blanket on surfaces
- prewarmed sheets
- cover scales
What is radiation heat loss and how can you prevent it?
Radiation: radiation heat loss is when the infant loses heat due to cooler objects nearby
Prevention:
- keep away from cold outside walls
- cover if stable
What is convection heat loss and how can you prevent it?
Convection: heat loss due to heat flowing from the surface of the body to cool surrounding air or circulating air
Prevention:
- avoid air currents
- babies inside incubator if possible
- provide warm O2/air
- minimize openings of isolete or incubator
What is the rule of thumb when covering a newborn?
1) Give the baby 2 more layers than what you are wearing
2) Take away 2 layers from the baby than what you are wearing
3) Give the baby 1 more layer than what you are wearing
4) Take away 1 layer from the baby than what you are wearing
3) Give the baby 1 more layer than what you are wearing
What are signs of a cold baby?
1) Hypoglycemia (body metabolism increases)
2) Restless
3) Crying
4) Increased flexion and activity
5) Acrocyanosis
Think fussy and blue
What is acrocyanosis and is it normal? What might it indicate?
Acroycyanosis: peripheral vasoconstriction leading to a pale, blue color
- May be an early sign of being cold
What is the primary source of heat production in a newborn?
Nonshivering thermogenesis
What is nonshivering thermogenesis?
Nonshivering thermogenesis is the primary source of heat production in a newborn by metabolising brown fat/brown adipose to produce heat
How much can heat production increase thorugh nonshivering thermogenesis in newborns?
Can increase by 100%
What time does brown fat increase and when does it disappear?
Increases: 2-5 weeks after birth
Disappears: 26-30 weeks after birth
When is a baby’s immune system activated?
1) Prenatally
2) Perinatally
3) Postpartum
3) Postpartum
- A baby’s immune system is not activated until after birth
True or false: Hypothermia rather than hyperthermia is a more accurate indicator of newborn infection
True: hypothermia, or being more cold, is a more common indicator of infections in newborns
What are signs and symptoms of newborn infection?
1) Hypothermia
2) Changes in activity level
3) Muscle tone changes
4) Color changes
5) Feeding changes
Less active, cold, doesn’t want to feed
What is passive immunity?
Passive immuinity: when IgG crosses the placenta in the third trimester providing immunity to bacteria and virsus the pregnant person is immune to
Who might be more susceptible to infection?
1) Pre-term newborn
2) Term newborn
3) Post-term newborn
4) Large for gestational age newborn
1) Pre-term newborn may be more susceptible to infection because they lack passive immunity
What physiologic function helps newborns continue passive immunity?
Breastfeeding allows passive immunity to continue
How long does passive immunity last for?
Weeks-months, up to 1 year
What does IgM protect against? When does it begin?
IgM: protects against gram negative bacteria
Begins: Increases rapidly a few days after birth
What does IgA protect? When does it begin?
IgA: protects the GI and respiratory system
Begins: at about 2 weeks of age
Which immunoglobulins are found in breast milk? (select all that apply)
1) IgG
2) IgM
3) IgE
4) IgA
1) IgG
2) IgM
4) IgA
Is gastric emptying quicker for breastfed infants or formula fed infants?
Gastric emptying is quicker for breastfed infants
Why may regurgitation occur in newborns?
They have a relaxed cardiac or gastroesophageal sphincter
Why may stooling occur in newborns? What does this allow them to do?
Stooling: increased gastric coil reflex which is stimulated during stomach filling causing intestinal peristalsis
- Allows them to eat more!
What enzymes are infants most deficient in?
pacreatic amylase and lipase
Why is breastmilk more digestable than formula for newborns?
Breastmilk contains lipase making fat digestion easier. There is no lipase in formula.
What are two well-digested nutrients in newborns?
Protein and lactose, both found in their milk diet
When does glucose maintenance switch to the liver and how is it stored fetally?
1) Glucose maintenance switches in the 3rd trimester
2) Storage: As glycogen for use after birth
What organ conjugates bilirubin?
The liver
What is the primary source of bilirubin?
1) Apoptosis
2) Hemolysis
3) Glycogenolysis
4) Lipolysis
2) Hemolysis
- When red blood cells are destryoed or lyse, bilirubin is a byproduct
Why is bilirubin dangerous to newborns?
Bilirubin is fat soluble -> aborbed by sub Q fat -> creates jaundice -> leads to accumulation in brain tissue -> bilirubin encephalopathy -> kernicticus (if left untreated) causing permanent neurologic injuruy
Why does bilirubin need to be conjugated?
It needs to be conjugated to become water soluble to be excreted from the body
What other roles does the liver play in the newborn?
1) Iron storage
2) Metabolism of drugs
3) Production of clotting factors
Where is iron stored in the last months of pregnancy? (select all that apply)
1) Liver
2) Kidney
3) Spleen
4) Pancreas
5) Gallbladder
1) Liver
3) Spleen
- Iron is stored in the liver and spleen during the last months of pregnancy
True or false: Breastfed infants do not need iron supplementation until 4-6 months old?
True: breastfeeding provides enough iron for the first months of life, but newborns may need iron supplementation after 6 months
Do non-breastfed infants need iron-fortified milk?
Yes, they need iron fortification if not breastfed
**What is physiologic jaundice and when does it typically disappear? Is it normal?
Physiologic jaundice: is transient hyperbilirubinemia that occurs 2-4 days after birth when bili levels peak at 5-6mg/dL then falls days 5-7
- It is a normal process
What perentage of term and pre-term infants have physiologic jaundice?
1) 25% of term and 40% of pre-term
2) 5% of term and 10% of pre-term
3) 30% of term and 50% of pre-term
4) 50% of term and 80% of pre-term
4) 50% of term and 80% of pre-term infants experience physiologic jaundice
What causes physiologic jaundice?
The accelerated destruction of fetal RBCs and increased reabsorption of bilirubin by the liver
What is early-onset breastfeeding jaundice? When does it occur?
Early-onset breastfeeding jaundice: Jaundice that occurs primarily d/t insufficient fluid intake
When: Within the first week of life (first 2-3 days usually)
What are risk factors for for early-onset breastfeeing juandice?
1) Sleepy
2) Poor suck
3) Not nursing frequently
Think of poor nursing
What nursing interventions can be given for early-onset breastfeeding jaundice? (Select all that apply)
1) Increase fluid intake
2) Decrease fluid intake
3) Increase solid food intake by giving canned or homemade baby fooods
4) Help mom with breastfeeding to stimulate milk production
1) Increase fluid intake
4) Help mom with breastfeeding to stimulate milk production
How much does breastfeeding increase the risk for early-onset breastfeeding jaundice?
Increasd risk by 3-6x
What is late-onset breastfeeding jaundice? When does it occur and how long does it last for
Late-onset breastfeeding juandice: True breast milk jaundice where the newborn holds onto bilirubin longer because substance in materenal milk may increase absorption of bilrubin from the intestine or interfere with conjugation
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When: 3-5 days of life
Duration: 3 weeks to 3 months
What is the treatment progress for late-onset breastfeeding jaundice?
1) Monitor total serum bilirubin (TSB) for 8-12 feeds over 24 hours
- If TSB is too high initiate phototherapy; breastfeeding continues
- If dangerously high initiate formula feeding for 1-3 days while the parent pumps to maintain milk supply
What is pathologic jaundice?
Pathologic jaundice: jaundice that occurs within 24 hours of birth and is not related to physiologic or breastfeeding - a lot of hemolysis is happening
- double digit TSB = bad
What are possible causes of pathologic jaundice:
1) Sepsis (infection interferes with conjugation)
2) Blood incompatibilities
3) Metbolic disorders
4) Hemolysis of RBC’s (bruising, cephalohemtoma from birthing)
- Overall hemolysis of RBCs or interference with conjugation
How is hyperbilirubinemia diagnosed?
1) S/S of jaundice
2) Total serum bilirubin
Can hyperbilirubinemia be managed inpatient or outpatient? What two treatment options are available?
Setting: Inpatient or outpatient
1) Phototherapy
2) Exhchanged transfusion in the NICU
When should noxious things like needle sticks and blood draws be completed for newborns?
1) At the beginning of the first hour of life
2) Within the first 3 hours of life
3) At the end of the first hour of life
4) Within 30 minutes of life
3) At the first end of the first hour of life
Why do newborns lack vitamin K
They lack vitamin K because they are missing the intestinal bacterial flora that produce it
Why is a vitamin K shot needed for newborns?
They are missing the bacterial flora for production of vitamin K and PT levels are low making them vulnerable to hemorrage.
When is the vitamin K injection given? Route?
Within the first 1 hour of life?
Route: IM
What is meconium? When should it pass by?
Meconium: is the thick, tarry, green-black substance made of aniotic fluid, bile, and other byproducts formed in utero
When: It should pass within 48 hours, usually by 12 hours
Why do newborns have meconium?
1) They lack a liver that properly conjugates bile
2) They lack proper splenic function for enzyme production
3) Their pancreatic function is overactive with enzymes
4) They lack proper digestive functioning
4) They lack proper digestive functioning
If stressed in utero, what does the fetus do with meconium?
It will expel it in utero
What is transitional stool?
Transitional stool: stool that is thin, and brown to green
What does breastfed vs. formula fed stool look like?
Breastfed: Yellow-gold, mushy, may appear seedy, sweet-sour odor
Formula fed: pale yellow to light brown, pasty, characteristic odor of feces
How often should breastfeeding occur?
3x/day until six weeks
What percentage of infants void within the first 24 hours? First 48 hours?
93% within first 24 hours
99% within first 48 hours
What should you check if there has been no newborn voiding within 48 hours?
1) Fluid intake
2) Bladder distension
3) Restlessness
4) S/S of pain
What assessments should be made for the baby right after birth?
1) Resuscitation need
2) Clean airway
3) Dry baby
Stability to initiate attachment
What assessments should be made 1-4 hours after birth?
1) Vitals Q30Min
2) Gestational size and age
3) Identify infant and initiate security system
4) obtain height, weight, length, and head cirfumerence
5) Assess skin color and acryocyanosis
6) Asses suck and swallow
7) Assess movements and reflexes
8) Assess for anomalies
What assessments should be completed within 24 hours/before discharge?
1) Physical exam
2) Nutrition status and ability to feed
3) All screenings
What is the first period of reactivity?
When babies are hyperalert and awake within the first hour of life
What nursing interventions should occur during the first period of reactivity?
1) APGAR
2) Encourage skin-to-skin and eye contact
3) Initiate feeding if stable
4) Vitamin K and Erythromycin (toward end of first hour)
What treatment is given to prevent eye infection in newborns and which infection? When should it be given and why?
Erythromycin oinment is given in case the birthing individual has gonorrhea
- It is given toward the end of the first hour becuase it can blur vision
At what time points is the APGAR done? What score indiciates internvention is needed?
- Done at 1 and 5 minutes
- Scores under 7 mean intervention is needed
- 4-6 = below normal, may need to stimulate baby
- 0-3 = bagging the baby, establishing an airway
What does APGAR stand for?
Activity
Pulse
Grimace
Appearance
Respirations
What percentiles are small, appropriate, or large for gestational age?
- Small: < 10%
- Appropriate: 10th-90th%
- Large: >90th%
- We want 10-90th percentile, small and large are risk factors for issues
What is the exam for gestational age and what does it tell us? What two categories are used?
The Ballard exam tells us how appropriate the baby is for gestational age.
1) External physical characteristics
2) Neurologic characteristics
When does the head-to-toe newborn assessment need to be done by?
1) Within the first hour of life
2) Within the first 24 hours of life
3) Within the first 1-4 hours of life
4) Within the first 6 hours of life
2) Within the first 24 hours of life
True or false: frog legs, a type of hip dysplasia, is an abnormal finding
False: Fog legs, where the newborn’s legs are flexed up and out, is a normal finding
What is the pulse rate for newborns? How should it be taken?
PR: 110-160 BPM
- Should be taken apically for one full minute
What is the respiratory rate for newborns? What should breathing look like?
RR: 30-60
- Breathing should appear predominantly diaphragmatic with brief periods of apnea
**What is the normal axillary and skin range for temperature in newborns?
Axillary: 97.5-99F
Skin: 96.8-97.7F
What is the normal blood glucose required for newborns?
BG: Greater or equal to 40mg/dL
What is the normal blood pressure for newborns?
BP: 60-90/40-50 mmHg
Molding: what is it, how long does it last, is it normal
Molding: when the newborns heads is in a cone shape or pointed due to pressure from the vaginal canal
Duration: lasts a few days to a week
It is a normal process
Caput succedaneum: what is it, what are its characteristics, how long does it last, what can increase the risk of it
Caput succedaneum: an area of localized edema on the scalp, usually over vertex, from pressure on mother’s cervix during labor
Characteristics: edema crosses sutures, soft, varies in size
Duration: lasts for days
Risk: Vaccum delivery can increase risk
Cephalohematoma: what is it, what are its characteristics, duration, what does it increase the risk of
Cephalohematoma: accumulation of blood under the scalp caused by birthing pressure, usually on parietal bones
Characteristics: parietal area, clear edges at sutures
Duration: slowly develops over 24-48 hours, lasts up to 3 months
Risk: increases the risk of hyperbilirubinemia d/t RBC breakdown
What does the female newborn genitalia look like?
Labia majora may be enlarged and darker then surrounding skin d/t maternal hormones
What is psuudomenstration? Is it normal?
Pseudomenstration: the small amount of vaginal bleeding from sudden withdrawal from maternal hormones
Normal ocurrence
What may the male scrotum look like at birth?
It may be dark brown d/t maternal hormones
What is hydrocele?
Hydrocele: A collection of fluid around both or one testicle, usually resolves on its own
What is cryptochidism?
Undescended testies on one or both sides, likely descends by 6 months
What is hypospadias versus epispadias?
Hypospadias: when the male urethra is abnormally located on the underside of the penis
Episadias: urethral meatus on upperside of penis
Is the Hepatitis B vaccination given inpatient or outpatient?
Inpatient
What are some ways to wake up a newborn?
1) No more than 3-4 hours w/o feeding
2) Dress, undress, bathe hands or feet
3) Talk to infant, place upright
4) Increase skin contact
5) Hand express milk onto baby’s lips
6) Stimulate rooting reflex by brushing the cheek
What are some ways to quiet an infant?
1) Talk or coo to them
2) Burp, change diaper, or feed them
What are the 5 S’s to quieting an infant?
1) Swaddle
2) Side/stomach position
3) Shushing + rhythmic sounds
4) Swining + rocking
5) Sucking (pacifier or fist)
How should a newvborns umbilical cord be cared for?
1) Kept dry and clean
2) Keep diapers folded down as not to irritate the cord
3) Do not bathe cord directly
Is it normal for the umbilical cord to become black/brown? When should it fall off?
- Yes, it should become black and brown within 2-3 days.
- It should fall off within 10-14 days
How often should you check for foul-smelling drainage on a circumcised baby?
1) 2x/day
2) 3x/day
3) Every other day
4) 1x/day
4) Check 1x/day
True or false: light, stick, yellow drainage is an expected finding after newborn circumcision
True: It is normal to observe light, yellow, sticky drainage
True or false: A moderate amount of bleeding is an expected finding after newborn cicumcision
False: A moderate amount of bleeding is not an expected finding. Only a small amount of bleeding should be observed.
What should you do after a newborn is circumcised? (Select all that apply)
1) Monitor first void within 6-8 hours
2) Place the baby on their stomach
3) Apply petroleum jelly to the penile glans
4) Avoid putting a diaper on the newborn for 24 hours
1) Monitor the first void within 6-8 hours (ensures no issues with voiding)
3) Apply petroleum jelly to the penile glans (helps prevent the penis from sticking to the diaper)
- You should not place them on their stomach
- A diaper should be placed on the newborn after circumcision
If the newborn has NOT been circumcised, what should you NOT do?
- Do NOT retract the newborn foreskin, it is adhered to the glans until the first 3-6 years
What nursing implications should be considered in each developmental range:
1) Infant
2) Toddler
3) Pre-school
4) School-age
5) Adolescent
1) Infant: anticipate meeds and provide comfort
2) Toddler: Promote safety, routines, comfort objects (parents, toys)
3) Pre-school: Provide reassurance, space to explore and ask questions
4) School-age: clear expectations, rules, all about mastery, give jobs, encouragement
5) Adolescent: respect privacy, allow space for emotions, encourage socialization
**What are the signs and symptoms of newborn distress/illness?
1) Grunting
2) Tachypnea
3) Retractions
4) Cyanosis
5) Seesaw (paradoxical) breathing where the chest and belly are not moving together
6) Assymetric chest expansion
What are other indicators of neonatal distress/illness?
1) More than 6-8 wet diapers/day
2) Green, watery stools
3) Foul discharge or more than mild bleeding from umbilical cord, circumcision, or opening
4) Lethargy
5) Inconsolable
6) Hypothermia
What are three ways to help prevent neontal distress/illness? (Select all that apply)
1) Place the newborn on their back when sleeping
2) Place 2 more layers than you’re wearing to keep them warm
3) Use a bulb syringe to remove fluid or mucus from mouth and nose
4) Place them in the proper position for feeding
5) Give them more solid food during mealtime to help their digestive system improve
1) Place the newborn on their back while sleeping (back is best)
3) Use a bulb syringe to remove fluid or mucus from mouth and nose (helps keep airways patent and clear)
4) Place them in the proper position for feeding (prevents aspiration, promoted digestion)
- You should only give them 1 more layer than you’re wearing to stay warm
- Noenates should not receive solid food
**What are risk factors for newborn hypoglycemia?
1) Small or large for gestational age
2) Maternal gestational diabetes
3) Pre- or post-term birth
4) Intrauterine growth restriction
5) Cold distress
6) Fetal distress/asphyxia
**What are signs and symptoms of newborn hypoglycemia?
1) Jitteriness
2) Poor muscle tone
3) Poor feeding
4) Tachycardia
5) Tachypnea
6) Apnea
7) Irritable
8) Lethargy
**How is nerborn hypoglycemia treated?
1) Feedings
2) Glucose gel
3) Fluids (D10 or D20)
4) Frequent checks and protocols
**What newborn glucose level requires intervention?
1) < 70mg/dL
2) < 40mg/dL
3) < 100mg/dL
4) < 50 mg/dL
2) < 40mg/dL
What are the signs and symptoms of neonatal abstinence syndrome?
1) High-pitched, incessant cry
2) Fusiness
3) Jitteriness
4) Hyper-reactive
5) Poor feeding
6) Blotchy, mottled skin
7) Uncoordinated suck/swallow
8) Diarrhea
What is the primary assessment for neonatal abstinence syndrome and what are the three parts?
Assessment: Eat-Sleep-Console (ESC)
1) Can they sustain feeding for greater than 10 minutes
2) Can they sleep for greater than 1 hour between feeds
3) Can they be consoled within 10 minutes or less
What is the preferred treatment for neonatal abstinence syndrome and why? What are two other treatment options?
Preferred treatment: for NAS is methadone d/t it’s long half life allowing less frequent doses
1) Phenobarbitol
2) Benzodiazepines
What are non-pharmacological ways to treat neonatal abstinence syndrome?
1) Co-rooming
2) Feeding early to reduce workup
3) Swaddling
4) Skin-skin
5) Holding
6) Soothing (pacifiers, finger)
7) Limit visitors
**What are signs of newborn sepsis?
1) Hypothermia or temperature instability
2) Tachycardia
3) Respiratory distress
4) Abdominal distension
5) Lethargy
6) Poor muscle tone
7) Decreased blood pressure
**What are risk factors for newborn sepsis? (Select all that apply)
1) Poor hand hygiene
2) Stomach sleeping
3) Small for gestational age (SGA)
4) Large for gestational age (LGA)
5) Pre-term birth
6) Meconium aspiration
7) Prolonged Rupture of Membranes (PROM)
8) Intrauterine growth restriction (IUGR)
1) Poor hand hygiene
3) Small for gestational age (SGA)
5) Pre-term birth
6) Meconium aspiration
7) Prolonged rupture of membranes (PROM)
- GBS positive and other infections can cause newborn sepsis, too
**What are some interventions to help reduce or manage sepsis?
1) Disinfect phones
2) Hand hygiene
3) Administer antibiotics
4) Early identification of maternal and newborn risk factors
Why is outpatient care potentially better than inpatient care?
Outpatient care:
1) Minimizes separation from families
2) Reduces cost
3) Decreases infection
4) Prevents discomfort of being in a high stress, unfamiliar environment
What are the leading causes of death among infants, 1-4 y/o, 5-9 y/o, 10-14 y/o, and 15-19 y/o?
1-4 y/o: Congenital malformations
All other age groups: accidents are the leading cause
What does atraumatic care look like?
1) Prevent/minimize separations from family
2) Promote a sense of control
3) Prevent/minimize bodily harm/pain
Separations, control, pain/harm
**What are the four beliefs of family-centered care?
1) Caregiver’s are important in the child’s life
2) Caregivers are the constant in the child’s life
3) Parents/caregivers know the child the best
4) Parents/caregivers are essential partners in the child’s care
They’re important, know best, are a constant, and parternship is needed
What does health literacy mean? What percentage of the U.S. population is health literate?
Health literacy: the ability of people to find, understand, and use information and services to inform health-related decisions and actions
About 35% of the population is health literate
What percentage of information do patients actually retain and how much of it is inaccurate?
They only retain about < 30% and about 50% is inaccurate
During stress literacy goes down leading to:
1) Increased ED visits
2) Decreased treatment compliance
3) Poor self-care
4) Increased mobidity and mortality
Who is at risk for poor health literacy?
1) Those 65+
2) Marginalized groups
3) Non-native English speakers
4) Impoverished individuals
What is the main influence on a child’s response to illness and what are other influences?
1) Parent’s response (main influence)
2) Age (primary influence)
3) Developmental level (primary influence)
4) Preparation
5) Previous experience
6) Coping skills
7) Culture
**What is the main source of anxiety in infants and toddlers in the hospital?
Separation anxiety (from caregivers) is the main source of anxiety 6-30 months
**What three stages do infants and toddlers go through when being hospitalized?
1) Protest: cying, agitation, inconsolable
2) Despair: Withdrawn, quiet, hopeless
3) Detachment: forms attachment to other caregivers, may ignore or punish parents
What do pre-schoolers (3-5 y/o) fear/have anxiety about during hospitalization? How can this be helped?
Fear/anxiety: mutiliation
Helped: avoid procedure in room and bed, use procedure room instead. Also, provide realistic choices and prepare them
What is the main source of anxiety in school age children (6-12 y/o)? How can this be helped?
Anxiety: related to a loss of control
Helped:
- Involve them in cares,
- They want to know the reason because they understand cause and effect = clearly explain and educate
- Friends are important = normalize activities like play, school, and socialize
What are the main sources of anxiety in adolescents (13-19 y/o)? How can this be helped?
Anixety: Separation from friends, identity and self, control, appearance
Helped:
- Respect privacy
- Engage patient in decision making
- Encourage socialization
Why is play important for children in the hospital?
1) It reduces negative effects during stay
2) It’s the child’s work!
3) Promotes a safe space (play area = safe)
4) Reveals coping
5) Can be used to teach
**How can siblings experience disruptions during anotther family member’s hospital stay? (i.e. what impact does it have)
1) May cause anxiety, confusion, or fear
2) May feel guilty or that they caused the illness
3) May feel resentment or jealous at the attention their family member receives
4) Insecurity and a loss of routine
**How can effects of a family member’s hospitilzation on siblings be reduced?
1) Encourage visits to the hosiptal
2) Provide education about what is going on
Which pediatric age groups are at greatest risk for falls? When are falls most common?
- Infants and toddlers are at greatest risk for falls
- Falls are more common with parents in the room
What is the nurse’s responsibility during informed and general consent? When should assent should be obtained?
1) Informed consent: nurse witnesses and advocates
2) General consent: nurse can obtain during routine procedures (meds, IV starts, labs)
3) Assent should be obtained for children 5 years and older
What is true about restraint use? (select all that apply)
1) Most require a provider order
2) Use the most restrictive restaints first
3) Ensure a proper fit
4) Secure ties to bed frames
5) Secure ties with double knots to prevent release
1) Most require a provider order
3) Ensure a proper fit
4) Secure ties to bed frames
- You should use the least restrictive restraint type first
- Restraints should be secured with quick tie knots for easy release
What are three important points when providing nutrition through NG/NJ and G-tubes?
1) Hold infants to create a bond (same as you would when breastfeeding or bottlefeeding)
2) Provide a pacifier for nonnutritive sucking
3) Have older children sit at the table to establish normalcy and routine
Why does hypoexmia devlop more rapidly in newborns?
It develops rapidly becuase they have a:
1) higher metabolic activity rate
2) immature lungs
**At what body weight is medication no longer dosed by weight?
1) 30kg
2) 20kg
3) 50kg
4) 75kg
3) 50kg
What are some reasons why medications may be dosed differently for pediatric pateints?
Think pharmacokinetics (absorption, distribution metabolism, concentrate
1) Delayed gastric emptying
2) Higher metabolic rate
3) Immature blood brain barrier
4) Immature kidney/renal function
5) Altered absorption
6) Immature hepatic system
What are three ways to promote medication administration for younger pediatric patients?
1) Flavored liquids
2) Chewables for toddlers
3) Provide choices and rewards
**Can toddlers swallow pills?
No, they cannot swallow pills.
At what age should pills be given to pediatric patients?
1) 12 y/o+
2) 5-6 y/o+
3) 4 y/o+
4) 7-8 y/o+
5-6 y/o+ can begin to receive pills to swallow
What IM injection location should be used for patients under 3 years old?
Under 3y/o: The vastus lateralis (outer, middle thigh)
At what age should the deltoid be used for IM injections?
The deltoid should be used starting at ages 3-6 years old
**What are signs and symptoms of dehydration in newborns?
1) Fewer wet diapers
2) Sunken fontanelles
3) No tears when crying
4) Inside of the mouth = dry and sticky
5) Lethargy
6) Poor skin turgor
7) Tachypnea
8) Sunken eyes
9) Abnormal skn color and temp
True or false: There are little to no differences in mild dehydration in newborns
True: little to no differences are seen in physical appearance or behavior at mild dehydration
What might be seen in a newborn who has severe dehydration?
- Skin
- Muscosa
- Eyes/tears
- CNS
- Fontanelle
- Pulse/quality
- Capillary refill
- Skin: clammy
- Mucosa: parched, cracked
- Eyes/tears: Sunken/none
- CNS: Lethargic
- Fontanelle: sunken
- Pulse/quality: increased/weak or absent
- Capillary refill: greater than 3 seconds
**What is the 4-2-1 rule of fluid administration?
4-2-1 rule is a weight-based dosing rule for fluids
- For the first 10kg, they will receive 4mL/kg
- For the second 10kg, they will receive 2mL/kg
- For the every kg beyond 20kg, they will receive 1mL/kg
**Your 31kg patient receive a new order for liquid acetaminophen. Based on the 4-2-1 requirement for fluid administration, how many mililiters should your patient receive?
71mL of liquid acetaminophen
- 10kg x 4mL = 40mL (first 10kg, 4 rule)
- 10kg x 2mL = 20mL (second 10kg, 2 rule)
- 11kg x 1mL = 11mL (remaining kg, 1 rule)
- Total: 40+20+11 = 71mL
How often should IV sites in pediatric patients be monitored?
They should be moniotred hourly for infiltration
What kind of syringe can be used for less than 1mL of liquid?
A 0.5mL syringe or tuberculin syringe
What tool should be used for newborn patients when dosing oral medications?
Use a syringe
True or false: You can dilute medication in formula to make it easier to administer to newborn patients
False: You should not dilute medication in fomula, it can change the tase of formula and make formula-fed infants less likely to feed
What question should be asked that is specific to pediatric patients when taking a history about their current status?
1) Cultural factors
2) Nutrition status
3) Response to hospitalization
4) School/daycare routine
4) School and daycare routine and utulization
**In what order should a nurse perform a pediatric head-to-toe assessment when using palpation, ascultation, and inspection?
- Inspect first
- Ascultate second
- Palpate last
Least to most invasive
What is an important point about choices when doing a physical assessment on pediatric patients?
Offer realistic choices
- If they can’t say no, do not offer them the option to say no
When taking a first glance at a pediatric patient for a physical assessment, what does ABC mean? (i.e. what are you looking at)
1) Appearance
2) Work of Breathing
3) Circulation to skin
**How long should you take respiratory rate and apical pulse for in pediatric assessments?
- Take respiratory rate and apical pulse for a full minute
How should temperature be taken in young pediatric patients (newborns, toddlers)?
Axillary temperature
True or false: Temperature can be taken orally starting at age 5
True: Temperature can be taken orally starting at age 5 instead of axillary
When should blood pressure be taken during pediatric vital sign assessments?
- Blood pressure does not need to be taken if under 3 years of age unless hospitalized
**How are anthropemtric measures taken for growth in pediatric patients? (i.e. height vs length, weight)
- Length is used instead of height until they are able stand independently around 2-3 y/o, then height is taken
- Weight and BMI are taken as normal
**At what age is head circumference not collected at?
Head circumference is collected until age 2 and stops after.
True or false: scarring and keloids are a normal skin finding becuase pediatric patient’s skin heals quickly
False: While it’s true pediatric patient’s skin heals quickly, scarring and keloids are still abnormal findings
True or false: Large tonsillar and adenoidal tissue at 2-6 years of age is normal
True: At 2-6 years of age, tonsilles and adenoid tissue is large
When do the posterior and anterior fontanelles close?
- Poster closes first at around 3 months
- Anterior closes last around 10-18 months
At ehat age ranges do you see normal gait findings in pediatric patients that you do not typically see in adults? (I.e. give the age range and the gait difference)
1) 1-3 y/o: tibial torsion and metatarsus adductus = feet pointed inward, pigeon toe
2) ~12 months: genu varum or bowleg
3) 3-4 y/o: genu valgus or knock-knee
What is stridor and what might it indicate?
Stridor: high pitched crowing
Indicates: obstruction in the airway
What is wheezing and what might it indicate?
Wheezing: high pitched or low whistling noise, usually louder on expiration
Indicates: narrowing of the airway
**What is different about the pediatric upper airway?
1) Tongue is disproportionately larger
2) Epiglottis is larger and floppier
3) Pharynx is smaller
4) Trachea is narrow and rigid
5) Airway grows in length, but not diameter until age 5 = long, skinny tube
6) Alevoli increase by age 3 and fully develop by age 8
What is different about infant airways?
1) Large tongue, small mouth
2) Insufficient surfactant
3) Obligatory nose breathing = if infection or congestion = obstruction
4) Brief periods of apnea < 15 seconds w/o cyanosis
What is different about infants and young-children’s airways?
1) Less developed intercostals
2) Airways are small and floppy
3) High respiratory rate increases metabolic demands
4) Eustacian tubes are relatively horizontal = plugged ears/infections more likely
5) Tonsillar enlargement
6) Flexible larynx prone to spasm
**What are the signs of early respiratory distress?
1) Grunting/noisy breathing
2) Tachycardia
3) Tachypnea
4) Shallow respirations
5) Asynchronous breathing, see-saw
6) Diaphoresis
7) Retractions
8) Nasal flaring
Loud, sweaty, quick breathing and heart rate
**What are the signs of late respiratory distress?
1) Bradycardia
2) Bradypnea/Apnea
3) Cyanosis
4) Decreased LoC
5) Coma
Why are foreign bodies a risk in younger children?
1) Place things in ears and nose
2) Lack molar teeth to prevent insertion/promote full chewing
3) Their anatomy is large and floppy
What signs indicate that you should suspect a foreign body (object) in a younger child?
1) Hoarseness
2) Difficulty swallowing (dysphagia)
3) Difficulty talking (dysphonia)
4) Stridor, wheezing
5) Painful swallow (odynophagia)
**When does a foreign body become a medical emergency?
1) When it enters the pharyngeal space
2) When it is stuck under the tongue
3) When it is lodged behind the molars
4) When it is obstructing the nose
1) When it enters the pharyngeal space
- It becomes a medical emergency and the airway must be protected
What is otitis media? What are the two types?
Otitis media: infection or fluid creating a blockage in the middle ear
1) Acute otitis media
2) Otitis media with effusion
Acute otitis media: what is it, signs and symptoms, how is it treated
What is it: sudden infection of the middle ear associated with other signs of infection
S/S:
- Earache
- Pulling on ears
- Bulging, red, opaque tympanic membrane
- Yellow-green pus
- Foul discharge
Treatment:
- Pain medication
- Antibiotics if not cleared within 48-72 hours
- Tube placement if persistent (recurrs within 1 month) or recurrent (3x/6months or 4 in a year)
Otitis media with effusion: what is it, signs and symptoms, how is it treated
What is it: fluid behind the tympanic membrane w/o infection usually occuring after acute otitis media
S/S:
- Tinnitus
- Popping sound
- Hearing loss
- Mild balance disturbances
- Tympanic membrane dull, gray, yellow
- Fluid or air bubbles
Treatment: Tubes if persistent (lasting longer than>3months)
Tonsilitis/Adenoiditis: what is it, signs and symptoms, how is it treaed
What is it: Inflammation of the tonsils/adenoids
S/S:
- Exudate
- Sore throat
- Snoring
- Bad breath
- Difficulty swallowing
Tx:
- Bacterial = antibiotics and supportive care
- Viral = supportive care and salt water gargle
- Persistent/recurrent = surgical removal
What are post-op interventions or monitoring for srugical removal of tonsils/adenoids?
1) S/S of bleeding
2) Manage pain
3) Fluids + ice chips
4) HoB up
5) Discourage coughing
6) S/S of edema
Streptococcal pharyngitis: what is it, signs and symptoms, diagnosis, treatment
What is it: inflammation of the throat d/t bacterial infection = “strep throat”
Dx: Throat culture
S/S:
- rapid onset
- Sore throat
- Fever
- Abdominal pain
Tx: Antibiotics (penicillin family), antipyretics, pain meds
Croup: what is it, what types are there, signs and symptoms
What is it: an infection of the upper airways
Types:
1) Viral - 6 months to 6 years d/t parainfluenza
2) Spasmodic - ages 1-3
3) Bacterial - tracheitis, epiglottitis, 3-7 y/o
S/S:
- upper airway symptoms w/ or w/o fever
- Harsh, barky cough
- Hoarse
- Restless, agitated
- Respiratory distress
How do you treat spasmodic croup?
At home treatment:
1) Calm
2) Fluids
3) Cool mist
4) Night air
How do you treat viral croup?
1) Steroids
2) Fluids
3) Rest
4) Antipyretics
5) Racemic epinephrine
6) O2
7) IV fluids
**Bacterial croup: age range, onset, 4’Ds, why is it dangerous?
Age range: 3-7 y/o
Onset: sudden fever and symptoms
4 D’s:
1) Drooling
2) Difficulty swallowing (dysphagia)
3) Difficulty speaking/hoarse (dysphonia)
4) Distressed inspirations
Dangerous: Because it is sudden and can obstruct the airway
What can bacterial croup transform into?
Epiglottitis
**What does AIR RAID stand for when assessing signs/symptoms of epiglottitis?
Airway inflammation/obstruction
Increased pulse
Restless/agitated
Retractions
Anxiety/fear
Inspiratory stridor
Drooling
**How do you treat epiglottits?
1) Sit upright
2) Assist with securing airway
3) Humidified O2 - keep above 95%
4) IV fluids
5) Antibiotics
6) Antipyretics
7) Manage child and parent anxiety
Why might bronchitis send younger children to the hospital?
They may become more easily fatigued d/t decreased intake and increased respiratory effort/distress
What is the most common cause of hospitalization in infants under 6 months?
Bronchiolitis
Bronchiolitis: what is it, types, and signs and symptoms
What is it: inflammation of the bronchioles, highly communicable by contact
Types:
- Viral is the most common type = Respiratory Synctial Virus (RSV)
- Parainfluenza
- Andovirus
- Mycoplasma
S/S:
- Tachypnea
- Cough
- Tachycardia
- Nostril flaring
- Retractions
- Wheezing d/t mucus
- Poor intake
- Cyanosis
- Crackles/ronchi
- Runny nose
How do you treat bronchiolitis?
1) Fluids
2) Cool mist
3) Rest
4) IV fluids
If hospitalized:
1) SpO2, CO2, apnea monitoring
2) Humidify O2
3) Nebs and suction
Why is skillful suctioning required in bronchiolitis?
Skillful suctioning is needed because bronchiolitis can cause a large increase in secretions, but oversuctioning can irritate the throat creating more secretions
**What are the pertussis stages? Describe them.
1) Catarrhal - Stage 1 (1-2 weeks): mild cough, low fever, runny nose
2) Paroxysmal - Stage 2 (2-6 weeks): persistent, harsh cough
- Whooping sound on inspiration
- Protrusion of the tongue, neck veins
- Vomiting/drooling
- Cyanosis
3) Convalescent - Stage 3 (1-2 weeks): episodic cough, whooping, and vomiting that may be triggered by sneezing, yawning, or intake
**True or false: It is appropriate to delay the DTaP vaccine if the infant is premature or small for gestational age to protect the immune system
False: you should not delay giving the DTaP vaccine, it’s especially important to give it if the newborn is pre-term or small for gestational age because their immune systems may be weaker
How is pertussis treated?
1) Supportive care
2) Erythromycin to reduce droplet transmission
If hospitalized:
1) IV fluids
2) Oxygen
3) Airway support + suction
**Cystic fibrosis: what is it, what are the effects, when are most people diagnosed
What is it: a progressive autosomal recessive disorder that causes a genetic defect on the cystic fibrosis transmembrane conductance regulator. -> Chloride cannot move to the cell surface causing decreased water movement across the cell surface -> thick mucus in lungs and other organs’
Effects:
- Lungs = wide airways, infection prone, obstructed by mucus
- Skin = salty sweat
- Liver = blocked biliary
- Pancreas = blocked duct
- Intestines = less absorption
- Reproductive = blocked vas deferens and thick mucus plug in the cervix leading to infertility
Diagnosed: 75% are diagnosed by age 2, most die by age 32, higher in caucasion individuals
**What are the signs and symptoms of cystic fibrosis?
1) Vomiting
2) Abdominal distress
3) Inability to pass stool
4) Meconium ileus (thick meconium blocking GI)
5) Foul stools
6) Recurrent infections
7) Constipation
8) Barrel chest/nail clubbing
9) Reflux
10) Absent sperm + thick cerivcal mucus
**How is cystic fibrosis diagnosed?
Dx: sodium chloride test
- Infants ( < 3months) = >40 chloride
- All other ages = >60 chloride
- Sodium = >90
**What are possible treatment options for cystic fibrosis?
1) Maintain a patent airway
2) Bronchodilators
3) Chest physiotherapy (vibrating vest w/ inhalation therapy)
4) Respiratory treatments
5) Pancreatic enzymes
6) Education
7) Emotional support
8) Lung transplant
9) Postural drainage
**What are some long-term concerns in cystic fibrosis?
1) 10x risk of colon cancer (20x after transplant)
2) Fertility issues
3) Mental health strugges = anxiety, depression, cargiver fatigue
**Asthma: what is it, epidemoiology, triggers
What is it: a reversible obstructive upper airway disorder causing increased airway responsiveness, bronchospasm d/t smooth muscle contraction, and imflammation and edema of mucus membranes causing thick secretions
Epidemiology:
- More common in boys than girls in adolescence
- More common in women than men in adulthood
- Black children are 3x more likely to develop asthma, 5x more likely to visit the ED
Triggers:
- Pollen
- Mold
- Dust
- Exercise
- Food allergies
- Stress
- Smoke
- Pollution
- Respiratory infection
- Dander
- Feces
**What is the leading causing of chronic disease in the U.S. for children?
- Asthma
What does an asthma action plan include?
An asthma action plan includes:
1) Peak flow use
2) Medication use and side effects
3) Triggers
4) When to seek help
**Why is education on peak flow important?
It helps those with asthma understand where there expiratory speed it as. It is not for treatment and patients can feel worse after using it, but it’s a necessary tool for measurement.
**Aside from SABAs (albuterol) and the anticholinergic (ipratropium), what can be used for short-term asthma relief? What do they do and how should they be used?
Corticosteroids like prednisone or methylprednisone
- They decrease inflammation
- They should only be used short term d/t side effects with long-term use
**What long term options are available for asthma control?
1) Inhaled corticosteroids - Flovent (low side effects)
2) Leukotrine modifiers - Singulair (side effects of hallucinations, depression, suicidal ideation)
3) Combination inhalers - Advair = LABA w/ corticosteroid
4) Theophylline - daily pill to relax smooth muscle, requires blood levels
**What signs and symptoms may indicate an asthma emergency?
1) Worsening wheeze/cough
2) Discontinuation of play, inability to resume activity
3) SoB, difficulty breathing
4) Listless, refusal to suck
5) Gray/blue lips
**What does the antibody IgA protect? How is it transferred to newborns?
It protects the GI tract, respiratory tract, and other mucus membanes.
- Can be transferred via breast milk
**Which immunoglobulin contains the most circulating antibodies? What percentage of circulating antibodies?
Hint: Passed to the fetus during 3rd trimester, fights viruses/bacteria
IgG contains 80% of circulating antibodies and can fight against viruses and bacteria
**What is IgM protect against, where is it found, what kind of response does it provide?
Protects: against gram negative bacteria
Found: within the intravascular response
Provides: an early response after 9 months of age
What is IgD hypothesized to do?
Possibly influences B cells
**What kind of response is IgE involved in?
Allergic response
Allerg-E
**What is the primary immune response?
It is the innate, non-specific, immune response that quickly mounts to fight antigens - antibodies only react to a specific antigen within 3 days
- Phagocytes
- Inflammation
**What is the secondary immune response?
The secondary or specific/adaptive immune response uses humor B cells and cell-mediated T cells, lymphocytes, and antibodies
Subsequent encoutners with an antigen -> triggers memory cells -> faster response within 24 hours
**What is passive immunity, what are three ways it can be transferred?
Passive immunity: antibodies produced in another host transferred to another individual
1) Placenta
2) Breastmilk
3) IVIG - intravenous immunoglobulins
**What is active immunity?
Body makes antibodies in response to antigen exposure or immunizations
**What are signs/symptoms that an immunodeficciency may be present in a child?
1) Recurrent or persistent otitis media
2) Respiratory tract infections
3) Sinusitis
4) Opportunistic infections like candidiasis or pneumonia
5) Severe bacterial infections
6) Poor treatment response
7) Skin lesions
8) Enlarged spleen
9) Failure to thrive
10) Chronic diarrhea
How are the majority of HIV cases transmitted? What percentage?
91% of cases are transmitted perinatally from birthing parent to child
HIV: diagnosis, transmission, severity, nursing implication
Diagnosis: 2 positive virologic assays (accurate only at 12-18 months)
Transmission: breastmilk, blood, other bodily fluid
Severity: faster progression in children under 5 y/o
Nursing implications:
- Tx to reduce viral load
- optimize nutrition
- educate
- altered immunization schedule
- do not assume child is aware of status
Why is emotional support imperative for pediatric individuals experiencing systemic lupus erythmatosus?
It is important becuase it can delay puberty, rashes, and cause an altered self-image
What immunosuppresants are used for systemic lupus erythmatosus and juvenile idiopathic arthritis?
SLE: cytoxan
JIA: methotrexate
Why does eczema occur?
It occurs because the immune system is hyperactive - too active, too often
Is lupus and arthritis more common in boys or girls?
Girls
**What are signs of increased intracranial pressure in infants?
This is on the test 100%
1) Bulging fontanelles
2) Increased head circumference
3) High pitchedd cry
4) Distended scalp veins
5) Bradycardia
6) Respiratory changes
**What are signs of increased intracranial pressure in children?
This is on the test 100%
1) irritability
2) Headache
3) Vomiting
4) Diplopia
5) Seizures
6) Bradycardia
7) Respiratory changes
**Meningitis: what is it, diagnosis, characteristics of viral vs. bacterial
What is it: inflammation and infection of the mininges surrounding the brain
Diagnosis:
- KErnig’s sign = knee extension while supine is painful
- BrudziNsKi’s = neck flexion causes knee flexion to reduce pressure
Viral: clear, normal glucose and protein, gram negative stain
Bacterial: cloudy, elevated glucose and protein, gram positive stain
**What are concerning signs and symptoms of a head injury?
1) Loss of consciousness or decreased level
2) Non-stop bleeding
3) < 2 y/o
4) Vomiting
5) Seizure
6) Slurred speech
7) Blurred vision
8) Iconsistent report
**What are nursing consideration for meningitis?
1) Monitor for S/S of increased ICP
2) Spinal headache post lumbar puncture
3) Seizure precautions
4) Calm, cool, dark, quiet room
5) Fluids + supportive care
6) Medications for bacterial
**What are common treatments for head injury?
1) Rest
2) Ice
3) Stitches
**What are the top 3 causes of concussion?
1) Sports
2) School PE
3) Bike/recreation
**How do you treat concussions?
1) Rest
2) Low light
3) Brain rest = no screens
4) Slow return to school
5) No activities until symptom free
What are the three types of headaches and one piece of information about each?
1) Tension: feels like a tight band around the crown of the head
2) Migraine: often unilateral, severe, headache, top of head
3) Cluster: daily/weekly patttern of severe headaches, behind the eye
**What is the difference between focal and generalized seizures?
Focal: Involves only one part or area of the brain
Generalized: involved the entire brain
**How is epilepsy diagnosed?
2 unprovoked seizures at least 24 hours apart with another occuring 1 time within the following 10 years
**What are seizure risk factors?
1) Fever
2) Drug/substance use
3) Tumor
4) Infection
**5) **Head injury
6) Toxins
**What kinds of childhood seizures are there? Describe them
Clonic-tonic (grand-mal):
- Clonic = LoC, eye roll and arch followed
- Tonic = which is violent jerking, and
- Post-ictal phase = sleepy and confused for 30 to 60 minutes
Absent (petit mal): brief LoC, staring, motionless
Myoclonic: brief contractions of one muscle group, no LoC, no post-ictal
Atonic (drop attacks): lose muscle tone, fall to the ground and confusion
Partial seizures: focalized, tingling, eye aversion
Infantile spasms (West Syndrome): seize a lot and often, rare after 2 y/o
- Tx: ACTH
What are safety considerations for seizures?
1) Side rails up with pads
2) Fall precautions
3) Helmets
4) O2 and suction
5) Side lying to prevent aspiration
What is important about long-term control meds for seizure?
1) Start quickly and at a high dose to treat seizures aggressively
2) Start slowly at a low dose to gradually control seizures
3) Start at a high dose and then quickly taper down to manage seizures
4) Start at a low dose and then quickly taper up to manage seizures
2) Start slowly at a low dose to gradually control seizures
What is a risk factor for cerebral palsy?
1) Large for gestational age
2) Maternal diabetes
3) Low birth weight babies
4) Neonatal hypoglycemia
3) Low birth weight babies
True or false: Cerebral palsy is a chronic neurocognitive disorder that is not progressive in nature
True: Cerebral palsy is not progressive, is chronic, and is neurocognitive
**In what pediatric population are fractures rare? What may they indicate?
- They are rare in infants and always warrant further investigation d/t possible abuse
**What is the most common fracture site in pediatric patients?
Distal forearm
**Who has the slowest fracture healing time in pediatrics and who has the fastest?
Adolescents have the slowest at 8-12 weeks and neonates have the fastest at 2-3 weeks
**What important points regarding skin integrity should the nurse monitor/assess for after a patient has a splint, cast, or fixation device placed?
1) Adequate padding
2) Check for adequate circulation
3) S/S of infection
4) Assess redness and breakdown
**What should a neurovascular assessment include after a paitent undergoes immobilization or tissue injury?
1) Skin color
2) Pulses distal to site
3) Capillary refill
4) Movement of digits
5) Temperature
6) Sensation
**What are the 5 P’s of compartment syndrome/fracture assessment?
1) Pulseless
2) Pain
3) Pallor
4) Poikilothermia (coolness/inability to regulate temperature)
5) Parathesias
6) Paralysis
**When is compartment syndrome most likely to occur? What are providers more likely to do within this time period instead of casting?
Within the first 24-48 hours
- Providers are more likely to splint instead of cast to avoid compartment syndrome
**Compartment syndrome: what is it, signs and symptoms, treatment
What is it: when there is bleeding and swelling into the tissue causing a loss of O2 and nutrients alongside increased pressure
S/S:
- Pain
- Pallor
- Poikliothermia (coolness)
- Parathesias (N/T)
- Puleslessness (Faint or diminished early on)
- Paralysis
Tx:
- Cast must come off
- Fasciotomy: cutting connective tissue around muscle to relieve pressure
Why is myoglobin dangerous in problems like acute viral myositis and rhabdomyolysis?
Myoglobin can obstuct tubular flow, can directly damage cells, and can break down into reactive oxygen species = kidney damage
What sign of rhabdomyolsis indicates the patient should come in immediately to be seen?
Dark, tea-colored urine
What is the most common bacteria causing osteomyelitis?
Staph aureus
What is the main diagnostic for osteomyelitis?
Bone scans
What is the most effective pain treatment for osteomyelitis
NSAIDs
What labs should be monitored in osteomyelitis?
Kidney (BUN, creatinine) and heptic response
**What physiological aspect of pain management are pediatric patients missing compared to adults?
They have an ascending pain pathway = they feel pain
They are missing the descending pain pathway for pain modulation
**What are some myths about pediatric pain management?
1) Infants do not feel pain (They have an ascending pathway for pain)
2) They will report pain if they have it (not they wont)
3) Parents overreport pain (No they accurately report pain)
4) If they are asleep, they cannot feel pain
5) Builds tolerance and character (no it can actually cause defects neurologically)
6) They have a higher risk for addiction (pain = need for medication, no higher risk for addiction)
7) They have no memory of pain
8) They have a quicker recover
What long-term developmental effect can untreated pain have on pediatric patients?
Untreated pain can lead to neurologic change and deficits that they do not recover from.
Opioids cause changes but they are able to recover from those by kindergarten.
**What are the three goals of pediatric pain management?
1) Relieve and reduce pain
2) Improve function
3) Minimize side effects (constipation, nausea, urinary retention, itching)
**What should you never promise during pediatric interventions or pain management?
Never promise that there will be no pain
**Who is the best source of comfort for pediatric patients in pain?
Their parents!
**Fill in the blank: Treat the patient not the _ _ _ _ _ _
Number
At what age can children being to self-report pain?
Starting at age 4
**How can you assess pain in a patient that is sedated and muscle relaxed?
1) Change in HR by 20%
2) Change in BP by 20%
3) Facial pallor/redness
4) Tears
If the patient cannot move, what scales can you not use?
You cannot use behavioral scales (and of course self-report too)
**What 4 components should a comprehensive pain assessment include?
1) Use a validated pain scale
2) Direction observation by nurse of play, sleeping, mobility, mood, attention
3) Parent report of norms and context
4) Reason for pain
What route should pain medications be used and what route should be avoided?
Use PO
Avoid IM
**What 4 steps are used to prevent pain from needles? When should this be done?
1) Numb the skin
2) Sucrose or breastfeeding
3) Comfort positioning (upright, holding)
4) Distraction
*It should be done everytime
