Foundations of Nursing Care of Children

Question 1

Temperature

Answer 1

3 months- 99.5F (37.5) (Axillary, Rectal)
6 months- 99.5F (37.5) (Axillary, Rectal)
1 year- 99.9F (37.7) (Axillary, Rectal)
3 years- 99.0F (37.2) (Axillary, Tympanic, Oral, Rectal)
5 years- 98.6F (37.0) (Axillary, Tympanic, Oral, Rectal)
7 years- 98.2F (36.8) (Axillary, Tympanic, Oral, Rectal)
9 years- 98.1F (36.7) (Axillary, Tympanic, Oral)
11 years- 98.1F (36.7) (Axillary, Tympanic, Oral)
13 years- 97.9F (36.6) (Axillary, Tympanic, Oral)

Question 2

Pulse/ HR

Answer 2

Newborn: 80-180/min
1 week to 3 months: 80-220/min
3 months to 2 years: 70-150/min
2 years to 10 years: 60-110/min
10 years and older: 50-90/min

Question 3

Respirations

Answer 3

Newborn - 1 year: 30-60/min
1-2 years: 25-30/min
3-6 years: 21-25/min
6-12 years: 19-21/min
12 years and older: 16-19/min

Question 4

Blood Pressure

Answer 4

Infants: 65-78/41-52

Girls
1 year: 83-114/38-67
3 years: 86-119/47-76
6 years: 91-122/54-83
10 years: 98-129/59-88
16 years: 108-138/64-93

Boys
1 year: 80-114/34-66
3 years: 86-120/44-75
6 years: 91-125/53-84
10 years: 97-130/58-90
16 years: 111-145/63-94

Question 5

Eyes/ Ears

Answer 5

Irises should be round with permanent color manifesting 6-12 months

infants and toddlers: pull pinna down and back
over 3 years: pull pinna up and back

tympanic membrane should be pearly pink or gray

Question 6

Development of a baby

Answer 6

-3 months: head side to side
-4 months: head control
-6 months: sit up
-12 months: walking

Question 7

Mouth/ Tongue

Answer 7

Infants have white coatings on tongue from milk

children/ adolescents should have pink symmetric tongues

have 6-8 teeth by 1 year

hard and soft pallets: intact, firm and concave

Tonsils: infants - might be visible, Children - barely visible

Speech: infants - strong cry, Children/ adolescents - clear and articulate

Question 8

Heart sounds/ Pulses

Answer 8

S1 and S2 heart sounds should be clear and crisp

sinus arrhythmias that are associated with respirations are common

infants: brachial, temporal, and femoral pulses are palpable, full and localized
Children/ adolescents: pulse locations and expected findings same as adults

Question 9

Abdomen

Answer 9

Without tenderness, no guarding, peristaltic waves visible in thinner children

symmetric and without protrusions around umbilicus

infants and toddlers have rounded abdomens
children and adolescents have flat abdomens

bowel sounds heard every 5-30 seconds

Question 10

Genitalia

Answer 10

Anus: surrounding skin should be intact
routine rectal exams are NOT done with pediatric population
Male: hair distribution is diamond shaped after puberty
no pubic hair noted in infants and small children

Question 11

Penis

Answer 11

should appear straight
urethral meatus should be at tip of penis
foreskin might be retractable in infants and small children
enlargement of the penis

Question 12

Female

Answer 12

no pubic hair
labia: symmetric without lesions
clitoris: small without bruising/ edema
urethral meatus: slit like in appearance with no discharge
vaginal orifice: hymen can be absent, or completely or partially cover vaginal opening prior to sexual intercourse

Question 13

Spine

Answer 13

Infant: spines should be without dimples or tufts of hair midline with overall c shaped lateral curve

toddlers appear squat with short legs and protuberant abdomens

children should develop the cervical, thoracic and lumber curvature like adults

adolescents should remain midline (no scoliosis noted)

Question 14

5 important factors of Safe Admin

Answer 14

-Drug Allergies
-Age of the child
-Stages of physical, social, intellectual and emotional development
-How medications are taken at home
-Child’s preference of form, flavor

Question 15

Nursing Assessment

Answer 15

-medication and food allergies
-appropriateness of medication dose for the child’s age and weight
-child’s development age
-child’s physiological and psychological condition
-tissue and skin integrity when administering intramuscular, subcutaneous, and topical medications
-IV patency
-calculate the safe dosage for medication
-notify the provider if medication dosage is determined to be outside the safe dosage range
-double check high risk and facility regulated medications with another nurse
-use two client identifiers prior to administration: clients name and date of birth
-two identifiers from the ID band must be confirmed: client name, DOB, or hospital identification number
-determine parental involvement with administration
-allow the child to make appropriate choices regarding administration
-prepare the child according to age and developmental stage

Question 16

Oral Medication

Answer 16

-determine ability to swallow pills
-use the smallest measuring device for doses of liquid medication. avoid measuring in a teaspoon or tablespoon
-avoid mixing medication with formula or putting it in a bottle of formula
-hold the infant in a semi reclining position similar to a feeding position
-hold child in upright position to prevent aspiration
-administer med in side of mouth in small amounts

Question 17

Optic

Answer 17

-place the child in a supine or sitting position
-extend the child’s head and ask the child to look up
-pull the lower eye lid downward and apply medication in the pocket
-administer ointments before nap or bedtime
-if infants clench eyes closed, place the drops in the nasal corner. when the infant opens his eyes, the medication will enter the eye
-apply light pressure to the lacrimal pun prevent unpleasant taste
-play games with younger children

Question 18

Otic

Answer 18

-place the child in a prone or supine position with the affected ear upward
-children younger than 3 years: pull pinna down and back
-children older than 3 years: pull pinna up and back
-allow refrigerated medications to warm to room temperature prior to administration
-massage the outer area for a few minutes following administration
-play games with younger children

Question 19

Nasal/ Aerosol

Answer 19

Nasal:
-position the child with the head extended
-use a football hold for infants
-insert the tip into the saris vertically, then angle it prior to administration

Aerosol:
-use a mask for younger children
-provide atraumatic care
-allow parents to hold the child during treatment
-use distraction

Question 20

Rectal

Answer 20

-insert beyond both rectal sphincters
-hold buttocks gently together for 5-10 mins
-halve the medication lengthwise, if necessary
-provide atraumatic care
-perform the procedure quickly
-use distraction

Question 21

Injection

Answer 21

-secure the infant
-assess the need for assistance
-avoid tracking of medication
-when selecting sites, consider the following:
–medication amount, viscosity, and type
–muscle mass, condition, access of site, and potential for contamination
–treatment course and number of injections
–age and size of child

Question 22

Subcutaneous

Answer 22

-give anywhere there is adequate subcutaneous tissue
-common sites are the lateral aspect of the upper arm, abdomen, and anterior thigh
-inject volumes of less than 0.5mL
-use a 1mL syringe with a 26- 30 gauge needle
-insert at a 90 angle. use a 45 angle for children who are thin
-check policy for aspiration practices

Question 23

Intramuscular

Answer 23

-use a 22 - 25 gauge 1/2 - 1 inch thick needle
-vastus lateralis is the recommended site in infants and small children
-position the child supine, side lying, or sitting
-inject up to 0.5mL for infants
-inject up to 2mL for children

Question 24

IV- Peripheral Venus Access Devices

Answer 24

-use a 24-20 gauge catheter
-use for continuous and intermittent IV medication administration
-short term IV therapy can be completed at home with the assistance of a home health nurse
-assess venipuncture site per facility protocol and prior to administration of medications

Question 25

IV- Central Venus Access Devices

Answer 25

-

Question 26

IV Placement

Answer 26

-