Pediatrics Flashcards
What teachings are important to include in the primary health care needs of a child with a disability?
Make sure parents know normal milestones, so they know what is abnormal
When does grief become abnormal?
When it causes the sufferer to neglect other parts of their life
What mile stones should occur at 6 weeks?
Infant recognizes faces, social smile, turns head from side to side, and begins to get some head control
By what point should an infant have full head control?
3-4 months
By what point should an infant sit up by themselves?
5-6 months
By what point do most infants begin to crawl?
10-11 months
By what point should an infant begin to walk?
12 months
What does the birth weight do by six months?
Doubles
What does the birth weight do by 12 months?
Triples
When does the posterior fontanel close?
2 months
When does the anterior fontanel close?
18 months
When should an infant start to speak?
12 months
What stage does Erikson say infants are in?
Trust vs. Mistrust
At what age will an infant develop separation anxiety?
7-8 months
What toys are appropriate for an infant?
Rattles, blocks, or anything bright and noisy
How old is a toddler?
1-3 years
At what age should a toddler reach 50% of their adult height?
2 years
When should a toddler throw a ball overhand?
18 months
When should a toddler kick a ball?
2 years
When should a toddler feed himself with a spoon?
2 years
Why do toddlers have temper tantrums?
They are developing a sense of autonomy and independence
How long should the sentences of a 2 year old be?
2-3 words
When should a toddler be potty trained?
2 years
What toys are appropriate for a toddler?
Crayons and pull-push toys
When should a child be screened for obesity?
1-3 years old
When should a child learn to tie his shoes?
5 years
Why does colorblindness become evident in childhood?
Because they are learning colors and shapes
What is Erikson’s stage for a child?
Initiative vs. Guilt
What do children see a hospitalization as?
Punishment
How should a child be spoken to in the hospital?
Explain everything you can to them
What toys are appropriate for a 3-6 year old in the hospital?
Coloring books, dolls, and blocks
What stage does Erikson think a school-aged child is in?
Industry vs. Inferiority
What toys are appropriate for a school-aged child?
Board games and card games
What does Tanner’s developmental scale show?
Puberty stages
When does adult thinking develop?
15 years
What stage does Erikson think adolescents are in?
Identity vs. Role Confusion
The nurse is caring for an 8-year-old child who has a chronic illness. The child has a tracheostomy, and a parent is rooming-in during this hospitalization. The parent insists on providing almost all of the child’s care and tells the nurses how to care for the child. When planning the child’s care, the primary nurse should recognize that the parent is:
The expert in care of the child
Denial is a common reaction to the diagnosis of a disability or chronic illness. The nurse knows that the use of denial as a defense mechanism:
Is a necessary cushion to prevent disintegration
The potential effects of chronic illness or disability on a child’s development vary at different ages. Which is a threat to a toddler’s normal development?
Hindered mobility
A 9-year-old child has several physical disabilities. His father explains to the nurse that his son concentrates on what he can, rather than cannot do and is as independent as possible. The nurse’s best interpretation of this is that:
The child is using an adaptive coping style
The nurse notes that the parents of a critically ill child spend a large amount of time talking with the parents of another child who is also seriously ill. They talk with these parents more than with the nurses. The nurse should recognize that the:
Parent-to-parent support is valuable
Parents ask the nurse for advice when telling their 4-year-old about a grandmother’s death. The nurse’s best response involves teaching the parents that the child’s concept of death is:
Temporary
A 5-year-old girl’s sibling dies from sudden infant death syndrome. The parents are concerned because she showed more outward grief when her cat died than she is showing now. The nurse should explain that:
The death may be so painful and threatening that the child must deny it for now
A child who is terminally ill with bone cancer is in severe pain. Nursing interventions should be based on knowledge that:
Large doses of opioids are justified when there are no other treatment options
The nurse is caring for a child dying from cancer. Physical signs that the child is approaching death include:
A change in respiratory pattern
Several nurses tell their nursing supervisor that they want to be able to attend the funeral of a child for whom they had cared. They say they felt especially close to both the child and the family. The supervisor should recognize that attending the funeral is:
Appropriate because it can assist in the resolution of personal grief
A terminally ill male adolescent is being admitted to the hospital due to lack of pain relief. When communicating with this patient about his feelings on death, the nurse should incorporate which actions into the plan of care?
Reassure the adolescent that the illness is not a result of him not cleaning his room and allow the adolescent to participate in the treatment decisions as much as possible
When planning a child safety health fair presentation addressing causes of death in children, the nurse should include which topics?
Sexually transmitted infection prevention for 15 to 19 years old; gun safety for 10 to 14 year olds; information on bullying and violence prevention for 15 to 19 year olds
What is the average IQ?
90
What are the requirements for a diagnosis of intellectual disability?
Subaverage IQ, impairment in 2 of 10 adaptive skills, and younger than 18
What are the adaptive skills?
Communication, home living, community use, leisure, health and safety, self-care, social skills, academics, work, and self-direction
How can intellectual impairment be prevented?
Folic acid
What are the clinical manifestations of Down’s syndrome?
Square head, small mouth, wide, slanted eyes, low ears, hypotonia, flat nose
What physical problems are children with Down’s syndrome at greater risk for?
Congenital heart disease, hypothyroidism, and leukemia
What is Fragile X syndrome caused by?
An abnormal gene on the lower end of the long arm of the X chromosome
What are the types of hearing loss?
Conductive, sensorineural, and mixed
What are the types of visual impairment?
Refraction, myopia, hyperopia, strabismus, and amblyopia
What is the nursing priority for a baby with vision loss?
Promote parent-child attachment
Which infectious disease can cause blindness?
Rubella
The primary goal in caring for the child with cognitive impairment is to:
Promote optimal development
The parents of a cognitively impaired child ask the nurse for guidance with discipline. The nurse’s BEST response is:
“Behavior modification is an excellent form of discipline.”
The genetic testing of a child with Down syndrome (DS) showed that it was caused by translocation. The parents ask about further genetic testing. The nurse’s BEST response for the parents is:
“The parents can be tested themselves because the child’s condition might be hereditary.”
A 2-week-old infant with Down syndrome is being seen in the clinic. His mother tells the nurse that he is difficult to hold; that “He’s like a rag doll. He doesn’t cuddle up to me like my other babies did.” The nurse’s best interpretation of this lack of clinging or molding is that it is:
The result of the physical characteristics of Down syndrome
The parents of a child with fragile X syndrome want to have another baby. They tell the nurse they worry that another child might be similarly affected. The MOST appropriate nursing action is to:
Explain that prenatal diagnosis of the syndrome is now available
A 6-year-old child has difficulty hearing faint or distant speech. His speech is normal, but he is having problems with his school performance. This hearing loss would MOST likely be classified as:
Slight
Early detection of a hearing impairment is critical because of its effect on areas of a child’s life. The nurse should evaluate further for effects of the hearing impairment on:
Speech development
A child in the clinic exhibits reduced visual acuity in one eye despite appropriate optical correction. The nurse expects the child’s health care provider to diagnosis the child with:
Amblyopia
A 5-year-old male child has bilateral eye patches that were put in place after surgery yesterday morning. Today he can be allowed to get out of bed. The MOST important nursing intervention is to:
Orient him to his immediate surroundings
Autism is a complex developmental disorder. Diagnostic criteria for autism include delayed or abnormal functioning in which area(s) before 3 years of age?
Social interaction; Inability to maintain eye contact; Language as used in social communication
The nurse working in an outpatient eye clinic should report which clinical manifestations to the health care provider out of concern for retinoblastoma?
White eye reflex; Strabismus; Red, painful eye, often with glaucoma; Sever permanent visual impairment
What are the phases of separation anxiety?
Protest phase, despair phase, and detachment phase
At what age does a child remember pain?
2-3 years
Which behavior would most likely be manifested in a young child experiencing the protest phase of separation anxiety?
Clings to parent
The most consistent indicator of pain in infants is:
Facial expression of discomfort
The psychosexual conflicts of preschool children make them extremely vulnerable to:
Bodily injury or pain
The nurse needs to start an intravenous (IV) line on an 8-year-old child to begin administering intravenous antibiotics. The child starts to cry and tells the nurse, “Do it later, O.K.?” The nurse should:
Start the IV line because unlimited procrastination results in heightened anxiety
A 4-year-old child will be having cardiac surgery next week. The child’s parents call the hospital, asking about how to prepare her for this. The nurse’s BEST response is to inform the parents that:
Children who are prepared experience less fear and stress during hospitalization
A mother tells the nurse that she will visit her 2-year-old son tomorrow about noon. During the child’s bath, he asks for mommy. The nurse’s BEST reply is:
“Mommy will be here at lunch”
The nurse working in an outpatient surgery center for children should understand that:
Families need to be prepared for what to expect after discharge
When completing a health history on a hospitalized child, the nurse should assess for which factors that can commonly affect the parents’ reaction to the child’s illness?
Previous experience with illness or hospitalization; Available support systems; Medical procedures involved with treatment; Previous coping abilities; Cultural and religious beliefs
When admitting a child to the inpatient pediatric unit, the nurse should assess for which risk factors that can increase the child’s stress level associated with hospitalization?
Lack of fit between parent and child; Below-average intelligence; Age; Gender
The nurse is discharging a young child from the hospital. The nurse should instruct the parents to look for which posthospital child behaviors?
Tendency to cling to parents; Demands for parents’ attention; New fears such as nightmares; Jealousy toward others; Anger toward parents
What drugs are generally used to anesthetize children?
Benzodiazapine and propovol
What are the alternatives to restraining a child?
Diversional activities, parental participation, and therapeutic holding
Where are specimen collected from children?
Heels
Why are IVs for children always on a smart pump?
Because it helps to preserve the IV access site
What type of inhaler is appropriate for all children?
Metered-dose with a spacer
How should oxygen be administered to a child?
It should always be humidified
What size ET tube should be used on a child?
The size of the ET tube should match the diameter of the child’s pinky finger
How are tube feeds administered to a child?
Bolus
How are Gavage feeding tubes checked for placement?
Air bolus
Why should cold water enemas not be given to children?
They can cause shock
The preferred site for an IM injection in a child is:
Vastus lateralis
The nurse needs to take the blood pressure of a preschool boy for the first time. Which action would be BEST in gaining his cooperation?
Permitting him to handle equipment and see the dial move before putting the cuff in place.
It is time to give a 3-year-old boy his medication. Which approach is MOST likely to receive a positive response?
“It’s time for your medication now. Would you like water or apple juice afterward?”
The nurse is doing preoperative teaching with a child and his parents. The parents say that he is “dreading the shot” for premedication. The nurse’s response should be based on the knowledge that:
Preanesthetic medication should be “atraumatic,” using oral, existing intravenous, or rectal routes
A 10-year-old female child requires daily medications for a chronic illness. Her mother tells the nurse that she is always nagging her to take her medicine before school. What is the MOST appropriate nursing action to promote the child’s compliance?
Establishing a contract with her, including rewards
A 7-year-old female child has a fever associated with a viral illness. She is being cared for at home. The nurse should recognize that the principal reason for treating fever in this child is:
Relief of discomfort
Standard Precautions for infection control include that:
Gloves are worn to change diapers when there are loose or explosive stools
The nurse is preparing a plan to teach a mother how to administer 1½ teaspoons of medicine to her 6-month-old child. The nurse should recommend using:
A plastic syringe (without needle) calibrated in milliliters
Several types of long-term central venous access devices are used. A benefit of using an implanted port (e.g., Port-a-cath) is that it:
Does not need to limit regular physical activity, including swimming
The nurse observes erythema, pain, and edema at a child’s intravenous (IV) site with streaking along the vein. What should the nurse do FIRST?
Immediately stop the infusion
The best explanation for why pulse oximetry is used on young children is that it:
Is noninvasive
When is bronchial (postural) drainage generally performed?
Before meals and at bedtime
The nurse is caring for an infant with a tracheostomy when accidental decannulation occurs. The nurse is unable to reinsert the tube. What should be the NEXT action by the nurse?
Try to insert a smaller-sized tube
A neonate had corrective surgery 3 days ago for esophageal atresia. The nurse notices that after the child receives his gastrostomy feeding, there is often a backup of formula feeding into the tube. As a result, the nurse should:
Leave the gastrostomy tube open and suspended after feedings
Informed consent is valid when:
A person is over the age of majority and competent; information is provided to make an intelligent decision; the choice exercised is free of force, fraud, duress, or coercion
When caring for a child with an intravenous (IV) infusion, the most appropriate nursing interventions are to:
Use an infusion pump with a microdropper to ensure the prescribed infusion rate; check IV fluids and infusion rate with another licensed professional; observe the insertion site frequently for signs of infiltration
What are the signs of respiratory distress in a child?
Obtunded, retracted, lethargic and inconsolable
Why are preterm babies at risk for alveolar collapse?
They have too little surfactant
What anti-viral is used to treat RSV?
Ribavarin
Who is at risk for developing RSV?
Children over 6 weeks but under 2 years
What is the causative agent for ear infections?
Haemophilus influenzae
What needs to be avoided in a child with RSV?
Dehydration
What are the signs and symptoms of RSV?
High fever, expiratory wheezing and cyanosis
Why does the infection rate increase in children 3-6 months old?
They lose the immunity from their mother
When is RSV season?
Winter and spring
When is infection-related asthma season?
Cold weather
When are mycoplasmal infections common?
In the fall and winter
What is seen in newborns instead of a fever?
A drop in temperature
What are the nursing priorities for children with respiratory infections?
Ease respiratory effort, promote rest and comfort, prevent the spread of infection, reduce temperature, promote hydration and nutrition, and provide support and reassurance
How can the flu be prevented in infants?
Vaccinate mom during the pregnancy
What are children with streptococcal pharyngitis at risk for developing?
Rheumatic fever
How is acute streptococcal pharyngitis treated in a child?
Tylenol, antibiotics, and fluid
Which type of wheezing is most ominous in children?
Inspiratory and expiratory
Why are tonsillectomies no longer performed unless there is an emergency?
It is very easy to hemorrhage after
When is a child at risk for hemorrhage post-tonsillectomy?
24-48 hours, then 5-14 days
When is surgical intervention necessary for children with otitis media?
When the build-up of fluid will not resolve on its own
What virus causes mononucleosis?
Epstein-Barr
What is the diagnostic test for mononucleosis?
Blood tests
What organs need to be periodically checked for a pediatric patient with mononucleosis?
Spleen and liver
What nursing care is needed for children with mononucleosis?
Steroids, proper nutrition and supportive care
What does mononucleosis usually follow?
A previous infection
Characterized by hoarseness, “barking” cough, inspiratory stridor, and varying degrees of respiratory distress
Croup
When is Croup more common?
Winter
What respiratory organs does Croup affect?
Larynx, trachea, and bronchi
What causes Croup?
H. influenzae type B
What does the severe cough cause children to do?
Stop breathing
What are the signs and symptoms of epiglottitis?
Drooling, tripod positioning, anxiousness, flushed face and wheezing
How is epiglottitis treated?
Steroids and the intubation or tracheotomy
What causes epiglottitis to worsen?
Crying and anxiousness
What are the manifestations of laryngotracheobronchitis?
Inspiratory stridor, suprasternal retractions, “barking” cough, hypoxia, and respiratory acidosis
How is LTB managed?
Maintain airway, maintain hydration, and nebulize with oxygen, steroids, and epinephrine
When does spasmodic laryngitis occur?
At night
What is the distinguishing sign of bacterial tracheitis?
Thick, purulent secretions that result in respiratory distress
Which respiratory disease is a possible precursor to asthma?
Spasmodic laryngitis
Why are cough suppressants rarely used in children?
There is an increased risk of pneumonia
What does bacterial pneumonia look like on an x-ray?
Consolidated
What does viral pneumonia look like on an x-ray?
Inflammation and mucous throughout lungs
What causes mycoplasmic pneumonia?
Inhaled substances
Who is pertussis common in?
Infants under 2 months
What is the treatment for pertussis?
Antipyretics, fluids, oxygen and supportive care
When is pertussis most common?
Spring and summer
What is the hallmark of TB?
Juicy cough
How is TB diagnosed?
Three sputum samples
What drug prevents the development of TB?
INH
What drug is used to treat TB?
Rifampin
What age group is most at risk for foreign body aspiration?
1-3 years
What children are most at risk for aspiration pneumonia?
Children with feeding difficulties, like a cleft lip or palate
How can aspiration pneumonia be prevented?
Hold head up high while feeding
Respiratory distress and hypoxia within 72 hours of a serious injury or surgery
Acute Respiratory Distress Syndrom
What causes ARDS?
An overreaction of the immune system
How is ARDS treated?
High pressure ventilation
What indicates smoke inhalation?
Singed nasal hairs and soot in nasal cavity
How is smoke inhalation treated?
Administer humidifying oxygen at 100%
How is asthma diagnosed?
Peak flow meter
What is the goal for children with asthma?
To maintain normal activity levels
What drugs are used for asthma maintenance?
Advair and singulair
What needs to be taught about asthma maintenance drugs?
They cannot be abruptly stopped
What is the side effect of too much theophylline?
Seizures
How is status asthmaticus treated?
IV steroids and SQ epinephrine
A humidified atmosphere is recommended for a young child with an upper respiratory tract infection because this environment facilitates:
Soothing inflamed mucous membrane
It is important that a child with Group A ß-hemolytic streptococci (GABHS) infection be treated with antibiotics to prevent:
Acute rheumatic fever
When caring for a child after a tonsillectomy, the nurse should:
Watch for continuous swelling
A 4-year-old girl is brought to the emergency room. She has a “froglike” croaking sound on inspiration, is agitated, and is drooling. She insists on sitting upright. The nurse should:
Notify the physician immediately and be prepared to assist with a tracheostomy or intubation
The mother of a 20-month-old boy tells the nurse that he has a barking cough at night. His temperature is 37° C. The nurse suspects croup and should recommend:
Trying a cool-mist vaporizer at night and watching for signs of difficulty breathing
An infant with a congenital heart defect is receiving palivizumab (Synagis). The purpose of this is to:
Prevent respiratory syncytial virus (RSV) infection
A child with asthma is having pulmonary function tests. The purpose of the peak expiratory flow rate (PEFR) is to:
Assess the severity of asthma
A 4-year-old boy needs to use a metered-dose inhaler to treat asthma. He cannot coordinate the breathing to use it effectively. The nurse should suggest that he use a:
Spacer
One of the goals for children with asthma is to prevent respiratory infection. This is because respiratory infection:
Can trigger an episode or aggravate an asthmatic state
An immediate intervention when an infant chokes on a piece of food would be to:
Position the infant in a head-down, face-down position and administer five quick blows between the shoulder blades
Asthma is classified into four categories: mild intermittent, mild persistent, moderate persistent, and severe persistent. Clinical features used to determine these categories include:
Lung function; frequency of symptoms; frequency and severity of exacerbations
A 5-year-old child is brought to the Emergency Department with abrupt onset of sore throat, pain with swallowing, fever, and sitting upright and forward. Acute epiglottitis is suspected. What are the most appropriate nursing interventions?
Vital signs; medical history; assessment of breath sounds; emergency airway equipment readily available
Abdominal pain or cramping that is manifested by loud crying and drying the legs up to the abdomen
Colic
When does colic resolve?
12-16 weeks
What are colicky babies at risk for?
Inadequate bonding and abuse
What are the causes of failure to thrive?
Inadequate caloric intake, inadequate absorption, increased metabolism, defective utilization, and poor parenting
What percentile does the child have to fall below for a diagnosis of failure to thrive?
5th
What are the nursing interventions for colic?
Gripe water, reglan, gas-x, put the baby over knee, walking, burping, pressure
What are the nursing interventions for SIDS?
Put the baby on its back with nothing in the crib, hard pacifiers, support
What are the nursing interventions for FTT?
Hold, cuddle, supplemental food, observe parenting
How can motor vehicle injuries be prevented?
Proper restraint of the child
What type of burn is the most common in children?
Scalding
How can burns be prevented?
Turn pot handles, turn water temperature down and smoke detectors
What are the signs of bacterial meningitis?
Extremely high fever, inconsolable child, and lethargy
Why should a child never be given aspirin?
It can cause a brain herniation
What are the signs of ADHD?
Inattention, hyperactivity, and impulsivity
What causes school phobia?
A fear of failure
What reproductive disorders can occur in male children?
Infection, hematuria, gynecomastica, precocious puberty, STIs, and testicular torsion
What reproductive disorders can occur in female children?
Amenorrhea, dysmenorrhea, and STIs
What is the main concern for a child with bulimia?
Fluid and electrolyte imbalance
How is congenital hypothyroidism diagnosed?
Neonatal screenings
What are the signs of congenital hypothyroidism in early infancy?
Depressed nasal bridge, short forehead, puffy eyelids, large tongue, thick/dry/mottled skin, coarse/dry/lustless hair, abdominal distention, umbilical hernia, hyporeflexia, bradycardia, hypothermia, hypotension, anemia, widely paten cranial sutures, prolonged jaundice and consitpation
What are the outcomes of untreated congenital hypothyroidism?
Permanent cognitive impairment
What are the metabolic effects of PKU?
FTT, vomiting, immobility, hyper-reactivity and erratic behavior
What two formulas are prescribed for infants with PKU?
Phenex-1 for infants and Phenex-2 for children and adults
What foods are high in phenylalanine content?
High protein foods, sweeteners, nuts, eggs, and fish
What are the three classic signs of diabetes?
Polyphagia, polydipsia, and polyuria
What are the signs of hypoglycemia?
Nervousness, pallor, tremulousness, palpitations, sweating, hunger, weakness, dizziness, headache, fatigue, irritability, loss of coordination, seizures and coma
What glucose level is considered to be hypoglycemic?
Under 60 mg/dL
What glucose level is considered to be hyperglycemic?
Over 250 mg/dL
What are the signs of hyperglycemia?
Confusion, thirst, weakness, fatigue, nausea, vomiting, abdominal pain, flushed, weak pulse, ketosis
What is the priority nursing care for children with ketoacidosis?
Administer fluids, electrolytes and insulin
What is the purpose of bronchodilators?
They relax the smooth muscles of the airways
What are the physical assessment findings for a child with asthma?
Inflammation, wheezing, breathlessness, chest tightness, cough, dyspnea, and itching
When does a cough occur for children with asthma?
At night or in the early morning
What nutritional support should be provided to a child with CF?
High fat and high calorie diet
What are the seven signs of respiratory distress in a pediatric client?
Restlessness, tachypnea, tachycardia, diaphoresis, nasal flaring, chest wall retraction, and wheezing/grunt
What position does a child with epiglottitis assume?
Tripod
Why are IV fluids important for a child with increased respiratory rate?
To prevent dehydration
Children with chronic otitis media are at risk for developing what problem?
Impaired hearing
What systems are involved in Cystic Fibrosis?
Thickened mucous gland secretions, elevated sweat electrolytes, increased enzymatic constituents of saliva and autonomic nervous system abnormalities
Why do children with CF have so many infections?
Their thickened mucous secretions act as a trap
What systems are predominantly affected in patients with CF?
Respiratory tract and pancreas
How is CF diagnosed?
Sweat chloride test
What kind of a cough do patients with CF present with?
Dry, non-productive
What is generally the first sign of CF?
Meconium ileus
What do the stools of a patient with CF look like?
Bulky, frothy, and have a foul odor
Why are children with CF chronically dehydrated?
They are not taking in fluids and have a high insensible loss
What kind of electrolyte imbalances do patients with CF have?
Hyponatremia, hypochloremia, and hypoalbuminemia
Why do patients with CF have chronic hypoxia?
Their bronchial epithelium gets destroyed with chronic infections, leading to a decreased O2/CO2 exchange
Why can the pancreatic enzymes of patients with CF not get to the duodenum?
Their thick secretions block the ducts
What digestive problems do patients with CF have?
Impaired digestion/absorption of fat and protein
What is the priority in caring for patients with CF?
Airway
Why should patients with CF exercise?
To strengthen their lungs
How should pancreatic enzymes be administered?
With food
What should patients with CF avoid?
Dairy
What does the diet of a patient with CF look like?
High protein, high calorie
When should chest PT be done for patients with CF?
Prior to meals or no sooner than 1 hour after meals
What are some symptoms of renal system dysfunction in children?
Very high fever, foul smelling urine, dry diapers and a change in demeanor
Why are uncircumcised boys under 3 months at high risk for UTIs?
Lack of knowledge on how to care for penis
If a pediatric patient has febrile symptoms associated with a UTI, what does that indicate?
Pyelonephritis
Infection in the upper urinary tract and kidneys
Pyelonephritis
Inflammation of the bladder
Cystitis
Bacterial illness; urinary pathogens in the blood
Urosepsis
Why is E. coli generally responsible for UTIs?
It is the primary bacteria in the stool
What is the single most important contributing factor for UTIs in children?
Stasis
How are UTIs treated?
An antibiotic, generally bactrim
A complication of a UTI in which the urine back up above the obstruction
Hydronephrosis
