Pedi 2016 Rationales:
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The nurse should identify the lower right quadrant of the abdomen between
the umbilicus and the anterior iliac crest as the location of mcburneys point.
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The nurse should instruct the parents to apply a thing layer of antibiotic
ointment on the infants suture line daily for 3 days and then continue to
apply petroleum jelly to the area for several weeks to promote healing.
Avoid placing tongue depressors in the infants mouth to prevent injury to the
suture line ( cheiloplasty).
Clean the infant’s sutures with sterile water or diluted hydrogen peroxide
following each feeding.
Excessive swallowing is indication of bleeding and should be reported to the
provider immediately.
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Symmetric burns of the lower extremities are clinical manifestations physical
abuse
.recurrent uti ate manifestations of sexual abuse.
Growth failure is a manifestation of physical neglect to malnutrition.
Lack of subcutaneous fat is Physical neglect. This manifestation is result of
poor healthcare, infections that were untreated, and .or lack or delay child
hood immunizations.
Inform the adolescent that wearing sandals, open toed, or well-ventilated
shoes will promote healing of his fungal infection. ( tinea pedis).
Plastic shoes increase the occurrence of tinea pedis.
Permethrin 5% cream is a scabide used to place on lesions.
Sealing non-washable items in plastic bags for 14 days is a recommend
practice for clients who have pediculosis.
Schedule toddler for a lead level rescreening in 1 year and educate the family
on ways to prevent exposure if lead is 4.
A serum lead level of 4 does not require a report of CPS.
Chelation therapy is required for a lead level of 45 mcg/dl or greater, and
depending on the situation can be initiated for lead levels over 10 mcg/dl.
Provide a diet rich in calcium because calcium, vitamin C and iron decrease
lead absorption.
The nurse should plan to maintain the adolescent on droplet precautions for
at least 24 hr following initiation of antimicrobial therapy. This practice will
ensure that the adolescent is no longer contagious, which protects family
members and the personnel caring for the client. Prophylactic antibiotics
might be prescribed to individuals who were in close contact with the client.
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Playing dress up is a play activity for pre school age child to socialize.
Creating a scrapbook is play activity for a school age child.
Using a push pull tory is a play activity for toddler.
Playing pat a cake is play activity for an infant.
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Sunken anterior fontanel = moderate to severe dehydration due to acute loss
of fluid.
Cap refill of 2 seconds is within expected range for a 3 month infant. An
infant who has moderate to severe dehydration is more likely to have
delayed cap refill of greater than 2 seconds.
Absence of tears = moderate to severe dehydration.
HR of 124 is within range. A 106 to 186 for a 3 to 5 month old infant.
Moderate to severe dehydration to have tachycardia.
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Over secretion of antidiuretic hormone leads to a decrease in urine output,
hyponatremia, and hypoosmoliaty due to over hydration.
SIADH will have fluid overload, full, bounding pulses, increased BP, and
tachycardia.
SIADH will have concentrated urine and urine specific gravity above the
expected reference range.
Sodium level of 148 is above the expected range. SIADH has a decreased
sodium level due to increased circulation of free water.
Septic shock = fever and chills.
Urinary output 100ml.hr is above expected range for a 10 year old. Septic
shock UO is within normal ranges.
HR of 60 is below the expected range for a 10 year old. Septic shock will be
within range.
BP 130/90 is above range. Septic shock will be within expected range.
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Blood cultures are drawn before the first dose of antibiotics. Takes 48 to 72
hrs for the organism to grow enough for identification. BC. are not a
determined factor for droplet precautions.
A temp within the expected reference range for an adolescent can be
achieved with acetaminophen. NOT factor for droplet.
The greatest risk to this child (tonic seizure) is aspiration, occlusion of the
airway, and bodily injury falling out of the chair. The nurse should ease the
child down to floor in a side lying position immediately. This position enables
the child secretions to drain from the mouth, preventing aspiration, and
maintaining a patent airway.
Apply oxygen mask to the child to prevent hypoxia. NOT FIRST ACTION.
Loosen childs clothing. NOT FIRST ACTION.
Clear area. NOT FIRST ACTION.
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Suspect child maltreatment if the adolescent exhibits a substance use
disorder with mood elevating drugs or alcohol.
Suspect child maltreatment if the adolescent expresses a desire to run away
from home.
Performance rapidly declines or stops attending classes.
Withdrawn behavior and poor relationships with peers.
The child is contagious 1 day prior to lesion eruption and until the vesicles
have crusted over, which takes about 6 days.
The incubation period of varicella is two to three weeks. However, this is not
related to the appearance and disappearance of the lesions.
The nurse should inform the parents that the child will remain contagious
longer than three days after the lesions appear.
Inform the parent that the absence of fever does not indicate the child is no
longer contagious.
Children who have cystic fibrosis require a high in protein and calories diet.
Need a diet that is unrestricted in fat. Require 35-45% of their calories to
come from fats.
No need to take supplemental sodium chloride tablets, diet should be
enough.
Diet high in calories, protein and carbs.
Cerebral palsy will have positive Babinski reflex, ankle clonus, spasticity or
exaggerated stretch reflexes, and contractures.
Uncontrollable movements of the face and extremities are nonspastic (
dyskinetic) cerebral palsy.
Priority for pneumonia is ABCS. Priority is nasal flaring. It indicates that the
infant is experiencing acute respiratory distress.
WBC of 11,300 is above and indicates infection. NOT FIRST.
Report diarrhea but NOT FIRST PRIORITY.
Instruct the parents to crush the childs teeth after giving digoxin to prevent
tooth decay caused by the med.
Instruct the parents to use the calibrated device that comes with medication
(digoxin) when measuring the med to avoid accidental overdose.
Administer digoxin at regular intervals, usually twice a day or every 12
hours. Instruct the parents not to double the med if they miss a dose.
Manifestations of digoxin toxicity are nausea, vomiting, decrease appetite.
Instruct the parents not to administer second dose if these occur.
A RR of 45 is above range for a 3 year old. Could indicate respiratory
dysfunction and acute respiratory distress. Report to provider.
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BP of 90/50 is within range for a 3 yr old.
Weight of 14.5 ( 32ib) is within range.
HR of 110 is within range.
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HCT of 28% is below range for a school age child. The child can exhibit
fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to decrease
oxygen carrying capacity.
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The nurse should inform the parents that her child will need pulmonary
function tests every 12 to 24 months to evaluate the presence of lung disease
and how the child is responding to the current treatment regimen.
When using the child’s airflow using a peak expiratory flow meter should be
done twice daily with the skill repeated in a sequence of three, waiting 20
seconds between each measurement. The parent should record the highest of
the three readings, rather than the average.
Salmeterol inhaler should never be used alone.
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Hydrotherapy is an painful procedure with requires analgesia and/or
sedation.
A nurse should apply mesh gauze to the childs wound following
hydrotherapy to prevent infection.
A nurse should apply topical antimicrobial ointment to the child’s wound
following hydrotherapy to prevent infection.
Encourage the child to perform independent self care. This will minimize the
child’s pain while maximizing the mobility.
Large joints should be exercised regularly.
Juvenile idiopathic arthritis should sleep on a firm mattress to enhance
comfort and rest.
Daily naps are discouraged because stiffness can occur quickly.
Tachypnea= reapid, regular breathing pattern. Occurs with anxiety, fever,
metabolic acidosis, and severe anemia.
Bradypnea= slow, regular breathing pattern.
Cheyne-strokes respirations are periods of apnea alternating with periods of
hyperventilation.
Biots respirations are periods of apnea alternating with two or three shallow
breaths.
Protective factors against sudden infant death syndrome include
breastfeeding and the use of a pacifier when the infant is sleeping.
Use a firm mattress and avoid waterbeds, bean bags and soft mattresses.
Placing the infant on a large pillow to sleep can increase the risk of
suffocation.
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Instruct the parent to place the infant in a supine position to sleep. Prone and
side lying positions are risk factors for SIDS.
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Administer immunization for a 4 year old using a 24 gauge to minimize the
pain.
Inject the immunization rapidly and avoid aspiration.
Allow caregiver to be near.
Place the child in an upright sitting position for the immunization.
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Use FACES pain rating scale for pedi cleints who are 3 years old and older.
Use the numeric pain scale when assessing pain for clients who are 5 years
old and older.
CRIES pain assessment is pain for infants.
Non communicating childs pain checklist when assessing the need for pain
management in pedi clients who have cognitive impairment.
Instruct the parents to administer the eye drops first and then wait min
before administering the eye ointment.
Instruct the parents to use one hand to pull the lower eyelid downward when
installing the eye med to ensure placement of the med in the conjunctional
sac.
Apply the eye ointment from the inner canthus to the outer canthus to
prevent the entry of infectious organisms.
Administer eye ointment prior to nap or bedtime since the medication can
cause temp blurred vision.
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Assess first.
o An episode of forceful vomiting is an indication of increased ICP in a
toddler who has a concussion.
o A report of headache is nonurgent because it is an expected finding
for a child who has infective endocarditis.
o Moderate pain is nonurgent because it is an expected finding for a
child who has a new halo traction device.
o Brown colored urine is nonurgent because it is an expected finding for
a school age child who has acute glomerulonephritis.
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School age child with oral candidiasis begin taking oral nystatin.
o She the med prior to administration in order to disperse the med
evenly.
o Put the med directly in the childs mouth and make sure the child
swishes it around before swallowing.
o Keep the med in the mouth for as long as possible before swallowing.
o Don’t mix med with food.
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Raisins contain highest mount of nonheme iron.
Raw carrots do not contain highest amount of iron.
Orange juice contains ascorbic acid which increase the amount of nonheme
iron absorbed by the body.
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A child who has nephrotic syndrome can experience edema due to the
increased glomerular permeability, which increases protein loss. Prednisone
decreases glomerular permeability, which causes fluid to shift from the
extracellular spaces, decreasing edema.
Expect decreased abdominal girth with prednisone therapy.
Increased appetite is an expected manifestation of corticosteroid therapy.
Expect decreased protein in the urine with prednisone therapy.
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Corticosteroids are the treatment of choice for minimal change nephrotic
syndrome.
MCNS patients are on a low sodium diet during the edema phase. There for
do not increase dietary sodium intake.
Don’t require isolation. Tuberculosis requires isolation.
MCNS are on a dietary restriction during the edema phase.
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The nurse should perform a finer stick on a toddler as a component of the
sickle turbidity. If the test is positive, hemoglobin electrophoresis is required
to distinguish between children who have the genetic trait and children who
have the disease.
An Allen test determines circulation by observing the cap refill.
Sputum specimens are collected to identify the infectious organism in a child
who has an acute respiratory tract infection.
Stool specimens are collected to identify organisms or parasites that cause
diarrhea or to check for presence of occult blood.
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Implement seizure precautions for an infant who has an epidural hematoma
as a safety measure.
Avoid suctioning the infants nares due to risk exposure of the suction
catheter to the brain through the fracture.
The nurse should monitor for indications of brainstem herniation, which
include Cushing’s triad: hypertension, bradycardia, and decreased
respirations.
Position the infant with her head elevated in a midline position to reduce the
risk of increased ICP.
Provide a school age child with a book as developmental activity.
The nurse should limit visitors for a child who has neutropenia because this
places the child at an increased risk for infection.
Large puzzle activity is for a preschooler.
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Use puppets to entertain toddlers. A school age child would not be
entertained for very long time.
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The nurse should refer an infant who is not making babbling sounds by the
age of 7 months to a provider for more extensive evaluation of hearing.
The nurse should refer a preschooler who prefers playing alone and avoids
interaction with others.
The nurse should refer infants who are under the age of 4 months and lack a
startle response to a provider.
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The nurse should teach the mother that her toddler will begin to express her
likes and dislikes. This is the time in life when a toddler is developing
autonomy and self concept. She will try to assert herself and frequently
refuse to comply. The parent should allow the child to have some control but
also set limits in order to learn form her behavior and learn to control her
actions.
Toddlers separate from her for a short of time, but the toddler is more likely
to experience acute separation anxiety when seperated from her mother for
an extended time.
Pre schooler to begin to understand right from wrong. A toddler is curious
but un able to fully understand right from wrong.
School age child is to be abl to control impulsive feelings.
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When having an anaphylactic reaction, administer EPI if the MAIN 1 THING.
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A child who has a head injury can get diabetes insipidus as a result of
pituitary hypofunction leading to a deficiency of antidiuretic hormone.
Underexctretion of antidiurectic hormone leads to polyuria, polydipsia and
possibly dehydration. With the excessive loss of free water, sodium levels
rise.
Blood glucose 45 is below range. DI should have a BG of range,
Urine output of 35 is within range.
Urine specific gravity of 1.045 is above expected range, DI is likely to have
diluted urine and urine specific gravity below the range.
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Instruct the parents to apply a waterproof sunscreen with an SPF of at least
15 for children.
Avoid the liberal application of sunscreen on infants under the age of 6
months. Parents should only apply sunscreen on infants under 6 months to
small areas of exposed skin and should take other measures to reduce or
prevent sun exposure.
Instruct parents to dress their children in a tight weave cotton fabric prior to
sun exposure to protect the skin.
The nurse should instruct parents to reapply sunscreen every 2 to 3 hr.
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