1. Findings you report in a child with Bronchiolitis, next gen (4 Points)
 EXPECTED FINDINGS
o INITIALLY: Rhinorrhea, intermittent fever, pharyngitis, coughing, sneezing, wheezing, possible ear or eye infection
o WITH ILLNESS PROGRESSION: Increased coughing and sneezing, fever, tachypnea and retractions, refusal to nurse or bottle
feed, copious secretions
o SEVERE ILLNESS: Tachypnea (greater than 70/min), listlessness, apneic spells, poor air exchange, poor breath sounds,
cyanosis
2. An infant with a respiratory infection teaching, next gen (3 Points)

3. Infant Immunization, a bow tie (5 Points)
4. Wellness exam in infant, a bow tie (5 Points)
5. Findings to report pneumonia in school age child, next gen (4 Points)
6. A drag an drop next gen, give you the findings figure out the condition, Steven Johnson
Syndrome, Pneumothorax, Pneumonia, Liver Failure (1 Point)
7. Complete the sentence next gen, determine what you should address in a patient that has a cold (2 Points)
8. Complete the sentence next gen, a preschooler, look out for rubeola (2 Points)
9. Care for a child with tonsillectomy
 Tonsillitis: Inflammation of the tonsils often occurs with pharyngitis and, thus, may also be viral or bacterial in nature. Viral infections
require only symptomatic treatment. Treatment for bacterial tonsillitis is the same as for bacterial pharyngitis. Occasionally surgical
intervention is warranted. Tonsillectomy (surgical removal of the palatine tonsils) may be indicated for the child with recurrent streptococcal
tonsillitis or massive tonsillar hypertrophy or for other reasons. When hypertrophied adenoids obstruct breathing, then adenoidectomy
(surgical removal of the adenoids) may be indicated.
 Nursing Management: Tonsillitis that is medically treated requires the same nursing management as pharyngitis.
 Nursing care for the child after tonsillectomy is described below.
o Promoting Airway Clearance: Until fully awake, place the child in a side-lying or prone position to facilitate safe drainage of secretions.
Once alert, the child may prefer to sit up or have the head of the bed elevated. Suctioning, if necessary, should be done carefully to
avoid trauma to the surgical site. Note that dried blood may be present on the teeth and the nares, with old blood present in emesis.
Since the presence of blood can be very frightening to parents, alert them to this possibility.
o Maintaining Fluid Volume: Though unusual postoperatively, monitor for hemorrhage as it may occur any time from the immediate
postoperative period to as late as 10 days after surgery. Inspect the throat for bleeding. Mucus tinged with blood may be expected,
but fresh blood in the secretions indicates bleeding. Watch for continuous swallowing of small amounts of blood while awake or
sleeping as this may indicate early bleeding. Monitor for other signs of hemorrhage including tachycardia, pallor, restlessness,
frequent throat clearing, and emesis of bright red blood.
o To avoid trauma to the surgical site, discourage the child from coughing, clearing the throat, blowing the nose, and using straws. Upon
discharge, instruct the parents to immediately report any sign of bleeding to the physician or nurse practitioner. To maintain fluid
volume postoperatively, encourage children to take any fluids they desire; popsicles and ice chips are particularly soothing. Citrus
juice and brown or red fluids should be avoided: the acid in citrus juice may irritate the throat, and red or brown fluids may be
confused with blood if vomiting occurs.
o Relieving Pain: Educate families that for the first 24 hours after surgery, the throat is very sore. Provide adequate pain relief (may be
with or without narcotics) in order to establish adequate oral fluid intake. Apply an ice collar if prescribed. Counsel parents to maintain
pain control upon discharge from the facility, not only for the child’s sake, but also to enable the child to continue to drink fluids.
10. Celiac disease, food recommendations & teaching (MISSING PICTURE PAGE 693) repeated question #25
 Providing child and family education is the key nursing role in managing children with celiac disease. The child must adhere to a strict
gluten-free diet for his or her entire life. This is often very challenging, because gluten is found in most wheat products, rye, barley, and
possibly oats. Encourage the parents and child to maintain this gluten-free diet. Often, families consult a dietitian to learn about the glutenfree diet
 The only current treatment for celiac disease is a strict gluten-free diet. Eliminating gluten will cause the villi of the intestines to heal and
function normally, with subsequent improvement of symptoms. Even very small amounts of gluten introduced back into the diet can cause
damage to the villi, so the child must adhere to the diet throughout life
11. Bacterial meningitis, precautions & care & Findings
 Bacterial meningitis is an infection of the meninges, the lining that surrounds the brain and spinal cord. It is a serious illness in children and
can lead to brain damage, nerve damage, deafness, stroke, and even death.
 S/S Finding: Sudden onset of symptoms, preceding respiratory illness or sore throat, Presence of fever, chills, Headache, Vomiting,
Photophobia, Stiff neck, Rash, Irritability, Drowsiness, Lethargy, Muscle rigidity, Seizures, infant will be in opisthotonic position
 Lab: positive kerning and Brudzinski, LP—Fluid pressure will be measured, and a sample is obtained for analysis and culture. CSF will be
elevated, and CSF will reveal increased white blood cells (WBCs) and protein and low glucose (the bacteria present feed on the glucose),
Complete blood count (CBC)—WBCs will be elevated, Complete blood count (CBC)—WBCs will be elevated.
 In addition to standard precautions, infants and children diagnosed with bacterial meningitis will be placed on droplet isolation until 24 hours
of antibiotics have been received to help prevent transmission to others.
 Nursing management: Administer prescribed antibiotics as soon as possible after obtaining cultures. Quickly initiate supportive measures to
ensure proper ventilation, reduce the inflammatory response, and help prevent injury to the brain. Interventions are aimed at reducing ICP
and maintaining cerebral perfusion along with treating fluid volume deficit, controlling seizures, and preventing injury that may result from
altered LOC or seizure activity. Initiate appropriate isolation precautions. In addition to standard precautions, infants and children diagnosed
with bacterial meningitis will be placed on droplet isolation until 24 hours of antibiotics have been received to help prevent transmission to
others.
 In addition to those diagnoses and interventions, note any measures taken to reduce fever and prevent bacterial meningitis.
o Reducing Fever: Increased body temperature; warm, flushed skin; and tachycardia may be present. Reducing fever is important to
help maintain optimal cerebral perfusion by reducing the metabolic needs of the brain. Administer antipyretics such as
acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, per order. Institute nonpharmacologic
measures, if needed. Reduce environmental temperature and use cooling blankets, fans, cold compresses, and tepid baths to
help reduce fever. Avoid measures that cause shivering because it increases heat production and is therefore counterproductive
and uncomfortable for the child.
o Preventing Bacterial Meningitis: Bacterial meningitis is a serious illness and prevention is important. It is transmitted by direct
close contact with respiratory droplets from the nose or throat. Most at risk are those living with the child or anyone with whom the
child played or was in close contact. Postexposure prophylaxis and postexposure immunization may be effective. Control
measures should be initiated in environments where risk exists. Disinfect toys and other shared objects to decrease transmission
of the micro-organisms to others. To reduce group B streptococcus infection in neonates, screen pregnant women. If the
screening results are positive, administer intrapartal antibiotics.
12. Influenza, what about the treatment, fever, aspirin
 Influenza viral infection (known commonly as the “flu”) occurs primarily during the winter. It is spread through inhalation of droplets or
contact with fine-particle aerosols. Infected children shed the virus for 1 to 2 days before symptoms begin and may continue shedding the
virus in increased amounts (as compared to adults) for as long as 2 weeks. Average annual infection rates in children range from 10% to
40% (Munoz, 2019). Influenza viruses primarily affect the upper respiratory epithelium but can cause systemic effects as well. Children with
chronic heart or lung conditions, diabetes, chronic renal disease, or immune deficiency are at higher risk for more severe influenza infection
compared to other children. Bacterial infections of the respiratory system commonly occur as complications of influenza infection, severe
pneumococcal pneumonia in particular. Otitis media occurs in 10% to 50% of children with influenza (Munoz, 2019). Rarely, Reye syndrome
occurs in children with influenza who have taken aspirin. Acute myositis is a rare and severe complication, which is particular to children. A
sudden onset of severe pain and tenderness in both calves causes the child to refuse to walk. Due to the potential for complications, a
prolonged fever or a fever that returns during convalescence should be investigated.
o S/S: Abrupt onset of fever, facial flushing, chills, headache, myalgia, and malaise are accompanied by cough and coryza (nasal
discharge). About half of infected individuals have a dry or sore throat. Ocular symptoms such as photophobia, tearing, burning,
and eye pain are common.
o Nursing management/ tx : of influenza is mainly supportive. Provide symptomatic treatment of cough and fever. Instruct parents
on the maintenance of hydration. Administer antiviral drugs as prescribed as they can reduce the symptoms associated with
influenza if they are started within the first 48 hours of the illness
13. autism spectrum disorder, look for the teaching you give to the parents, behavior issues, what
would you do?
 The spectrum of autism disorder ranges from mild to severe. Many children with autism are intellectually disabled, requiring lifelong
supervision, though the majority of children with ASD display normal to high intelligence levels. Autistic behaviors may be first noticed in
infancy as developmental delays or between the age of 12 and 36 months when the child regresses or loses previously acquired skills.
Children with ASD display impaired social interactions and communication as well as perseverative or stereotypic behaviors. They may fail
to develop interpersonal relationships and experience social isolation.
 There are no medications or treatments available to cure autism. The goal of therapeutic management is for the child to reach optimal
functioning within the limitations of the disorder. Each child’s treatment is individualized; behavioral and communication therapies are very
important. Children with ASD respond very well to highly structured educational environments, so early, intensive behavioral interventions
are necessary. Stimulants may be used to control hyperactivity, and antipsychotic medications are sometimes helpful in children with
repetitive and aggressive behaviors.
 Finding: The infant may resist cuddling, lack eye contact, be indifferent to touch or affection, and have little change in facial expression.
Toddlers may display hyperactivity, aggression, temper tantrums, or self-injury behaviors, such as head banging or hand biting. The history
may also reveal hypersensitivity to touch or hyposensitivity to pain.

Nursing Implications: Caring for a child with autism can be intense and exhausting. If adaptive behaviors can be improved, the both the
child and parents will benefit. Assist families to find schools or centers utilizing early intensive behavioral intervention to enroll their child in.
Support and encourage parents to encourage interventions in the home setting as prescribed. When children are initially diagnosed with
autism, provide parents with an extensive amount of emotional support, professional guidance, and education about the disorder while
they are attempting to adjust to the diagnosis. Assess the parents’ need for respite care and make referrals accordingly. Provide positive
feedback to parents for their perseverance in working with their child. Provide family-centered care, being sure to treat the family not just
the child. Minimize parent–child separation
14. Child abuse, bruising and burns
 Physical Examination: Perform a gentle but thorough physical examination, using a soft touch and calm voice. Observe the parent– child
interaction, noting fear or an excessive desire to please. Note the infant’s level of consciousness. Vigorous shaking in the infant leads to
intracranial hemorrhage and shaken baby syndrome. Inspect the skin for bruises, burns, cuts, abrasions, contusions, scars, and any other
unusual or suspicious marks. Current or healed scratches or cuts may be found on parts of the body ordinarily covered by clothing in the
child who self-mutilates. Burns that occur in a stocking or glove pattern, or only to the soles or palms, are highly suspicious for inflicted
burns. Injuries in various stages of healing are also indicative of abuse. Bruises on the chest, head, neck, or abdomen are suspicious for
abuse. Nonambulatory children infrequently experience bruises or fractures.
 A history of childhood abuse is associated with the development of anxiety and depressive disorders, suicidal ideation and attempts, and
alcohol and drug use. Child maltreatment may result in significant physical injury, poor physical health, and, in some cases, impaired brain
development. Being a victim of abuse places children at risk for developmental and behavioral problems, decreased cognitive functioning,
poor academic achievement, and deficits in relationships
 Identify abuse and violence by screening all children and families using these questions:
o Questions for children:
-Are you afraid of anyone at home?
-Who could you tell if someone hurt you or touched you in a way that made you uncomfortable?
-Has anyone hurt you or touched you in that way?
o Questions for parents:
-Are you afraid of anyone at home?
-Do you ever feel like you may hit or hurt your child when frustrated?
15. Urine sample collection in general, an infant (catheter)
 Urine specimens may be collected using a variety of different methods in infants and children. Suprapubic aspiration is a useful method for
obtaining a sterile urine specimen from the neonate or young infant. A sterile needle is inserted into the bladder through the anterior wall of
the abdomen and the urine is then aspirated. The physician or nurse practitioner generally performs this method. Infants and toddlers who
are not toilet trained may require a urine bag for urine collection. A sterile urine bag is required for a urine culture, a clean bag for routine
urinalysis. A 24-hour urine collection bag is also available. Nursing Procedure 21.1 gives details on the use of the urine bag.
 Sterile urinary catheterization is performed like that in adults. The size of the catheter varies depending on the size of the child. General
size recommendations are:
o 6 French: Birth to 2 years old
o 6 to 8 French: 2 to 5 years old
o 8 to 10 French: 5 to 10 years old
o 10 to 12 French: 10 to 16 years old
16. Look for characteristics of Wilms Tumor? (PAGE 892)

Wilms tumor is the most common renal tumor, the second most common abdominal solid
tumor in children, and most commonly occurs between the ages of 2 and 5 years.

Wilms tumor demonstrates rapid growth and is usually large at diagnosis. Metastasis
occurs via direct extension or through the bloodstream. Wilms tumor most commonly
metastasizes to the perirenal tissues, liver, diaphragm, lungs, abdominal muscles, and lymph
nodes.

Physical Examination:
Measure blood pressure; hypertension occurs in 25% of children with Wilms tumor (Craddock et
al., 2018). Inspect the abdomen for asymmetry or a visible mass. Observe for associated
anomalies as noted above. Auscultate the lungs for adventitious breath sounds associated with
tumor metastasis. Palpate for lymphadenopathy.

AVOID palpating the abdomen after the initial assessment preoperatively. Wilms tumor is
highly vascular and soft, so excessive handling of the tumor may result in tumor seeding and
metastasis.

To AVOID injuring the remaining kidney, children with a single kidney should not play
contact sports.
 Wilms tumor is usually unilateral.
 Laboratory and Diagnostic Testing:
Laboratory and diagnostic testing may include:
o Renal or abdominal ultrasound to assess the tumor and the contralateral kidney
o CT scan or MRI of the abdomen and chest to determine local spread to lymph nodes or adjacent organs, as well as any distant
metastasis
o CBC, BUN, and creatinine: usually within normal limits
o Urinalysis: may reveal hematuria or leukocytes
o 24-hour urine collection for HVA and VMA to distinguish the tumor from neuroblastoma (levels will not be elevated with Wilms
tumor)
17. Muscular Dystrophy, which common one, Duchenne (Characteristics)
 Muscular dystrophy refers to a group of inherited conditions that result in progressive muscle weakness and wasting. The muscles affected
are primarily the skeletal (voluntary) muscles. Nine types of muscular dystrophy exist. All include muscle weakness over the lifetime; it is
progressive in all cases but more severe in others. The various muscular dystrophies are most often diagnosed in childhood and affect a
variety of muscle groups. The inheritance pattern for muscular dystrophy differs for each type but may be X-linked, autosomal dominant, or
recessive. The genetic mutation in muscular dystrophy results in absence or decrease of a specific muscle protein that prevents normal
function of the muscle. The skeletal muscle fibers are affected, yet there are no structural abnormalities in the spinal cord or the peripheral
nerves. Gives specifics related to the various types of muscular dystrophy.
 Duchenne muscular dystrophy, the most common neuromuscular disorder of childhood, results in a shortened life expectancy. Due to
advances in medical care, such as improvements in noninvasive mechanical ventilation, better management of cardiac dysfunction using
angiotensin-converting enzymes (ACE) inhibitors and the use of steroids, survival into their 30s, with some cases into their 40s or 50s, is
becoming more common (Darras, 2018). The incidence is about 1 in 3,600 live male births. For these reasons, this discussion will focus on
Duchenne muscular dystrophy.
18. Asthma, how would you assess, what type of things would you tell them to do (Pic Espirectomy)
 INSPECTION
Observe the child’s general appearance and color. During mild exacerbations, the child’s color might remain pink, but as the child worsens,
cyanosis might result. Assess work of breathing which is variable, ranging from mild retractions to significant accessory muscle use and
eventually head bobbing if not treated effectively. Note lethargy, irritability or the appearance of anxiety or fearfulness. An audible wheeze
might be present. Children with persistent severe asthma may have a barrel chest and routinely demonstrate mildly increased work of
breathing.
 AUSCULTATION AND PERCUSSION
A thorough assessment of lung fields is necessary. Wheezing is the hallmark of airway obstruction and might vary throughout the lung
fields. Coarseness might also be present. Assess the adequacy of aeration. Breath sounds might be diminished in the bases or
throughout. A quiet chest in an asthmatic child can be an ominous sign. With severe airway obstruction, air movement can be so poor that
wheezes might not be heard upon auscultation. Percussion may yield hyperresonance.
 Laboratory and diagnostic studies commonly ordered for the assessment of asthma include:
Pulse oximetry: oxygen saturation may be decreased significantly or normal during a mild exacerbation
Chest radiograph: usually reveals hyperinflation
Blood gases: might show carbon dioxide retention and hypoxemia
Pulmonary function tests (PFTs): can be very useful in determining the degree of disease but are not useful during an acute
attack. Children as young as 5 or 6 years might be able to comply with spirometry.
o Peak expiratory flow rate (PEFR): is decreased during an exacerbation
o Allergy testing: skin test or RAST can determine allergic triggers for the asthmatic child
19. Pharmacokinetics, biggest differences between kids and adults, skin is thinner they absorb the medication faster
 The child’s age, weight, body surface area (BSA), and body composition also can affect the drug’s pharmacokinetics (movement of drugs
throughout the body via absorption, distribution, metabolism, and excretion). Drugs are administered to children via many of the same
routes that are used for adults. However, this similarity ends once the drug is administered. During the absorption process, drugs move
from the administration site into the bloodstream. In infants and young children, the absorption of orally administered medications is
affected by slower gastric emptying, increased intestinal motility, a proportionately larger small intestine surface area, higher gastric pH,
and decreased lipase and amylase secretion compared with adults.
Intramuscular (IM) absorption in infants and young children is affected by the amount of muscle mass, muscle tone and perfusion, and
vasomotor instability. Similarly, decreased perfusion alters subcutaneous (SQ) absorption. Absorption by these routes is erratic and may
be decreased. In contrast, topical absorption of medications is increased in infants and young children, which can result in adverse effects
not seen in adults. Infants and young children have a greater BSA, leading to increased absorption of topical medications. Absorption in
infants is also increased due to greater permeability of the infant’s skin.
 The distribution (movement of a drug from the blood to interstitial spaces and then into cells) of medications is also altered in infants and
young children. Medication distribution in children is affected by:
o Higher percentage of body water than adults
o More rapid extracellular fluid exchange
o Decreased body fat
o Liver immaturity, altering first-pass elimination
o Decreased amounts of plasma proteins available for drug binding
o Immature blood–brain barrier, especially in neonates, allowing permeation by certain medications.
 Metabolism of medications in children is altered because of differences in hepatic enzyme production and the child’s increased metabolic
rate. Biotransformation (the alteration of chemical structures from their original form, which allows for the eventual excretion of the
substance) is affected by the same variations affecting distribution in children. In addition, the immaturity of the kidneys until the age of 1 to
2 years affects renal blood flow, glomerular filtration, and active tubular secretion. This results in a longer half-life and increases the
potential for toxicity of drugs primarily excreted by the kidneys
20. Instructions to the child and family before imminent death
 There are many important decisions to be made when a child is diagnosed with a terminal illness, including the following:
o Right to refuse treatment. The child and family may have the right to refuse certain kinds treatment. Often, choices for treatment are
offered that may extend the child's life, but not provide a cure. Consider the child's quality of life as well as the possibility of extending it.
o Decision to die in the home versus hospital setting. Many families want their loved ones to die at home in their natural and most
comfortable setting. Others don't feel they can emotionally handle the death in their home. Siblings may or may not influence this decision.
Include all family members in this important decision. Not all decisions have to be made at once. In some cases, families think they want to
be at home and then find the hospital to be more comfortable. Whereas, some families choose to be in the hospital and then find the child
and themselves are more comfortable at home. Time and circumstances can help to make these decisions. Ask as many questions as
possible to get the information needed to make the best decision for your family.
o Advance directives, if age appropriate (18 or older). Adults, 18 years of age or older, can prepare an advance directive. These are
documents that are looked to only if a person loses capacity to make decisions or suffers an injury or disease that leaves them unable to
communicate their wishes. Persons under age 18 may prepare an advance directive. However, by law (in most cases), parents or
healthcare providers are not required to honor it.
o Do not resuscitate (DNR) order. A do not resuscitate (DNR) order is a formal request by a person or a person's family to not take extreme
measures to save his or her life. A DNR order is usually reserved for a person near death or with a terminal illness that, even if
resuscitated, would not have a high quality of life or a long period before death would happen even with resuscitative efforts. DNR orders
can specify how much intervention is desired before death. For example, a person may choose not to have antibiotics or artificial feeding.
These need to be discussed and written by a healthcare provider. A DNR is also needed for home and in the event that emergency
medical services are involved.
o Autopsy decisions. An autopsy is an exam of the organs and tissues of the body after death. It's often used to determine the cause of
death. It may also be done to research the fatal disease for future diagnosis, treatment, and prevention strategies. The decision to have an
autopsy is a very personal choice and should be decided when the family is ready. Often an autopsy may help the family with closure and
may help other children with a similar illness. In a child with a rare disease or cancer, or a condition which has a genetic cause, an autopsy
can provide important information for other family members, or for parents who may decide to have more children. If genetic testing has
not already been done, or is not available at the time, DNA banking may provide a choice when testing in the future.
o Organ donation, if possible. Laws governing organ donation vary slightly from state to state. Your healthcare provider will be able to tell
you of these choices.
o Funeral arrangements. Arranging for a child's funeral is a situation for which no parent is prepared. For many parents, this is the first
funeral they have attended and the first time they will have made funeral plans. Sometimes, parents are eager to rush the process because
o
o
o
o
they are so stunned and upset. Families should not rush their decisions about what plans they want for their child. Parents need to have
some time to determine what they want for their child before going to the funeral home, so that they are not making these decisions about
the services during a time of great stress.
It's important to take the time to ask questions of the funeral director to understand all of the choices for planning the service. Involving
other family members in the planning, such as siblings and grandparents, can make the service more meaningful for everyone. Clergy and
religious communities can also provide support and resources as families make funeral plans. Memorial gifts to certain organizations,
causes, or funds are one way to acknowledge what a family wants and needs to honor their child's life.
o Palliative and hospice care. Palliative care is care aimed at comfort versus cure and treatment. Hospice is a type of palliative care. It
provides services to improve the quality of life for the family and child, stressing peace, comfort, and dignity.
21. Plan of care for amblyopia, eye patch for the kid (page 538)
 Amblyopia refers to poor visual development in the otherwise structurally normal eye. It develops within the first decade of life and, if left
untreated, is the most common cause of vision loss in children and young adults, occurring in about 1% to 4% of children (Coats & Paysse,
2018a). The vision in one eye is reduced because the eye and the brain are not working together properly. While the eyes are fighting to
focus differently because of their differences in visual acuity, one eye is stronger than the other. This is why amblyopia is often referred to
as “lazy eye.”
 It is very important for children with amblyopia to receive appropriate treatment during the early years of visual development. Therapeutic
management of amblyopia focuses on strengthening the weaker eye. This may be achieved through patching for several hours per day,
using atropine drops in the better eye (once daily), vision therapy, or eye muscle surgery if the cause is strabismus. Patching the better eye
for several hours each day encourages the eye with poorer vision to be used appropriately and promotes visual development in that eye.
The once-daily use of atropine drops in the better eye results in blurring in that eye, similarly encouraging use and development of the
weaker eye
22. Diabetes, insulin, how does it get administered
23. Look for visual impairments, what is the population that gets the highest problems with the eyes (race)\
 Factors that increase the risk for developing visual impairment include prematurity, developmental delay, genetic syndrome, family history
of eye disease, African-American heritage, previous serious eye injury, diabetes, HIV, and chronic corticosteroid use. Trauma is also an
important cause of blindness in children. Visual impairments are associated with many other syndromes. For example, many children with
genetic syndromes have visual impairments, and albinism is associated with blindness (Lighthouse International, 2019).
24. Recommendations for appropriate nutrition toddler, ounces of milk (less than 24 oz) (page 107)
 Adequate calcium intake and appropriate exercise lay the foundation for proper bone mineralization. The toddler requires an average
intake of 700 mg calcium per day (Ben-Joseph, 2018). Dairy products are considered the primary sources of dietary calcium. One cup of
low-fat or whole milk, 8 ounces of low-fat yogurt, and 1½ ounces of cheddar cheese each provide 300 mg of calcium. Broccoli, oranges,
sweet potatoes, tofu, and dried beans or legumes are also good sources of calcium (35- to 120-mg calcium per serving).
 Parents should encourage toddlers to drink water. Juice intake should be limited to 4 to 6 ounces per day. Milk intake should be limited to
16 to 24 ounces per day. Juice and milk should be served along with meals or snacks. Water should be offered for between-meal drinking.
Toddlers should drink from a cup.
 Toddlers are often afraid to try new things anyway, so the parent or caregiver should be flexible with the toddler’s acceptance or rejection
of new foods. If the toddler refuses healthy food choices at meal or snack time, parents should not substitute high-fat, high-sugar,
processed food just to make sure that the child eats something.
 Food should always be cut into bite-size pieces.
 Picky eaters: Alternative Food Choices for the Picky Eater
o Won’t drink milk? Obtain calcium through yogurt (frozen or regular), cheese, pudding, and hot cocoa.
o Poor meat intake? Obtain iron through unsweetened iron-fortified cereals or breakfast bars, or raisins; cook with an iron skillet.
o Loves processed white bread? Encourage fiber intake with fresh fruits and vegetables, bran muffins, beans, or peas (can be in soup).
o Refuses vegetables? Encourage vitamin A intake with apricots, sweet potatoes, and vegetable juices.
25. Description of respiratory patterns,
choose which type of respiration is that
26. Infant reflexes, what is normal?
27. Milestones in an infant, fine and gross?
28. Milestones in a 3-year-old child, fine and gross
29. Normal findings in a 9-month-old baby?
 9 months (GROSS MOTOR): crawls, abdomen off floor months, The term “gross motor skills” refers to those that use the large muscles
(e.g., head control, rolling, sitting, and walking). Gross motor skills develop in a cephalocaudal fashion (from the head to the tail)
 9 months (FINE): bang on objects (Fine motor development includes the maturation of hand and finger use. Fine motor skills develop in a
proximodistal fashion (from the center to the periphery)
 At 9 to 12 months of age the infant begins to attach meaning to “mama” and “dada” and starts to imitate other speech sounds
 8–12 months appropriate toys: Plastic cups, bowls, buckets, Unbreakable mirror, Large building blocks, Stacking toys, Busy boxes (with
buttons or knobs that make things happen), Balls, Dolls, Board books with large pictures, Toy telephone, Push–pull toys (older infants)
30. Characteristics of a child with down syndrome, physical findings?
 Trisomy 21 is associated with some degree of intellectual disability, characteristic facial
features (e.g., slanted eyes and depressed nasal bridge), and other health problems (e.g.,
cardiac defects, visual and hearing impairment, intestinal malformations, and an increased
susceptibility to infections). The severity of these problems varies.
 Common Clinical Manifestations of Down Syndrome:
o Hypotonia, Short stature, Flattened occiput, Small (brachycephalic) head, Flat facial
profile, Depressed nasal bridge and small nose, Oblique palpebral fissures (an
upward slant to the eyes), Brushfield spots (white spots on the iris of the eye), Low-set, small ears, Abnormally shaped ears,
Small mouth, Protrusion of tongue; tongue is large compared to mouth size, Arched, narrow palate, Hands with broad, short
fingers, A single deep transverse crease on the palm of the hand (simian crease), Congenital heart defect, Short neck, with
excessive skin at the nape, Hyperflexibility and looseness of joints (excessive ability to extend the joints), Dysplastic middle
phalanx of fifth finger (one flexion furrow instead of two), Epicanthal folds (small skin folds on the inner corner of the eyes),
Excessive space between large and second toe
 The older infant or child known to have Down syndrome is often admitted to the hospital for corrective surgeries or other complications of
the disease, such as infections. Elicit a description of the present illness and chief complaint. In an infant or child returning for a clinic visit
or hospitalization, the health history should include questions related to:
o Cardiac defects or disease (treatment regimen, surgical repair)
o Hearing or vision impairment (last hearing and vision evaluation, any corrective measures)
o Developmental delays (speech, gross and fine motor skills)
o Sucking or feeding problems
o Cognitive abilities (degree of intellectual disability)
o Gastrointestinal disorders such as vomiting or absence of stools (special dietary management, surgical interventions)
o Thyroid disease
o Hematologic problems, such as anemia, leukemia
o Atlantoaxial instability
o Seizures
o Infections such as recurrent or chronic respiratory infections, otitis media
o Growth (height and weight changes, feeding problems, unexplained weight gain)
o Signs and symptoms of sleep apnea, such as snoring, restlessness during sleep, daytime sleepiness
o Any other changes in physical state or medication regimen
31. Epilepsy, what would be the teaching for the parents?
 Epilepsy is a complex disorder of the CNS in which brain function is affected. Recurrent or
unprovoked seizures are the clinical manifestation of epilepsy and result from a disruption
of electrical communication among the neurons of the brain. This disruption results from an
imbalance between the excitatory and inhibitory mechanisms in the brain, causing the
neurons to either fire when they are not supposed to or not fire when they should. Epilepsy
has numerous causes.
 Management of epilepsy focuses on controlling seizures or reducing their frequency.
Another focus of epilepsy management involves helping the child who has recurrent
seizures and his or her family to learn to live with the seizures. The primary mode of
treatment is the use of anticonvulsants. The goal for every child should be the use of the
fewest drugs with the fewest possible side effects for the control of seizures.
 Encourage parents to be involved in the management of their child’s seizures but
encourage allowing the child to learn about the disorder and its management as soon as he
or she is old enough. Encourage parents to treat the child with epilepsy just as they would
treat a child without this disorder. Children who are brought up no differently than children
without epilepsy will be more likely to develop a positive self-image and have increased
self-esteem. Any activity restrictions, such as limiting swimming or participation in sports,
will be based on the type, frequency, and severity of the seizures the child has. Educate parents and children on any restrictions and
encourage parents to place only the necessary restrictions on the child.
 An important nursing function is to educate not only the child and family but also the community, including the child’s teachers and
caregivers, on the reality and facts of the disorder
32. Hospitalized child, what way of preventing stressors?
 The child life specialist (CLS) is an individual specially trained in the developmental
impact of illness, injury, and trauma and who provides programs that prepare
children for hospitalization, surgery, and other procedures that could be painful or
distressing
 Therapeutic hugging (a holding position that promotes close physical contact
between the child and a parent or caregiver) may be used for certain procedures or
treatments where the child must remain still.
 Appropriate preparation for procedures helps to decrease the child’s and family’s
anxiety level, promote the child’s cooperation, support the child’s and family’s coping
skills, improve recovery, and increase trust between the child, his or her family, and
the physician’s health care team.
 General guidelines for preparation include the following:
o Provide a description of and the reason for the procedure using ageappropriate language (“the doctor will look at your blood to see why you
are sick”).
o Describe where the procedure will occur (“the x-ray department has big
machines that won’t hurt you; it’s a little cold there too”).
o Introduce strange equipment the child may see (“you will lie on a special
bed that moves in the big machine, but you can still see out”).
o Describe how long the procedure will last (“you will be in the x-ray department until lunchtime”).
o Identify unusual sensations that may occur during the procedure (“you may smell something different” [e.g., alcohol smell]; “the
MRI machine makes loud noises”).
o Inform the child if any pain is involved.
o Tell the child it is okay to cry or yell.
o Identify any special care required after the procedure (“you will need to lie quietly for 15 minutes afterward”).
o Discuss ways that may help the child stay calm, such as using distraction methods or relaxation techniques (“during the
procedure you may want to count from 1 to 100 or sing your favorite song”)
33. What is the classification of Hep B vaccine?
 Recombinant vaccines use genetically engineered organisms. For example, the hepatitis B vaccine (HepB) is produced by splicing a gene
portion of the virus into a gene of a yeast cell. The yeast cell is then able to produce hepatitis B surface antigen to use for vaccine
production.
34. Vision screening, in a preschooler and schooler, what will you use for color and visual acuity?

Newborns with ocular structural abnormalities are at high risk for vision impairment. Vision
screening is performed at every scheduled health supervision visit. The screening procedures
for children younger than 3 years of age or for nonverbal children involve evaluating the child’s
ability to fixate on and follow objects. The neonate should be able to fixate on an object
approximately 25 to 30 cm (10 to 12 in) from the face. After fixation, the infant should be able to
follow the object to the midline. By 2 months of age, the infant should be able to follow the
object 180 degrees. The technique of photo screening can help identify problems such as ocular
malalignment, refractive error, and lens and retinal problems.
 After the age of 3 years, a variety of standardized age-appropriate vision screening charts are
available. These charts include the “tumbling E” and Allen figures. These charts allow for a more
precise vision assessment and aid the nurse in identifying preschool children with visual acuity
problems. By age 5 or 6, most children know the alphabet well enough to use the traditional
Snellen chart for vision screening (Fig. 9.2C). Refer to Healthy People 2030. Gives further
information about vision screening tools.
 Screenings should be performed when children are alert, as fatigue and lack of interest can
mimic poor vision. When using any vision screening chart, several simple steps need to be
followed:
o Place the chart at the child’s eye level.
o Make sure there is sufficient lighting.
o Place a mark on the floor approximately 300 to 600 cm (10 to 20 ft) from the chart
(distance depends on what the tool is calibrated for).
o Align the child’s heels on the mark.
o Have the child read each line with one eye covered and then with the other eye
covered. Explain to the child to keep the eye covered but open (Fig. 9.3).
o Have the child read each line with both eyes.
 In addition to visual acuity screening, children should also be screened for color discrimination. Any child with eye abnormalities or who
has failed visual screening needs to be evaluated by a specialist appropriately trained to treat children.
35. Temp. check, how would you do it? (Ear check)
 The routes for taking the child’s temperature are tympanic, temporal, oral, axillary, and rectal. Numerous research studies have been
undertaken to determine the best method for temperature assessment in children. Take the child’s temperature using the least invasive
method that is best accepted by the child, parent, and physician or nurse practitioner.
 Temporal scanning uses infrared scanning on the skin over the temporal artery combined with a mathematical computation to determine
the child’s arterial temperature. Temporal artery thermometry may be used with any age child except infants younger than 90 days of age
who are ill or have a fever for whom the rectal method should be used (Society of Pediatric Nurses [SPN], 2016). Measure temperature on
the exposed side of the head (not the side that has been lying on a pillow or covered by a hat). Depress the sensor button and slide the
sensor tip externally in a horizontal line across the child’s forehead, midway between the eyebrows and hairline and ending at the lateral
hairline (Fig. 10.4). Continuing to depress the button, lift the sensor from the forehead and then place it on the soft spot behind the ear
lobe. Hold it there until the device registers the temperature reading, which usually requires 1 second. Accuracy may be affected by
excessive sweating (Exergen Corporation, 2018).
 Oral temperature is highly reliable if the child can cooperate. By 5 years of age, the child can hold an electronic oral thermometer in the
mouth well enough to obtain a reading. Place the probe under the tongue and ensure the child’s mouth remains closed until the device
registers the temperature. Oral intake, oxygen administration, and nebulized medications or treatments may affect oral temperature.
 The axillary method may be used for children who are uncooperative, neurologically impaired, or immunosuppressed or have injuries or
have had surgery to the oral cavity (Bowden & Greenberg, 2016). Place the tip of the electronic or digital thermometer in the axilla to obtain
the reading. Make sure the tip is indeed in the axilla and not just between the arm and the child’s side. Hold the thermometer parallel rather
than perpendicular to the child’s side to obtain the most accurate reading. Keep the child’s arm pressed down to the side until the
thermometer registers, which will be as little as 10 seconds with certain electronic models but 2 or 3 minutes with digital models commonly
used at home.
 Though long considered to reflect core temperature, the rectal route is invasive, not well accepted by some children, and probably
unnecessary with the modern alternative methods now available (Chiocca, 2015). To take the rectal temperature, position the young infant
supine with legs flexed. The older infant or child should be prone or side-lying. Small children may lie across the parent’s lap for additional
comfort. Apply a water-soluble jelly to the covered probe, insert the thermometer past the anal sphincter no more than 1 inch (2.5 cm), and
hold it there until the temperature registers (as little as 15 seconds with certain electronic models but longer with digital models).
36. Assessing fontanels, when do they close?
 Gently palpate the anterior and posterior fontanels (Fig. 10.17). The fontanels are the soft areas on the skull that remain open in infancy to
allow for rapid brain growth in the first months of life. Note the size of the fontanels. The anterior fontanel’s size is 1 to 4 cm in either
direction until it can no longer be felt when it is closed by the age of 9 to 18 months (Chiocca, 2015). The posterior fontanel is much smaller
and may close any time between shortly after birth and approximately 2 months of age. The fontanels should not be depressed or taut and
bulging, though it is not uncommon to see them pulsate or briefly bulge if the baby cries.
37. Failure to thrive, first assess a problem not allowing them to develop correctly, if not look for child abuse findings (malnutrition)
 Failure to thrive (FTT) is a term used to describe inadequate growth in infants and children. The child fails to demonstrate appropriate
weight gain over a prolonged period of time. Length or height velocity and head circumference growth may also be affected. Typical
children may experience FTT, but it is much more common in the child with special needs. Adequate nutrition is critical for appropriate
brain growth in the first 2 years of life and obviously for growth in general throughout childhood and adolescence (Fortin & Downes, 2019).
FTT is a multifactorial problem. Developmental disability (mental or physical or combination impairment resulting in lifelong disability) may
contribute to FTT, as the child’s ability to consume adequate nutrition is impaired because of sensory or motor delays, such as with
cerebral palsy. Other organic causes of FTT include inability to suck and/or swallow correctly, malabsorption, diarrhea, vomiting, or
alterations in metabolism and caloric/nutrient needs associated with a variety of chronic illnesses. Infants and children with cardiac or
metabolic disease, chronic lung disease (bronchopulmonary dysplasia), cleft palate, or gastroesophageal reflux disease are at particular
risk. Feeding disorders or food refusal may occur in infants or children who have required prolonged mechanical ventilation, long-term
enteral tube feedings, or an unpleasant event such as a choking episode. Additional causes of FTT include poverty, neglect, abuse,
behavioral problems, lack of appropriate maternal interaction, poor feeding techniques, lack of parental knowledge, or parental mental
illness (Fortin & Downes, 2019).
 Screen all children for FTT to identify them early. In addition to poor growth, the infant or child with FTT may present with a history of
developmental delay or loss of acquired milestones. Infants or children with feeding problems may display nipple, spoon, or food refusal;
difficulty sucking; disinterest in feeding; or difficulty progressing from liquid to puréed to textured food. Perform a detailed dietary history
and instruct the parents to complete a 3-day food diary to identify what the child actually eats and drinks. Assess the parent–child
interaction, with particular attention to the parent’s ability to read and respond to the infant’s or child’s cues. Observe feeding, noting the
child’s oral interest or aversion, oral–motor coordination, and swallowing ability, as well as parent–child interactions before, during, and
after the feeding (Fortin & Downes, 2019).
o Significant FTT may require hospitalization for evaluation and management. Sometimes, enteral tube feedings are necessary in order
for children with FTT or feeding disorders to demonstrate adequate growth. Box 12.4 lists nursing interventions for the hospitalized
child with FTT.
38. Child with anorexia, psychosocial disorders, what are the characteristics?
 Adolescents with anorexia may have a history of constipation, syncope, secondary amenorrhea, abdominal pain, and periodic episodes of
cold hands and feet. Parents usually note the chief complaint as weight loss. Note history of depression in the child with bulimia. Evaluate
the child’s self-concept, noting multiple fears, high need for acceptance, disordered body image, and perfectionism.
 Perform a thorough physical examination. The anorexic is usually severely underweight, with a body mass index (BMI) of less than 17.
Note cachectic appearance, dry sallow skin, thinning scalp hair, soft sparse body hair, and nail pitting. Measure vital signs, noting low
temperature, bradycardia, or hypotension. Auscultate the heart, noting murmur as a result of mitral valve prolapse (occurs in about one
third of adolescents with anorexia).
 Those with anorexia who display severe weight loss, unstable vital signs, food refusal, or arrested pubertal development or who require
enteral nutrition will need to be hospitalized. Refeeding syndrome (cardiovascular, hematologic, and neurologic complications) may occur
in the severely malnourished adolescent with anorexia if rapid nutritional replacement is given. Therefore, slow refeeding is essential to
avoid complications. Give phosphorus supplements as ordered. Assess vital signs frequently for orthostatic hypotension, irregular and
decreased pulse, or hypothermia.
39. Dyspraxia, what is that?
 Children with dyspraxia have problems with manual dexterity and coordination.
40. Teaching in a child with diabetes, based on age group you know you need to make the child involved depending on age group (industry vs
inferiority)
 For the child with diabetes mellitus:
o First teach “survival skills” (e.g., glucose and urine testing, administering insulin, record keeping, food guidelines, when to call
physician) to provide initial base of knowledge for self-management.
o Implement second-phase home management program with more extensive instruction: providing additional teaching over time is
necessary for management of a significant chronic illness.
o Monitor outcomes of teaching with every contact to ensure progress with child/family education.
41. Immunodeficiency in a child, priority in plan of care
 Preventing Infection (interventions with rationale)
o Maintain meticulous hand-washing procedures (include family, visitors, staff) to minimize spread of infectious organisms.
o Maintain isolation as prescribed to minimize exposure to infectious organisms.
o Clean frequently touched surfaces with an appropriate cleanser to minimize spread of infectious organisms.
o Educate family and visitors that child should be restricted from contact with known infectious exposures (in hospital and at home)
to encourage cooperation with infection control.
o Strictly observe medical asepsis to avoid unintentional introduction of microorganisms.
o Promote nutrition and appropriate rest to maximize body’s potential to heal.
o Educate family to contact physician or nurse practitioner if child has known exposure to chickenpox or measles so that
preventive measures (e.g., varicella zoster immunoglobulin [VZIG]) can be taken.
o Administer vaccines (not live) as prescribed to prevent common childhood communicable diseases.
o Administer prophylactic antibiotics as prescribed to prevent infection with opportunistic organisms.
 Promoting Adequate Nutritional Intake (interventions with rationale)
o Monitor growth (weight and height/length weekly) to determine progress toward goal.
o Determine realistic goal for weight gain for age (consulting dietitian if necessary) to have a specific outcome to work toward.
o Observe child’s physical ability to eat (if pain from candidiasis or motor impairment is present, will need additional interventions).
o Provide nutrient-rich meals and snacks to maximize caloric intake.
o Supplement milkshakes with protein powder or other additives to maximize caloric intake.
o Provide child’s favorite foods to encourage increased intake.
o Provide smaller, more frequent meals to reduce sensation of fullness and increase overall intake.
o If vomiting is an issue, administer antiemetics as ordered prior to meals to provide optimal state for success at mealtime.
 Preventing Skin Impairment (interventions with rationale)
o Assess and monitor extent and location of rash to provide baseline information and evaluate success of interventions.
o Keep skin clean and dry to prevent secondary infection.
o For the child with limited mobility, turn frequently and use specialty mattress or bed to prevent pressure ulcers.
o Implement a written plan of care directed toward topical treatment of skin integrity impairment to provide consistency of care and
documentation.
o Educate child and family to limit direct sun exposure and use sunscreen to prevent sun damage.
 Promoting Activity (interventions with rationale)
o Cluster care to decrease disturbances and allow for longer uninterrupted rest periods.
o Pace activities and encourage regular rest periods to conserve energy.
o Administer early morning warm bath to ease a.m. stiffness (juvenile arthritis).
o Use assistive devices such as splints and orthotics to improve physical function.
o Plan developmentally appropriate activities that the child can participate in while in bed to encourage play and continued
development.
o Schedule activities for the time of day the child usually has the most energy to encourage successful participation.
 Enhancing Development (interventions with rationale)
o Screen for developmental capabilities to determine child’s current level of functioning.
o Offer age-appropriate toys, play, and activities (including gross motor) to encourage further development.
o Encourage peer contact through telephone, e-mail, or letters to promote/continue socialization.
o Perform interventions as prescribed by physical or occupational therapist: repeat participation in those activities helps child
improve function and acquire developmental skills.
o Provide support to families of children with developmental delay: progress in achieving developmental milestones can be slow,
and ongoing motivation is needed.
o Encourage child to continue schoolwork so that child will not fall behind.
o Reinforce positive attributes in the child to maintain motivation.
42. Juvenile Idiopathic arthritis, recommendations, and teaching for the child
 Nursing Management
o Nursing management focuses on managing pain, maintaining mobility, and promoting a normal life. Refer the child to a pediatric
rheumatologist to ensure that he or she receives the most up-to-date treatment. Administer disease-modifying medications and teach
children and families how to do so. Refer families Childhood Arthritis & Rheumatology Research Alliance for clinical research trial
information. Encourage regular eye examinations and vision screening to allow for early treatment of visual changes and to prevent
blindness.
o Managing Pain and Maintaining Mobility
 Administer medications as prescribed to control inflammation and prevent disease progression. Refer to Drug Guide 25.1 for
information related to NSAIDs, corticosteroids, and disease-modifying antirheumatic drugs. Maintain joint range of motion and
muscle strength via exercise (physical or occupational therapy). Swimming is a particularly useful exercise to maintain joint
mobility without placing pressure on the joints. Teach families appropriate use of splints prescribed to prevent joint contractures.
Monitor for pressure areas or skin breakdown with splint or orthotic use.
o Promoting Normal Life
 Chronic pain and decreased mobility may impact the child’s psychological and emotional status significantly, during both
childhood and adulthood. Providing adequate pain relief and promoting compliance with the disease-modifying medication
regimen may allow the child to have a more normal life in the present as well as in the future. In addition to measures described
in the previous section, encourage adequate sleep to improve the child’s ability to cope with symptoms and with school function.
Promote sleep with a warm bath at bedtime and warm compresses to affected joints or massage. To prevent social isolation,
encourage the child to attend school and ensure that teachers, the school nurse, and classmates are educated about the child’s
disease and any limitations on activity. Having two sets of books (one at school and one at home) allows the child to do
homework without having to carry heavy books home. Modifications such as allowing the child to leave the classroom early in
order to get to the next class on time may seem small but can have a significant impact on the child’s life.
 Encourage children and families to become involved with local support groups so they can see that they are not alone. Assist
children to set and achieve goals to increase their sense of hopefulness. Special summer camps for children with juvenile
arthritis allow the child to socialize and belong to a group and have been shown to promote self-esteem in the child with chronic
illness. Encourage appropriate family functioning and refer the family to support groups such as those sponsored by the
American Juvenile Arthritis Organization.
43. How to identify child abuse?
 Abuse in Children
o Child abuse, including physical abuse and sexual abuse, is a common crime of violence against children. An estimated 4.2 million reports
of child abuse are made annually to child protective services in the United States (U.S. Department of Health & Human Services,
Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau, 2018). Over 676,000 cases
were substantiated in 2016, with 74.8% being victims of neglect, 18.2% victims of physical abuse, 8.5% victims of sexual abuse, and 6.9%
were victims of other abuse, such as drug or alcohol addiction, emotional or psychological abuse (U.S. Department of Health & Human
Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau, 2018). The abusers
of children are family, friends, and strangers. It is important for parents to teach children the concept of “good touch” versus “bad touch”
prior to school-age years. Whenever the school-age child’s behavior yields suspicion of physical or sexual abuse, the nurse should report
to the appropriate authorities in his or her state. These topics will be discussed in more depth in Chapter 28.
 Child Maltreatment
o Child maltreatment includes physical abuse, sexual abuse, emotional abuse, and neglect. Physical abuse refers to injuries that are
intentionally inflicted on a child and result in morbidity or mortality. Sexual abuse refers to involvement of the child in any activity meant to
provide sexual gratification to an adult. Emotional abuse may be verbal denigration of the child or occur as a result of the child witnessing
domestic violence. Neglect is defined as failure to provide a child with appropriate food, clothing, shelter, medical care, and schooling
(Chiesa & Sirotnak, 2018).
o Statistics related to family violence as well as child physical and sexual abuse is difficult to determine, as the perpetrator usually forces the
victim into silence. Children usually do not want to admit that their parent or relative has hurt them, partly from feelings of guilt and partly
because they do not want to lose that parent. In 2015, 4 million referrals to child protective services were made alleging child maltreatment
in 7.2 million children, yet this may be an underestimate of the prevalence of child abuse (Chiesa & Sirotnak, 2018). Abuse and violence
occur across all socioeconomic levels but are more prevalent among the poor, and the largest percentage of those affected are under 3
years of age. Despite the lack of adequate statistics, it is well known that the problem of abuse and violence is widespread. Parents or
caregivers are the most frequent perpetrators of abuse against children (Chiesa & Sirotnak, 2018).
o A history of childhood abuse is associated with the development of anxiety and depressive disorders, suicidal ideation and attempts, and
alcohol and drug use. Child maltreatment may result in significant physical injury, poor physical health, and, in some cases, impaired brain
development. Being a victim of abuse places children at risk for developmental and behavioral problems, decreased cognitive functioning,
poor academic achievement, and deficits in relationships (Kleinschmidt, 2018).
o Therapeutic management of victims of abuse and violence involves physical treatment of the injury, palliative care in some cases, and
intervention to preserve or restore the child’s mental well-being as well as family functioning. To protect children, all states require by law
that healthcare professionals report suspected cases of child abuse or neglect (Child Welfare Information Gateway, 2019).
44. Diaper rash, what type of candida can a child experience? Fungi, keep it dry, nothing dark, moist
 Antifungals (topical)
o Fungicidal used to treat tinea, candida diaper rash
 Apply a thin layer as prescribed
 Comply with length of treatment as prescribed to prevent reemergence of the rash
45. Renal failure, what are the medications that can contribute to renal failure, antibiotics?
 Medications commonly used in children can reduce renal function. Cephalosporins may cause a transient increase in BUN and creatinine. Truly
nephrotoxic drugs often used in children include aminoglycosides, sulfonamides, vancomycin, and NSAIDs. Make sure that potentially
nephrotoxic drugs are administered according to published safe guidelines (dosage, frequency, rate of administration) (Wolters Kluwer Clinical
Drug Information [WKCDI], 2019).
46. Testicular torsion, medical emergency
 Testicular Torsion
o In testicular torsion, a testicle is abnormally attached to the scrotum and twisted. It requires immediate attention because ischemia can
result if the torsion is left untreated, leading to infertility. Testicular torsion may occur at any age but most commonly occurs in boys aged
12 to 18 years (Palmer, 2017).
o Nursing Assessment
 Symptoms of testicular torsion include sudden, severe scrotal pain. Inspect the affected side for significant swelling, which may
appear hemorrhagic or blue-black.
o Nursing Management
 Surgical correction is necessary immediately. Administer pain medication prior to surgery. Reassure the child and family that surgery
will alleviate the problem and is performed to restore adequate blood flow to the testicle. After surgical repair, provide routine
postoperative care.
47. Physical examination, abnormal findings in the penis
 Hypospadias/Epispadias
o Hypospadias is a urethral defect in which the opening is on the ventral surface of the penis rather than at the end of the penis (Fig. 21.3).
Epispadias is a urethral defect in which the opening is on the dorsal surface of the penis. In either case, the opening may be near the glans
of the penis, midway along the penis, or near the base. If left uncorrected, the boy may not be capable of appropriately aiming a urinary
stream from a standing position. In addition, the abnormal placement of the urethral opening may result in erectile dysfunction or interfere
with the deposition of sperm during intercourse, leaving the man infertile. For these reasons, the defect is usually repaired at 6 months and
1 year of age (Baskin, 2019). The goal of surgical correction for either condition is to provide for an appropriately placed meatus that allows
for normal voiding and ejaculation. The meatus is moved to the glans penis and the urethra is reconstructed as needed. Most repairs are
accomplished in one surgery. More extensive reconstructions may require two stages.
48. Seizures, precautions
 Seizure Precautions
Padding of side rails and other hard objects
Side rails raised on bed at all times when child is in bed
Oxygen and suction at bedside
Supervision, especially during bathing, ambulation, or other potentially hazardous activities
Use of a protective helmet during activity may be appropriate
Child should wear a medical alert bracelet
49. Motor vehicle accidents, an an iv what do you monitor
 Complications That Can Occur With Central Venous Access Devices and Total Parenteral Nutrition (TPN)
o Air embolism from inadvertent entry of air into the system during tubing or cap changes or accidental disconnection
o Cardiac tamponade due to catheter advancement with movement of the arm, neck, or shoulder
o Catheter occlusion from the development of a fibrin sheath or thrombus at the catheter tip, mispositioning or kinking, or the deposition of
precipitates or a blood clot
o Venous thrombosis from injury to the vessel wall during insertion or movement of the catheter after insertion or from chemical irritation due
to administration of concentrated solutions, vesicants, and other medications through the catheter
o Hyperglycemia, typically with too rapid an infusion of TPN
o Hypoglycemia, which may occur with rapid cessation
o Dehydration as the child’s body attempts to rid itself of excess glucose through renal excretion
o Electrolyte imbalance (particularly potassium, sodium, calcium, magnesium, and phosphorus)
o Infection at the skin insertion site, along the catheter pathway, or in the bloodstream. Organisms can arise from the skin, hands of
caregivers, or other areas such as wound drainage, droplets from the lungs, or urine. For example, connection sites can be contaminated
during tubing or dressing changes.
50. Diabetes insipidus, low specific gravity and hypernatremia, monitor I&o
 Diabetes Insipidus
o DI can be classified into two types—nephrogenic DI and central DI. Nephrogenic DI can be transmitted genetically (e.g., sex-linked,
autosomal dominant, or autosomal recessive forms) or be acquired due to chronic renal disease, hypercalcemia, hypokalemia, or use of
certain drugs such as lithium, amphotericin, methicillin, and rifampin (Breault & Majzoub, 2016a). This variant of DI is not associated with
the pituitary gland and is related to decreased renal sensitivity to antidiuretic hormone (ADH). Therapeutic management for nephrogenic DI
involves diuretics, high fluid intake, restricted sodium intake, and a high-protein diet. Desmopressin acetate (DDAVP) is usually ineffective
in the treatment of nephrogenic DI.
Central DI is a disorder of the posterior pituitary gland and is the most common form of DI (Children’s Hospital of Boston, 2019). Therefore,
central DI will be the focus of the remainder of this discussion. Central DI is characterized by excessive thirst (polydipsia) and excessive
urination (polyuria) that is not affected by decreasing fluid intake. Typically, this disorder occurs in children as a result of complications from
head trauma or after cranial surgery to remove hypothalamic–pituitary tumors such as craniopharyngioma. Some cases can be hereditary;
however, 10% of central DI cases in children are idiopathic (Breault & Majzoub, 2016a). Other causes include genetic mutations,
granulomatous disease, infections such as meningitis or encephalitis, vascular anomalies, congenital malformations, infiltrative disease
such as leukemia, or administration of certain drugs that are associated with inhibition of vasopressin release, such as phenytoin (Breault
& Majzoub, 2016a). DI is usually permanent and requires treatment throughout life.
 CLINICAL REASONING ALERT!
o Notify the physician or nurse practitioner if the urine output is greater than 1,000 mL/hr for two consecutive voids.
o Maintain fluid intake regimens as ordered. Monitor fluid status by measuring vital signs, fluid intake and output, and daily weights (using the
same scale at the same time of day). If fluids are stopped too soon, the child may become hypernatremic, which can lead to seizures.
Feed infants more frequently, since they excrete more dilute urine, consume larger volumes of free water, and secrete lower amounts of
vasopressin than older children. Monitor for signs and symptoms of dehydration during the fluid deprivation test as well as when starting
the treatment regimen.
51. Iron deficiency anemia, what meals do you give them?
 Providing Dietary Interventions
o Ensure that iron-deficient infants are fed only formulas fortified with iron. Interventions for breast-fed infants include beginning iron
supplementation around the age of 4 or 5 months. Iron supplementation may range from adding iron-fortified cereals to the child’s diet to
giving iron-containing drops. Encourage breastfeeding mothers to increase their dietary intake of iron or take iron supplements when
breastfeeding so that the iron may be passed on to the infant. For children over 1 year of age, limit cow’s milk intake to 24 oz per day to
decrease risk of microscopic GI bleeding and increase appetite for other foods. Limit fast-food consumption and encourage intake of ironrich foods such as red meats (iron from red meat is the easiest for the body to absorb), tuna, salmon, eggs, tofu, enriched grains, dried
beans and peas, dried fruits, leafy green vegetables, and iron-fortified breakfast cereals.
o Teach the parents about dietary intake of iron. Encourage parents to provide a variety of foods for iron support and vitamins and other
minerals necessary for growth. A big problem for toddlers is their picky eating. This often becomes a means of control for the child, and
parents should guard against getting involved in a power struggle with their child. Referring parents to a developmental specialist who can
assist them in their approach to diet may prove beneficial. Refer families who meet the financial limits and who have children aged 5 and
younger to the Women, Infants, and Children (WIC) program, which provides for supplementation of infants’ and children’s diets. See
Healthy People 2030.
52 & 53. PKU, avoid milk and protein, food recommendations
o
54. Reyes
syndrome,
acute stage,
assess for
what?
 Reye Syndrome
o Reye syndrome is an extremely rare disease that primarily affects children younger than 15 years of age who are recovering from a viral
illness. The exact cause of Reye syndrome is unknown. It has been found that Reye syndrome is a reaction that is triggered by the use of
salicylates or salicylate-containing products to treat a viral infection. This reaction causes brain swelling, liver failure, and death in hours, if
treatment in not initiated. In the 1980s, the adverse effects of salicylates used to treat viral illnesses began to be publicized and the U.S.
Food and Drug Administration (FDA) required warning labels to be placed on all salicylate-containing products, such as aspirin. Since then,
there has been a dramatic decrease in the occurrence of Reye syndrome.
o Nursing Assessment
 Elicit a description of the present illness and chief complaint. Common signs and symptoms reported during the health history might
include:
Severe and continual vomiting
Changes in mental status
Lethargy
Irritability
Confusion
Hyperreflexia
Explore the child’s current and past medical history for risk factors such as:
 A prodromal viral illness, like chickenpox, croup, flu, or an upper respiratory infection
Ingestion of salicylate-containing products within 3 weeks of the start of the viral illness
Elevated liver function tests and elevated serum ammonia levels can confirm diagnosis.
o Nursing Management
 Early recognition and treatment are the most important aspects of managing this illness. Nursing management is aimed at maintaining
cerebral perfusion, managing and preventing increased ICP, providing safety measures due to changes in LOC and risk for seizures,
and monitoring fluid status to prevent dehydration and overhydration.
 Education is an important aspect of preventing this disease. Salicylates are found in many products, including many over-the-counter
products, such as Alka-Seltzer and Pepto-Bismol. A complete list can be found on . Recovery from Reye syndrome is dependent on
the severity of swelling of the brain. Some children will make a full recovery, while others may suffer long-term neurologic damage.
55. Iron deficiency anemia, what is the teaching when taking iron supplements?
 Teaching About Iron Supplement Administration
o The use of iron supplements in infants begins with the use of formula fortified with iron in the formula-fed infant. Oral supplements may
also be necessary if the baby’s iron levels are extremely low. Oral supplements or multivitamin formulas that contain iron are often dark in
color because the iron is pigmented. Teach parents to precisely measure the amount of iron to be administered. Parents should place the
liquid behind the teeth, as iron in liquid form can stain the teeth. Iron supplementation can also cause constipation. In some cases,
reducing the amount of iron can resolve this problem, but stool softeners may be necessary to control painful or difficult-to-pass stools.
Encourage parents to increase their child’s fluid intake and include adequate dietary fiber to avoid constipation.
56. A child that has artificial heart valves, you need to do prophylaxis, need antibiotics?
57. Heart murmurs, what are the characteristics for a newborn? Know the characteristics of each one
 Tricuspid Atresia
o Tricuspid atresia is a congenital heart defect in which the valve between the right
atrium and right ventricle fails to develop. As a result, there is no opening to allow
blood to flow from the right atrium to the right ventricle and subsequently through
the pulmonary artery into the lungs (Jone et al., 2018; Schneider, 2019).
o Pathophysiology
 In tricuspid atresia, blood returning from the systemic circulation to the right
atrium cannot directly enter the right ventricle due to agenesis of the tricuspid
valve. Subsequently, deoxygenated blood may pass through an opening in
the atrial septum (patent foramen ovale) into the left atrium, never entering
the pulmonary vasculature. Thus, deoxygenated blood mixes with





oxygenated blood in the left atrium. The blood then travels to the lungs through a PDA. Most cases of tricuspid atresia are associated
with a VSD and the newborn receives inadequately oxygenated blood (Fig. 19.3) (Jone et al., 2018; Schneider, 2019).
Atrial Septal Defect
o An ASD is a passageway or hole in the wall (septum) that divides the right atrium from the left atrium (Fig. 19.4). Three types of ASDs are
identified based on the location of the opening:
 Ostium primum (ASD1): The opening is at the lower portion of the septum.
 Ostium secundum (ASD2): The opening is near the center of the septum.
 Sinus venosus defect: The opening is near the junction of the superior vena cava and the right atrium.
o When the ASD is small, most infants may have a spontaneous closure within the first 18 months of life. If it does not spontaneously close
by age 3, the child will most likely need corrective surgery (Jone et al., 2018; Schneider, 2019).
o Pathophysiology
 With ASD, blood flows through the opening from the left atrium to the right atrium due to pressure differences. The shunting increases
the blood volume entering the right atrium. This, in turn, leads to increased blood flow into the lungs. If untreated, the defect can
cause problems such as pulmonary hypertension, heart failure, atrial arrhythmias, or stroke (Jone et al., 2018; Schneider, 2019).
Ventricular Septal Defect
o A VSD is an opening between the right and left ventricular chambers of the heart (Fig. 19.5). It is one of the most common congenital heart
defects and accounts for about 25% of all congenital heart defects. Spontaneous closure of small VSDs occurs in about half of children by
age 2 years. Long-term outcomes for surgically repaired VSDs are good. Repair of larger defects by 2 years of age is recommended to
prevent the development of pulmonary disease (Jone et al., 2018; Schneider, 2019).
o Pathophysiology
 In VSD, there is an abnormal opening between the right and left ventricles. The opening varies in size, from as small as a pinhole to a
complete opening between the ventricles so that the right and left sides are as one. Children with small VSDs may remain
asymptomatic. In other children, blood shunts across the opening in the septum. Pulmonary vascular resistance and systemic
vascular resistance determine the direction of blood flow. A left-to-right shunt results when pulmonary vascular resistance is low.
Increased amounts of blood flowing into the right ventricle are then pumped to the pulmonary circulation, eventually causing an
increase in pulmonary vascular resistance. Increased pulmonary vascular resistance leads to increased pulmonary artery pressure
(pulmonary hypertension) and right ventricular hypertrophy. When the pulmonary vascular resistance exceeds the systemic vascular
resistance, right-to-left shunting of blood across the VSD occurs, resulting in Eisenmenger syndrome (pulmonary hypertension and
cyanosis). Heart failure commonly occurs in children with moderate to severe unrepaired VSDs. Children with VSDs are also at risk
for the development of aortic valve regurgitation as well as infective endocarditis (Jone et al., 2018; Schneider, 2019).
Atrioventricular Canal Defect
o Atrioventricular canal defect (atrioventricular septal defect [AVSD], AV canal, or endocardial cushion defect) accounts for 4% of CHD.
Thirty-five to forty percent of children with Down syndrome and CHD have this defect (Jone et al., 2018).
o Pathophysiology
 AV canal defect occurs because of failure of the endocardial cushions to fuse (Fig. 19.6). These cushions are needed to separate the
central parts of the heart near the tricuspid and mitral (AV) valves. The complete AV canal defect involves ASDs and VSDs as well as
a common AV orifice and a common AV valve. Partial and transitional forms of AV canal defect also occur, involving variations of the
complete form.
 The complete AV canal defect permits oxygenated blood from the lungs to enter the left atrium and ventricle, crossing over the atrial
or ventricular septum and returning to the lungs via the pulmonary artery. This recirculation problem, which typically involves a left-toright shunt, is inefficient because the left ventricle must pump blood back to the lungs and also meet the body’s peripheral demand for
oxygenated blood. Subsequently, the left ventricle must pump two to three times more blood than in a normal heart. Therefore, this
specific type of cardiac defect causes a large left-to-right shunt; an increased workload of the left ventricle; and high pulmonary
arterial pressure, resulting in an increased amount of blood in the lungs and causing pulmonary edema (Jone et al., 2018; Schneider,
2019).
Patent Ductus Arteriosus
o PDA is failure of the ductus arteriosus, a fetal circulatory structure, to close within the first weeks of life (Fig. 19.7). As a result, there is a
connection between the aorta and pulmonary artery. PDA is the second most common congenital heart defect and accounts for 10% of
CHD cases (Jone et al., 2018; Schneider, 2019). PDA occurs much more frequently in premature than in term infants and in infants born at
high altitudes compared with those born at sea level. Infants with other CHDs that result in right-to-left shunting of blood and cyanosis may
additionally display a PDA. In these infants, the PDA allows for some level of oxygenated blood to reach the systemic circulation (Jone et
al., 2018; Schneider, 2019).
o Pathophysiology
 Failure of the ductus arteriosus to close leads to continued blood flow from the aorta to the pulmonary artery. Blood returning to the
left atrium passes to the left ventricle, enters the aorta, and then travels to the pulmonary artery via the PDA instead of entering the
systemic circulation. This altered blood flow pattern increases the workload of the left side of the heart. Pulmonary vascular
congestion occurs, causing an increase in pressure. Right ventricular pressure increases in an attempt to overcome this increase in
pulmonary pressure. Eventually, right ventricular hypertrophy occurs (Jone et al., 2018; Schneider, 2019).
Coarctation of the Aorta
Coarctation of the aorta is narrowing of the aorta, the major blood vessel carrying highly oxygenated blood from the left ventricle of the
heart to the rest of the body (Fig. 19.8). It accounts for about 10% of congenital heart defects (Schneider, 2019).
o Pathophysiology
 Coarctation of the aorta occurs most often in the area near the ductus arteriosus. The narrowing can be preductal (between the
subclavian artery and ductus arteriosus) or postductal (after the ductus arteriosus). As a result of the narrowing, blood flow is
impeded, causing pressure to increase in the area proximal to the defect and to decrease in the area distal to it. Thus, BP is increased
in the heart and upper portions of the body and decreased in the lower portions of the body. Left ventricular afterload is increased,
and in some children this may lead to heart failure. Collateral circulation also may develop as the body attempts to ensure adequate
blood flow to the descending aorta. Due to the elevation in BP, the child is also at risk for aortic rupture, aortic aneurysm, and CVA
(Jone et al., 2018; Schneider, 2019).
 Aortic Stenosis
o Aortic stenosis is a condition causing obstruction of the blood flow between the left ventricle and the aorta. The incidence of aortic stenosis
is about 5% of all congenital heart defects (Schneider, 2019).
o Pathophysiology
 Aortic stenosis can be caused by a muscle obstruction below the aortic valve, an obstruction at the valve itself, or an aortic narrowing
just above the valve (Fig. 19.9). The most common type is an obstruction of the valve itself, called aortic valve stenosis. The aortic
valve consists of three very pliable leaflets. Normally the leaflets of the aortic valve spread open easily when the left ventricle ejects
blood into the aorta. Aortic stenosis occurs when the aortic valve narrows, causing an obstruction between the left ventricle and the
aorta. As a result, cardiac output decreases. When the aortic valve does not function properly, the left ventricle must work harder to
pump blood into the aorta. Because of the increased workload, the left ventricular muscle hypertrophies. If this continues, left
ventricular failure can occur, leading to a backup of pressure in the pulmonary circulation and pulmonary edema. Heart failure may
occur, but this is more commonly seen in the infant (Jone et al., 2018; Schneider, 2019).
 Pulmonary Stenosis
o Pulmonary stenosis is a condition that causes an obstruction in blood flow between the right ventricle and the pulmonary arteries.
Pulmonary stenosis occurs in 0.6 to 0.8 per 1,000 live births (Peng & Perry, 2018). It is often associated with other heart anomalies and
with genetic syndromes. Children may be asymptomatic, although some children with right ventricle outlet obstruction may exhibit dyspnea
and fatigue with exertion (demonstrating hypercyanotic spells similar to those in children with tetralogy of Fallot) (Peng & Perry, 2018).
o Pathophysiology
 Pulmonary stenosis may occur as a muscular obstruction below the pulmonary valve, an obstruction at the valve, or a narrowing of
the pulmonary artery above the valve (Fig. 19.10). Valve obstruction is the most common form of pulmonary stenosis. Normally the
pulmonary valve is constructed with three thin and pliable valve leaflets; they spread apart easily, allowing the right ventricle to eject
blood freely into the pulmonary artery. The most common problem causing pulmonary stenosis is that the pulmonary valve leaflets are
thickened and fused together along their separation lines, causing the obstruction to blood flow. The right ventricle has an additional
workload, causing the muscle to thicken, resulting in right ventricular hypertrophy, and decreased pulmonary blood flow. When the
pulmonary valve is severely obstructed, the right ventricle cannot eject sufficient blood into the pulmonary artery. As a result, pressure
in the right atrium increases, which could lead to a reopening of the foramen ovale. If this occurs, deoxygenated blood will pass
through the foramen ovale into the left side of the heart and would then be pumped to the systemic circulation. In some cases, a PDA
may be present, thus allowing for some compensation by shunting blood from the aorta to the pulmonary circulation for oxygenation
(Peng & Perry, 2018).
58. Tretalogy of fallot, right ventricular hypertrophy, select all that apply
 Health History and Physical Examination
o Obtain the health history, noting a history of color changes associated with feeding, activity, or crying. Determine if the infant or child is
demonstrating hypercyanotic spells. Hypercyanosis develops suddenly and is manifested as increased cyanosis, hypoxemia, dyspnea,
and agitation. If the infant’s oxygen demand is greater than the supply, such as with crying or during feeding, then the spell progresses to
anoxia. When the degree of cyanosis is severe and persistent, the infant may become unresponsive. As the infant gets older, he or she
may use specific postures, such as bending at the knees or assuming the fetal position, to relieve a hypercyanotic spell. The walking infant
or toddler may squat periodically. These positions improve pulmonary blood flow by increasing systemic vascular resistance. Ask the
parents if they have noticed any of these unusual positions. Note history of irritability, sleepiness, or difficulty breathing.
o During the physical examination, observe the skin color and note any evidence of cyanosis. Also observe for changes in skin color with
positional changes and inspect the fingers for clubbing. Note if the child has a hypercyanotic spell during the assessment. Count the child’s
respiratory rate and observe work of breathing, noting retractions, shortness of breath, or noisy breathing. Document oxygen saturation via
pulse oximetry; it will likely be decreased. Auscultate the chest for adventitious breath sounds, which may suggest the development of
heart failure. Auscultate the heart, noting a loud, harsh murmur characteristic of this disorder.
59. Nutrition in an infant, breastmilk up to what age, when do you introduce cereal?
 BREAST MILK COMPOSITION
o Breast milk includes lactose, lipids, polyunsaturated fatty acids, and amino acids. The ratio of whey to casein protein in breast milk makes
it readily digestible. The high concentration of fats and the balance of amino acids are believed to contribute to proper myelination of the
nervous system. The concentration of iron in breast milk is less than that of formula, but the iron has increased bioavailability and is
sufficient to meet the infant’s requirements for the first 4 to 6 months of life. In addition to complete nutrition, immunologic protection is
transferred from mother to infant via breast milk and maternal–infant bonding is promoted. The benefits of breastfeeding are listed in Box
3.1.
o Progressing to Solid Foods
o
After 6 months of age, infants usually require the nutrients available in solid foods in addition to their breast milk or formula.
Progressing to feeding solid foods can be exciting and trying. Before solid foods are attempted, the infant should be assessed for
readiness to progress. Parents need instruction in choosing appropriate solid foods and support in the progression process.
60. PKU, what are the most common complications and concerning?

61.
Communication with children, no parents no
appt
62. Motor skills with a two-year-old
63. Erickson's look for the characteristics in each age group, put in order
64. Newborn screening, why is the apgar score important, in order to check for abnormalities?
65. Vaccination, what is the needle size, subq, im, etc.?

66. Characteristics of a child with
acrocyanosis?
Acrocyanosis (blueness of the hands and feet) is normal in the newborn; it decreases over the first few days of life (Fig. 3.3). Newborns often
experience mottling of the skin (a pink-and-white marbled appearance) because of their immature circulatory system. Mottling decreases over
the first few months of life (Fig. 3.3). The newborn and young infant’s skin is relatively thinner than that of the adult, with the peripheral
capillaries being closer to the surface. This may cause increased absorption of topical medications.
67 & 68. Secondary sexual changes (tanner stages)
69. Vaccines
you give to a
child from 5 to
12
70. UTI
Prevention

Preventing Urinary Tract Infection in Females
o Drink enough fluid (to keep urine flushed through bladder).
o Drink cranberry juice to acidify the urine.
o Avoid colas and caffeine, which irritate the bladder.
o Urinate frequently and do not “hold” urine (to discourage urinary stasis).
o Avoid bubble baths (they contribute to vulvar and perineal irritation).
o Wipe from front to back after voiding (to avoid contaminating the urethra with rectal material).
o Wear cotton underwear (to decrease the incidence of perineal irritation).
o Avoid wearing tight jeans or pants.
o Wash the perineal area daily with soap and water.
o While menstruating, change sanitary pads frequently to discourage bacterial growth.
o Void immediately after sexual intercourse.
71. Bed wetting regression or child abuse
 Why Does Bedwetting Happen?
o Doctors don't know for sure what causes bedwetting or why it stops. But it's often a natural part of development, and kids usually grow out
of it. It's most common in young kids, but can last into the teen years. Most of the time, bedwetting is not a sign of any deeper medical or
emotional issues.
o Bedwetting often runs in families: many kids who wet the bed have a relative who did too. If both parents wet the bed when they were
young, it's very likely that their child will.
 How Can We Cope With Bedwetting?
o Bedwetting is an issue that millions of families face every night, and can be very stressful. Kids can feel embarrassed and guilty about
wetting the bed and anxious about spending the night at a friend's house or at camp. Parents often feel helpless to stop it.
o Bedwetting usually goes away on its own, but may last for a while. It can be embarrassing and uncomfortable for your child, so it's
important to provide emotional support until it stops.
o Reassure your child that bedwetting is a normal part of growing up and that it's not going to last forever. It may comfort your child to hear
about any other family members who struggled with it when they were young.
o Try to have your child drink more fluids during the daytime hours and less at night (and avoid caffeine-containing drinks). Then remind your
child to go to the bathroom one final time before bedtime. Many parents find that using a motivational system, such as stickers for dry
nights with a small reward (such as a book) after a certain number of stickers, can work well. Bedwetting alarms also can be helpful.
o When your child wakes with wet sheets, don't yell or punish. Have your child help you change the sheets. Explain that this isn't
punishment, but it is part of the process. It may even help your child feel better knowing that he or she helped out. Offer praise when your
child has a dry night.
72. Child exanthemas, skin conditions, viruses

Rubella (German measles)
o Caused by rubella virus
o Transmission: by direct or indirect contact with droplets, primarily by nasopharyngeal secretions, but also in blood, stool, and urine. Also
transmitted from mother to fetus
o Peak incidence: late winter and early spring
o Incubation period: 12–23 days (usually 14)
o Communicable: 7 days before to 7 days after onset of rash
 Rubeola (measles)
o Caused by measles virus
o Transmission: direct or indirect contact with droplets, primarily by nasopharyngeal secretions, but also blood and urine. Highly contagious
o Peak incidence: late winter and spring
o Incubation period: 10–12 days
o Communicable 1–2 days before the onset of symptoms (3–5 days before onset of rash) until 4–6 days after rash has appeared
 Varicella Zoster (chickenpox)
o Caused by varicella zoster virus, human herpes virus 3
o Transmission: direct contact with infected persons’ nasopharyngeal secretions or via air-borne spread, to a lesser degree by contact with
unscabbed lesions. Highly contagious. Also transmitted from mother to fetus
o Peak incidence: late fall, winter, and spring
o Incubation period: 10–21 days, usually 14–16 days
o Communicable 1–2 days before the onset of rash until all vesicles have crusted over (about 3–7 days after the onset of rash)
 Exanthem Subitum (roseola infantum or sixth disease)
o Caused by human herpes virus 6 (HHV-6); less frequently human herpes virus 7 (HHV-7)
o Transmission: little is known but suspected to be from saliva of infected person and enters the host through the oral, nasal, or conjunctival
mucosa
o Peak incidence: ages 7–13 months
o Incubation period: 5–15 days, average of 10 days
o Communicability is unknown, but most likely contagious before symptoms appear
 Erythema Infectiosum (fifth disease)
o Caused by human parvovirus B19
o Transmitted by large droplet spread from nasopharyngeal viral shedding or percutaneous exposure to blood and blood products. Also
transmitted from mother to fetus
o Peak incidence late winter and early spring
o Incubation period: 4–28 days, average 16–17 days
o Communicability is uncertain, but most children are no longer infectious by the time the rash appears and diagnosis is made, so isolation
or exclusion from school, once the child is diagnosed, is unnecessary (those with aplastic crisis may be communicable up to 1 week after
the onset of symptoms and those who are immunosuppressed with chronic infection and severe anemia may be communicable for months
to years).
 Hand, Foot, and Mouth Disease, or Herpangina (if only mouth involvement)
o Caused by viruses belonging to enterovirus genus. Coxsackie A viruses (especially A16) is the most common. Transmitted by direct
contact with infected fecal, oral secretions; spread mostly through saliva
o Peak incidence during spring and summer, particularly in children who wear diapers (1- to 4-year-olds)
o Incubation period: 3–6 days
o Communicable from time of infection until fever resolves; virus is shed for several weeks after the infection begins.
73. Temper tantrums
 Even children who displayed an easygoing personality as infants may lose their temper frequently during the toddler years (Fig. 4.14). A
toddler who was more intense as an infant may have more temper tantrums. Temper tantrums are a natural result of the frustration that
toddlers experience. Toddlers are eager to explore new things, but their efforts are often thwarted (usually for safety reasons). Toddlers do
not behave badly on purpose. They need time and maturity to learn the rules and regulations. Some of their frustration may come from lack
of language skills to express themselves. Toddlers are just starting to learn how to verbalize feelings and to use alternative actions rather
than just “pitching a fit.” The temper tantrum may be manifested as a screaming and crying fit or a full-blown episode in which the toddler
throws himself or herself on the floor kicking, screaming, and pounding, perhaps even holding the breath. Fatigue or hunger may limit the
toddler’s coping abilities and promote negative behavior and temper tantrums (O’Donnell, 2018).
 Although tantrums are annoying to parents and caregivers, they are a normal part of the toddler’s quest for independence. As toddlers
mature, they become better able to express themselves and to understand their environment. Parents need to learn their toddler’s
behavioral cues in order to limit activity that is frustrating. When the parent notes the beginnings of frustration, a friendly warning might be
given. Intervening early with an activity change might prevent a tantrum. Use distraction, refocusing, or removal from the situation.
 When a temper tantrum does occur, the best course of action is to ignore the behavior and ensure that the child is safe during the tantrum.
Physical punishment will probably just prolong the tantrum and in fact produce more intense negative behavior. If the tantrum occurs in
public, it may be necessary for the parent to immobilize the child with a big bear hug and use a calm voice to soothe the toddler. It is very
important for parents to model self-control. Since toddlers’ tantrums most often result from frustration, the role-modeled behavior of selfcontrol helps to teach toddlers to control their temper when they can’t get what they want (O’Donnell, 2018).