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During CPR on a child between 1 and 8 years of age, how many breaths per minute do you deliver?
20 breaths per minute
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CPR on an infant, how many chest compression per minute do you deliver?
100 times per minute
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What is the most appropriate location to assess the pulse on an infant?
Brachial
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During CPR on an infant, do you do blind finger sweep? why?
- No.
- because the object may be forced back further into the throat
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According to Erickson's developmental theory, an infant should be allowed to __
signal a need
- prolonged or delayed response would inhibit the development of trust and lead to mistrust of others
- if needs are anticipated at all times, infant will not learn to control their environment
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When a 3-year-old is constantly rebelling and having temper tantrums, the appropriate action for the mother is to __
set limits on the child's behavior
- according to Erickson, the child's focus is on being independent, and this behavior is normal
- being consistent and setting limits on the child's behavior are necessary elements
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Is it normal when an 8-year-old child is more attentive to their friends more than parents?
Yes
- according to Erickson, ages 7 - 12 years, child begin to move for support toward peers and friends and away from their parents
- the child also begins to develop special interests that reflect his or her developing personalities instead of the parents
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Is it normal for a 4-year-old to masturbate?
Yes
According to Freud's psychosexual stages of development, the child is in the phallic stage between the ages of 3 and 6 years. At this time, the child devotes much energy to examining his or her genitalia, masturbating, and expressing interest in sexual concerns.
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A hospitalized 2-year-old ignores parent in the play room during visit, this behavior indicates:
normal behavior
The toddler is particularly vulnerable to separation. A toddler often shows anger at being left by ignoring the parent or by pretending to be more interested in play than in going home. Parents of hospitalized toddlers are frequently distressed by such behavior. The toddler normally engages in parallel play and plays alongside, but not with, other children.
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When does the anterior fontanel normally close?
12 - 18 months of age
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When does the posterior fontanel normally close?
2 - 3 months of age
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The best way to check for the major symptom of hydrocephalus is to:
palpate the anterior fontanel
An elevated or bulging anterior fontanel indicates an increase in cerebrospinal fluid collection in the cerebral ventricle.
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What are the late signs of increased intracranial pressure?
- widening pulse pressure
- tachycardia leading to bradycardia
- apnea
- systolic hypertension
- posturing
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What is the major symptom of Reye's syndrome?
Persistent vomiting
- persistent vomiting is a major symptom associated with intracranial pressure
- Reye's syndrome is related to a history of viral infections, and hypoglycemia is a symptom of this disease
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A nursing care plan for a child diagnosed with Reye's syndrome should include:
providing a quiet environment with dimmed lights
- -the major elements of care are to maintain effective cerebral perfusion and control intracranial pressure. Decreasing stimuli in the environment would decrease the stress on the cerebral tissue and neuron responses. Cerebral edema is a progressive part of this disease process
- -the child should be in a head-elevated position to decrease the progression of the cerebral edema and promote drainage of cerebrospinal fluid
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Which finding by the nurse would suggest a potential complication associated with tonic-clonic seizure?
Blood on the pillow
The complications associated with seizures include airway compromise, extremity and teeth injuries, and tongue lacerations. Night seizures can cause the child to bite down on the tongue. Cyanosis can occur during the tonic-clonic part of the seizure activity, but blanching does not occur. Migraine headaches are not common in children with seizures. Seizures do not cause a high-pitched cry, unless a tumor or intracranial pressure is the cause of the seizure diagnosis.
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For an infant who's at risk for seizures, what items should be kept at bedside for safety?
a suction apparatus and an airway
- -seizures cause tightening of all body muscles followed by tremors. Obstructive airway and increased oral secretions are the major complications during and following the seizure
- -emergency carts are never kept at bedside
- -tracheostomy is not done
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Data collection on a child with a diagnosis of seizure, the nurse checks for the causes of the seizure activities by:
obtaining a history regarding factors that might precipitate seizure activity
Fever and infections increase the body's metabolic rate. This can cause seizure activity in children under the age of 5 years old. Dehydration and electrolyte imbalance can also contribute to the occurrence of a seizure. Falls can cause head injury, which would increase intracranial pressure or cerebral edema. Some medications could cause seizures.
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What is Cerebral Palsy?
Cerebral palsy is a chronic disability characterized by difficulty in controlling the muscles as a result of an abnormality in the extrapyramidal or pyramidal motor system.
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What is the primary goal in treating a child with Cerebral Palsy?
Maximizing the child's assets and minimizing the limitations caused by the disease
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When caring for a child with basilar skull fracture, what procedure is contraindicated?
nasotracheal suctioning
Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture. Because of the nature of the injury, the suction catheter may be introduced into the brain.
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Cerebrospinal fluid obtained for the diagnosis of bacterial meningitis, which result would verify diagnosis?
cloudy CSF with high protein and low glucose
In the case of bacterial meningitis, findings usually include increased pressure, cloudy CSF, high protein level, and low glucose level.
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Based on the mode of transmission of meningococal meningitis, which precaution should be included into the plan of care?
maintain isolation precaution at least 24 hours after the initiation of antibiotics
Meningococcal meningitis is transmitted primarily by droplet infection. Isolation is begun and maintained for at least 24 hours after antibiotics are given.
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What is the primary characteristics of autism?
Lack of social interaction and awareness
Autism is a severe developmental disorder that begins in infancy or toddlerhood. The primary characteristic is lack of social interaction and awareness. Social behaviors in autism include lack of or abnormal imitation of others actions, and the lack of or abnormal social play. Additional characteristics include lack of or impaired verbal communication and markedly abnormal nonverbal communication.
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Which data during data collection most likely indicate the suspicion of sexual abuse?
swelling of the genitals
The most likely findings in sexual abuse include difficulty walking or sitting, torn, stained, or bloody underclothing, pain, swelling, or itching of the genitals, and bruises, bleeding, or lacerations in the genital or anal area. Poor hygiene may be indicative of physical neglect. Bald spots on the scalp and fear of the parents are most likely associated with physical abuse.
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Which plan of care is appropriate for a child during a seizure?
- time the seizure
- stay with the child
- move furniture away from the child
During a seizure, the child is placed on his or her side in a lateral position. Positioning on the side will prevent aspiration because saliva will drain out the corner of the child's mouth. The child is not restrained because this could cause injury to the child. The nurse would loosen clothing around the child's neck and ensure a patent airway. Nothing is placed into the child's mouth during a seizure because this action may cause injury to the child's mouth, gums, or teeth. The nurse would stay with the child to reduce the risk of injury and allow for observation and timing of the seizure.
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Which observation might indicate strabismus?
The nurse may suspect strabismus in a child when the child complains of frequent headaches, squints, or tilts the head to see.
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What should the nurse include in her instructions to parents caring for an infant with recurring otitis media?
- parents should be encouraged to breast-feed during infancy
- discontinue bottle-feeding as soon as possible
- feed the infant in an upright position
- not to give the infant a bottle in bed
- not to smoke in the child's presence, because passive smoking increases the incidence of otitis media.
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Following myringotomy with insertion of tympanostomy tubes, the nurse notes a small amount of reddish drainage from the child's ear. What should the nurse do?
Document the finding
A small amount of reddish drainage is normal for the first few days after surgery. Any heavy bleeding or bleeding that occurs after 3 days should be reported.
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How should an ear drop be administered to a 2-year-old child?
pull earlobe down and back
To administer ear drops in a child younger than age 3 years, the ear should be pulled down and back. In children older than 3 years, the ear is pulled up and back. Gloves do not need to be worn by the parents, but hand washing before and after the procedure needs to be performed. The child needs to be in a side-lying position with the affected ear facing upward to facilitate the flow of medication down the ear canal by gravity.
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Which pre-op check should a nurse do prior to a tonsillectomy for a child to prevent aspiration?
The presence of loose teeth
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Appropriate position for a child after toncillectomy is?
Prone or side lying to facilitate drainage
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Following toncillectomy, the child begins to vomit bright red blood, what should the nurse do first?
turn the child to the side
Following tonsillectomy, if bleeding occurs, the child is turned to the side and the RN is notified, who will then contact the physician.
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Following toncillectomy, which food is appropriate to offer to the child?
Jell-O
Following tonsillectomy, clear, cool liquids should be administered. Citrus, carbonated, and extremely hot or cold liquids need to be avoided because they may irritate the throat. Red liquids need to be avoided because they give the appearance of blood if the child vomits. Milk and milk products (pudding) are avoided because they coat the throat and cause the child to clear the throat, thus increasing the risk of bleeding.
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When can a child resume regular diet of rough and scratchy foods following a toncillectomy?
3 weeks
Rough, scratchy foods or spicy foods are to be avoided for 3 weeks. Citrus juices, which irritate the throat, need to be avoided for 10 days. Red liquids are avoided because they will give the appearance of blood if the child vomits. A full liquid diet is allowed on the second postoperative day and soft foods are allowed as the child tolerates them.
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Which measures is not appropriate if an acute spasmodic episode occurs in a child with croup?
steam vaporizer in the child's room
Steam from warm running water in a closed bathroom and cool mist from a bedside humidifier are effective in reducing mucosal edema. Cool mist humidifiers are recommended over steam vaporizers, which present a danger of scald burns. Taking the child out into the cool humid night air may also relieve mucosal swelling. Remember, however, that a cold mist may precipitate bronchospasm.
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