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Pediatric Nursing

Terms in this set (211)

An 18-Month-Old is discharged from the hospital after having a febrile seizure secondary to exanthem subitum (Roseola). On discharge, the mother asks the nurse if her 6-year-old twins will get sick. Which teaching about the transmission of roseola would be most accurate?

1. The child should be isolated at home until the vesicles have dried.

2. The child does not need to be isolated from the older siblings.

3. Administer acetaminophen to the older siblings to prevent seizures.

4. Monitor older children for seizure development.
. 2. The route of roseola transmission is unkown, and the disease is more commonly seen in children 6 months to 3 years of age, so siblings do not need to be isolated.
Which would be the priority intervention for a child suspected of having varicella (chickenpox)?

1. Contact Precautions
2. Contact and Droplet Respiratory Precautions?
3. Droplet respiratory precautions?
4. Universal Precautions and standard precautions.
2. Varicella (Chickenpox) is highly contagious. Contact & Droplet respiratory precautions should be started immediately because the primary source of transmission is secretions of the respiratory tract (droplet) and also by contaminated objects.
Which s&s would the nurse expect with rheumatic fever?

1. Ankle and Knee Joint Pain.
2. Negative group A beta strep culture.
3. Large, red "bulls eye" - appearing rash.
4. stiff neck with photophobia.
Ankle and knee joint pain.
Nursing Assessment suspects the newborn has cystic fibrosis. Which interventions would the nurse begin.
1. Observe frequency and nature of stools.
2. Provide Chest PT
3. Observe for weight gain.
4. Assess parent's compliance with fluid restrictions.
5. Assess respiratory system frequently.
1 & 3

Cystic fibrosis is an inherited autsomal trait, causing exocrien gland dysfunction. 7-10% present meconium ileus, so assessing stool frequency and consistency is important.

Assessing weight is important in newborns because they lose up to 10% of their birth weight, and can take 2 weeks for them to regain their birth weight.

Assessing the newborn's respiratory system frequently would be monitored as frequently as other infants if the newborn has no respiratory symptoms. Chest PT would not be initiated in a newborn without a definitive diagnosis.
Can a mother breastfeed their infant if they have PKU?
Yes. Breast milk has low amounts of phenylalanine, so the mother can breast as long as the infants phenylalanine level is monitored.
signs of intussusception
bloody stools or "currant jelly stools", diarrhea, Large palpable sausage shaped mass in the abdomen, abdominal distention, grunting, dehydration Fever, and pain (legs pulled towards abdomen)!
Flat Ribbon Stools indicate
Hirschsprung Disease
Treatment for Intussusception
Barium or air enema
Nursing Care for Intussusception
Document I & O
Monitor for peritonitis & perforation
Monitor and record stools
Biggest complications of Intussusception
Peritonitis and Perforation
Risk factors for intussusception
Cystic Fibrosis
Ages 3 months to 3 years old.
Post-Operative Care for Intussusception
Bowel sounds should return in four hours, progressive diet, hydration.
Priority nursing diagnosis for intussusception
Acute Pain!
A 2 year old has just been diagnosed with CF. The parents ask the nurse what early respiratory symptoms they should expect to see in their child. Which is the nurse's best response?
1. Barrel shaped chest
2. Chronic productive cough
3. bronchiectasis
4. wheezing
Wheezing respirations and a dry nonproductive cough are common early symptoms of CF.

A barrel shaped chest is a long-term respiratory problem that occurs with recurrent hyperinflation. A chronic productive cough is common as pulmonary damage increases. Bronchiectasis develops in advanced stages of CF.

Test taking hint: "chronic: implies the disease process is advanced rather than in initial stages.
A school age child has been diagnosed with strep throat. The parent asks the RN when the child can go back to school. Which is the nurse's best response?
Children with strep are no longer contagious 24 hours after initiation of antibiotic therapy.
The RN is revieing discharge insturctuon with a parent of a child who has a tonsillectomy a few hours ago. The parents tell the nurse that the child is a big eater, and they want to know what foods to give their child for the next 24 hours. What is the nurses's best response?
1. no restrictions at all
2. clear liquids only
3. restricted to ice cream and cold liquids
4. restricted to soft foods.
4. Soft foods
Which of the following children with asthma should the nurse see first?
1. a 12 month old who has a mild cry, is pale in color, has diminished breathe sounds, and has an O2 sat of 93%.
2. A 5 year old who is speaking in complete sentences, is pink in color, wheezing bilaterally, and has an O2 sat of 93%,
3. A 9 year old who is quiet, pale in color, wheezing biliaterally with an O2 sat of 92%,
4. A 16 year old who is speaking in short sentences, wheezing, sitting upright, and has an O2 sat of 93%,
1. Diminished breathe sounds are a sign of severe asthma.
Frog Like Croaking indicates
Epiglottitis, a medical emergency.
What would confirm Epiglottis
Xray. A CBC would only show elevated WBC count, it is non-confirmatory.
What should be the nurse's first action with action with a child who has a high fever, dysphagia, drooling, tachypnea, tachycardia, and tachypnea?

1. Immediate IV placement
2. Immediate respiratory treatment
3. Thorough physical exam
4. Lateral neck radiograph.
4.

Immediate respiratory treatment may agitate the child and progress the inflammation, increasing risks.
Is exercise prohibited in patient's with CF?
Exercise is effective in helping CF patient's clear secretions.
What chloride level is definitive of CF?
The definitive diagnosis of C is made when the child has a sweat test level of 60 mEq/L or greater. A normal chloride level is <40mEq/L.
What pediatric GI Disorder may have chest tubes placed post-operatively
Tracheal Esophageal Fistula
Most common age for Hirschsprung's Disease
Usually occurs younger (infant fails to pass meconium in the first 48 hours of life). but can occur at any age.
What is Hirschsprung disease
A disorder related to the absence of ganglion cells that results in decreased motility; A condition that affects the large intestine (colon) and causes problems with passing stool.
Complication of Hirschsprung disease
enterocolitis-inflammation of colon can leadd to sepsis and death
fever, explosive, foul smelling diarrhea
worsening abd distension
A laxative is ordered for a child for Hirschsprung disease. Why should the nurse question this order?
Giving a laxative to a child with Hirschsprung disease can cause perforation or rupture of the colon /large intestine, leading to peritonitis and shock.
Common viral cause of Gastroenteritis
Rotavirus
Risk factor for TEF
Poly-hydramnios
Olive-Shaped mass is indicate of what GI disorder
Hypertrophic Pyloric Stenosis
Folic acid deficiency can cause _________ , _________, and neural tube defects
Cleft Lip, Cleft Palate
What maternal drug prescriptions cause a risk for CL/CP?
Steroids and Anticonvulsants
Non-Bilious Vomiting
= pyloric stenosis
Sausage shaped mass, and bloody stools
Intussusception.
Trisomy Children (13, 18, & 21) may be at risk for:
Celiac Disease and Hirschprung Disease
Lactose Intolerance is associated with what GI motility disorder?
Celiac Disease
How to protect suture lines in Cleft Lip?
Prevent Crying (Cuddling), Supine position with elbow restraints, or on the side with head elevated up right. Logan's bar. No sippy cups, toothbrush, or straws.
Why is a cleft lip/cleft palate child at risk for infection
Oropharyngeal airways are exposed and dry, making them at risk for infection.
What congenital defect is associated with inefficient eustachian tube function, Otitis Media, and hearing loss
Cleft Lip & Cleft Palate
Symptom of Hirschsprung's disease?
constipation, vomitting, abdominal swelling, growth retardation, failure to pass meconium in first 48 hours of life, poor feeding
Cystic Fibrosis is associated with what other GI disorder
Intussusception
When is pincer grasp mastered
Between 9 and 12 months.
Normal fine motor skill at 10 months
Points at objects
When can a child hop on one foot?
4 years of age.
Causes of Urinary Stasis
- reflux
- anatomic abnormalities
- voiding dysfunction
- Ureteral or bladder compression caused by constipation
pylenophritis
inflammation of renal parenchyma
- fever
- vomiting
- chills

** calls for immediate administration of IV antibiotics
Orchiopexy is done for
Testicular torsion and Cryptochordism
Cryptochordism
Congenital undescended tests or not formed in utero.
- surgery done at 6-12 months of age
- infertility issues, fertility increases post surgical repair.
- lifelong increased risk of testicular cancer (higher if uncorrected by puberty)
- do surgery by 12 months to prevent infertility
- may treat with HCG in older children
Phimosis
foreskin adheres, narrowing or stenosis. Do manual retraction & cleaning, may need circumcision if severe.
Bladder Extrophy
- moist non-adherent dressing
- may progress to renal failure
- eversion of the bladder through the abdominal wall.
- surgery done early to preserve renal function, prevent infection, attain continence and preserve renal function .
Nephrotic Syndrome
This is a clinical state or disorder, and not a single disease. May follow a previous upper respiratory condition. Usually occurs between ages 2-8.
- May be caused by several diseases or unknown.
- body is excreting too much protein. glomeruli become very permeable to protein.
- Causes change in osmotic pressure --> fluid into tissues, perioribtal edema, ascites (excess peritoneal fluid, 3rd spacing.
- Edema: swelling around eyes, hands, and feet. Facial edema subsides in the afternoon and replaced with abdominal, genital and lower extremity edema.
- decreased activity/fatigue
- foamy urine
- weight gain
- anorexia
- Labs: MASSIVE PROTEINURIA, HYPOALBUMINEMIA, HYPERLIPIDEMIA, & EDEMA, oliguria, and hypercholestermia.
Primary Nephrotic Snydrome
Can be from:
(1) MCNS: Minimal change nephrotic syndrome. Do renal biopsy and find that glomeruli look ok, but not functioning correctly. No scarring or damage.
(2) Inherited of from other cause of glomerular change (meds, antibiotics)
Complication of Nephrotic Syndrome
- hyper-coagulability leading to blood clot
- Fluid loss in vascular spaces causes hypovolemia, stimulates renin-angiotensin system. -- liquid portion of blood plasma is low. Symptoms are weakness, dizziness, decreased urine output. Treat with IV fluids, blood or both.
- Infection
Treatment of Nephrotic Syndrome
- steroids 1-3 weeks, then gradually tapered. (prednisone [prednisolone]). Prevents or delays loss of kidney function; may reduce protein levels.
- ACE inhibitors: "prils". can reduce proteinuria, but can cause hypotension.
- Immunosuppressive drugs if they do not respond to steroids.
- Diuretics:
(1) thiazide/loop diuretics, also called potassium sparing diuretics. Spironolactone (aldactone) & Triamterene (Dyrenium)
(2) Furosemide (Lasix): promotes diuresis, can cause dehydration, hypocalcemia and hypokalemia (low potassium)
- Regular diet with water and sodium restriction.
- Monitor I&O
- 1 1/2 X maintenance unless cardiac or renal contraindications.
- Sometimes IV albumin
Contraindications during corticosteroid therapy
- Live Vaccines (MMR & Varicella)
Nursing Care for Nephrotic Syndrome
- Strict I&O
- testing urine protein (at least once daily)
- weights daily (same scale, time, clothing)
- skin care (will be stretched)
- V/S
- Monitor temp for infection
- Good Nutrition (low salt, low fat)
- Modified activity (no sports) until there is no more protein in the urine. Can take up to a year.
Acute Glomerulonephritis (AGN)
Many types & causes, but most commonly occurs post-streptoccocal hemolytic group A, in children (immune reaction)
- can also be chemical
- follows impetigo or strep
- More common in school age
- 10-21 recovery time
- Characterized by OLIGURIA, EDEMA, HYPERTENSION, INCREASED SPECIFIC GRAVITY, NEGATIVE URINE CULTURE, HEMATURIA, PROTEINURIA, & CIRCULATORY CONGESTION
Normal BUN levels in pediatrics
children under 2: 4-15 mg/dL
Older Individuals: 5-20 mg/dL

Good indication of renal function. Elevated in kidney disease, dehydration, hemorrhage, steroid therapy, and high protein intake.
Normal Creatinine Levels in Pediatrics
0.2-1.0. Elevated in severe kidney disease
Normal Specific Gravity
of the urine in a child is <1.015 and infants <1.010. A specific gravity >1.025 in any child is suggestive of dehydration and >1.015 in infants as the infantile kidney can only maximally concentrate urine to
Diagnostics for AGN
- Positive ASO titer (antistreptolysin titer, indicating they recently had strep)
- mild proteinuria
- Chest X-Ray: possible cardiomegaly & pulmonary congestion
Management of Acute Glomerulonephritis
- Moderate Na & H2O restrictions
- AVOID HIGH K+ FOODS (bananas)
- Monitor V/S frequently
- may need seizure precautions
- check for ICP, Encephalopathy, CVA
- daily weights
- May be a standing order for an Antihypertensive if BP is highL (ACE inhibitors)
- Bedrest
- modified activity at home until no blood in urine (may take up to 6 months)
prognosis of acute glomerulonephritis
generally good. normal kidney function is restored after time, rest, and salt restrictions.
Prognosis of nephrotic syndrome
- in children due to minimal glomerular change & responds to corticosteroids = complete recovery
- in adults usually a manifestation of severe progressive renal disease
Estimating Bladder Capacity in children
By adding the #2 to their age. For example a 3-year old has a bladder capacity of approximately 5 fl. oz.
Which statement by a parent is most consistent with Minimal Change Nephrotic Syndrome (MCNS)?
1. My child missed 2 days of school last week because of a really bad cold.
2. After camping last week, my child's legs were covered in bug bites.
3. My child came home from school a week ago because of vomiting and stomach cramps.
4. We have a pet turtle, but no one washes their hands after playing with the turtle.
1. Nephrotic Syndrome usually follows an upper respiratory infection. (around 1-3 days).
Which medication is mostly likely prescribed after a bladder exstrophy repair
1. Furosemide (lasix)
2. Mannitol
3. Meperidine (Demerol)
4. Oxybutynine (Ditropan)
4. Oxybutynine (Ditropan) is used to help control bladder spasms.
Which two disaeases are at risk for Latex Allergy
- Cystic Fibrosis
- Bladder Exstrophy infants
Should stay away from playgrounds with rubber surfaces (turf), because they often contain latex.
- myelomeningocele patients
Sickle Cell Anemia & Thalassemia
Both developed as chromosomal mutations of normal hemoglobin, therefore both are hemoglobinopathies. Both are genetic (hereditary disease). Both provide some protection against malaria.
Genetic Inheritance of SCD
Autosomal recessive gene
SC trait is HgA and HbS where normal Hg is A.
- Sickle Cell C & Thalassemia are other forms of SCD.
- mild symptoms (anemia) with trait, but full life expectancy.
Pathophysiology of Sickle Cell Disease (SCD)
Sickle shaped RBC's obstruct flow, leading to tissue hypoxia, ischemia, infarction and necrosis. Ex:
- Vaso-occulusive crisis
- CVA
- Retinopathy
- Renal Problems
- Priapism (persistent painful erection)
- Leg Ulcers
- Ortho Changes
Body Recognizes Sickle Cell's as abnormal and destroys them faster than replacing them. - leads to fatigue & susceptibility to infection.
First action to prevent infarct in SCD
Increase fluids to prevent/disrupt obstruction--Assists in circulation of blood.
General Symptoms of SCD
- Poor growth/growth retardation
- Chronic anemia (Hg 6-9)
- Possible delayed sexual maturation.
- marked susceptibility to infection & sepsis
- risk for osteomyelitis
Average Life expectancy for Sickle Cell Disease
On average is the 40's.
Sequestrian Crisis
happens when a lot of sickled red blood cells become trapped in the spleen. Splenomegaly and damage.
- May do a splenectomy
- most common place for occlusion
- auto-splenectomy:s a negative outcome of disease and occurs when a disease damages the spleen to such an extent that it becomes shrunken and non-functional.
- patient will appear hypovolemic
- difficulty breathing because spleen is enlarged.
chest syndrome
is a leading cause of death for patients with sickle cell disease (SCD) . Defined as a new radiodensity on chest radiograph accompanied by chest pain, fever and/or respiratory symptoms
- EKG to r/o MI
- REST to decrease demands!
- Then fluid
- Then oxygen
dactylitis
inflammation of the fingers and/or toes (hand foot syndrome)
- Painful!
- Treated with fluid and pain medication..
- FIRST clinical sign of SCD.
Diagnosis of SCD
- Hgb Electrophoresis
- Fetal Hg prevents symptoms until 6 months
- Prenatal D/x (Amnio, Chorionic Villi Sampling, Pre-implantation, In Vitro)
Treatment for SCD (Not in Crisis)
- Prophylactic Penicillin from 2 mos to age 6
- Folic acid everyday for life (1mg)
- Immunizations (especially Hib & Pneumococcal Vaccine)
- Hydroxyurea/ Butyric acid: enhance RBC production
- Erythropoietin
- Gene Therapy/Stem Cell
- Clotrimazole: helps prevent water loss from RBC's
- Nitric Oxide: helps keep blood vessels open/dilated
- Splenectomy
- Bone Marrow Transplant
Erythropoietin
A hormone produced and released by the kidney that stimulates the production of red blood cells by the bone marrow.
Hydroxyurea
- an antineoplastic drug (anti-cancer drug)
- used to reduce the number of painful crisis in sickle cell anemia and decreased need for transfusions in adult patients with a history of recurrent moderate to severe crises
Nitric Oxide
vasodilator; improves oxygenation via vasodilatation of the ventilated part of the lungs, resulting in decreased shunting and improved ventilation-perfusion matching.
- Used in SCD
When to call HCP in SCD disease
sick with even a low-grade fever or a cold.
Nursing Care for SCD
- adequate hydration
- Promoting G&D
- Education (disease process, vaccines, F/U, when to call MD
- Anticipatory guidance (enuresis, delayed sexual maturation)
- Recognizing and avoiding infections
- Emotional Support of pt & family.
enuresis
bed wetting; normally stops at age 6, but may persist in Sickle Cell Disease.
What can cause constriction/occlusion in SCD
- Dehydration
- Cold Weather
- Stress
Nursing Care During SC crisis
- bed rest, decrease O2 demands
- hydration
- check electrolytes & maintain normal pH.
- Analgesics : opioids, PCA pump over age 6, AVOID DEMEROL, toradol (ketorolac), acetaminophen & ibuprofen when pain is less severe.
- Antibiotics
- O2 as indicated
- Comfort measures: heat , warm massage, IV fluids
Thalassemia
inherited defect in ability to produce hemoglobin, leading to hypochromia
- deficiency of b chain Hgb molecule from mutation of chromosome 11, increase in alpha chain, defect hgb & destruction of RBC's.
Cooley's anemia
Thalassemia major
If Thalassemia is left untreated
- chronic hypoxia (listlessness, pallor, anorexia, FTT, decreased exercise tolerance)
- bone changes (bossing/enlarged cheek bones); bones that do not normally aid in RBC production start to do so.
- Delayed sexual maturation
- Bronze discoloration of skin
- If untreated leads to death in early childhood from profound anemia & septicemia.
Treatment of Thalassemia
- Frequent blood transfusions for up to 3 weeks.
- Splenectomy in presence of severe splenomegaly.
- Monitor for iron overload.
Disease caused by Hib
- Pneumonia* (lung infection)
- Bacteremia (bloodstream infection)
- Meningitis (infection of the tissue covering of the brain and spinal cord)
- Epiglotittis (swelling in the throat)
- Cellulitis (skin infection)
Infectious arthritis (inflammation of the joi
Rotavirus causes what?
Gastroenteritis
Respiratory Syncytial Virus
A highly contagious virus that causes an infection of the upper and lower respiratory system.(Bronchiolitis, Pneumonia, Croup)
Risks for Repeated Transfusions
- Storages of excess iron = hemosiderosis & hemachromatosis
- damage to heart, liver, endocrine organs.
- Treated with Fe Chelation Therapy (Desferoxamine [Desferal]), Given with Vitamin C, Given over 12 hours OD, IV, usually after 1 year of transfusions, Exjade (Desferasirox) oral for children over 2.
Desferal (deferoxamine)
binds Fe and excretes in urine and stool **check renal function
Exjade (deferasirox)
oral chelation therapy for children over 2
Life expectancy for Thalassemia Major
30's; Often die from iron overload. Important for RN's to emphasize chelation therapy and transfusion compliance. Assist client with coping skills (support groups).
A 6 year old child with sickle cell disease is admitted for a vaso-occlusive crisis (painful episode). What are the PRIORITY nursing concerns? Select all that apply.
1. Nutrition
2. Hydration
3. Pain Management
4. Prevention from infection
5. Oxygen Supplementation
2 & 3

Preventing from infection is not a priority at this time. Oxygen may be helpful to prevent further sickling, but it is not effective in reversing sickling because it cannot penetrate the sickled RBCs in the clogged blood vessels.
An adolescent in sickle cell crisis (knee pain) reports right knee pain. What should the nurse anticipate the health care provider will order?
1. Wrap the knee in a cold pack.
2. Apply a warm soak to the knee
3. Administer 0.5 mg of morphine
4. Decrease amount of IV fluids.
2. Apply a warm soak to the knee.
0.5 mg of morphine would be insufficient for an adolescent.
A nurse is developing a teaching plan for a child who has anemia related to inadequate nutrition. In addition to iron, which nutrients should the nurse include that are necessary for RBC synthesis?
1. Protein
2. Calcium
3. Vitamin C
4. Vitamin D
5. Carbohydrates
Protein & Vitamin C.
(page 249 in nursing key terms topic review: pediatrics)
A nurse is explaining how hemophilia is inherited to the parents of a recently diagnosed child. What is the best explanation of the genetic factor that is involved?
1. The mother is the carrier of the disorder, but is not affected by it.
2. It is an autosomal dominant disorder in which the woman carries the trait.
3. A carrier can be male or female, but it occurs in the sex opposite of the carrier.
1. The mother is the carrier of the disorder, but is not affected by it.

Number 3 describes sex-linked autosomal recessive disorders, but the carrier can only be a female.
Can acetaminophen be given to children with hemophilia?
Yes, Doctors often recommend acetaminophen, such as Tylenol, for pain relief in people who have hemophilia.
Desmopressin (DDAVP)
Increases circulating factor VIII, and secretion of vWF (both made by endothelial cells): Used for Mild hemophilia A
Principal Signs of Rheumatic Fever
Follows a strep infection.
(1) Fever
(2) Joint Pain (especially in knees, wrist or ankles) Joints become swollen, and often hot and red.
(3) Curved red lines or lumps (erythema marginatum) blanching in the middle of the lesions appear on the trunk, BUT NEVER ON THE FACE OR HANDS.
(4) Weakness, SOB, chest pain, carditis (involving mitral or aortic valve), murmur.
complication of rheumatic fever
rheumatic heart disease & sydenham chorea (neuro disorder - aimless movements of the face and extremities; grimacing present)
Diagnosis of Rheumatic Fever
- test for strep; looking for an increased AO titer, which would indicate a recent strep infection. 80% of case have had a positive strep infection in the past week or two.
- Jones Criteria
- Other S/x arthralgia, fever, elevated sedimentation rate or C-reactive protein, or a prolonged PR interval on EKG.
Treatment of Rheumatic Heart Disease
- Antibiotics (Penicillin, sulfdiazine, or erythromycin)
- Apsirin (ASA used for fever, arthritis, and arthralgia's(
- Corticosteroids to reduce inflammation and for severe carditis causing CHF.
Prognosis of Rheumatic Fever
Most children recover fully but are always at risk for another episode.
Symptoms of Kawasaki disease
- mild anemia
- elevated WBC count & ESR
- increase in plt's
- mild proteinuria and Pyuria (wbc in blood)
- increase in alanine aminotransferase
- hypoalbuminemia
- Strawberry Tongue!
- red, bloodshot eyes
- red swollen hands
- fever
- red cracked lips
- rash all over the body (compare with rheumatic heart disease)
Kawasaki disease
- (inflammation of blood vessels, hence the strawberry tongue) causes coronary artery aneurysms.
- More common in Asian and Pacific Islander children
- cause is unknown, it is an exaggerated immune response in genetically susceptible children.
Acute Phase of Kawasaki Disease
Lasts 1-2 weeks.
- Irritability
- High Fever
- red throat
- swollen hands & feet
- maculopapular rash on trunk, hands and feet
- enlarged cervical lymph nodes
- diarrhea
- hepatic dysfunction
Subacute phase of Kawasaki Disease
Lasts 2-4 weeks. Cracking of lips and fissures, desquamation of skin on the tips of fingers and toes, joint pain, cardiac disease, and thrombocytosis.
Convalescent stage of Kawasaki Disease
6 to 8 weeks after the disaese child appears normal. lingering signs may appear.
Treatment of Kawasaki Disease
- IV immunoglobulins & ASA (Aspirin)
- Corticosteroids may be given
When may aspirin be indicated in pediatrics?
Rheumatic Fever and Kawasaki Disease
nursing care kawasaki disease
- Temp q 4 hours, bed rest, check the skin, eyes, and rash. I&O, Heart sounds, S/E of ASA, lubricate lips, and cool compresses.
atrial septal defect (ASD)
an opening in the wall between the upper chambers of the heart
patent ductus arteriosus
passageway between the aorta and the pulmonary artery remains open after birth
A newborn is Diagnosed with a congenital heart defect. The test results reveal that the lumen of the duct between the aorta and pulmonary artery remains open. The defect is known as_____________>
patent ductus arteriosus
Tetrology of Fallot
DROP (Defect [VSD], septal, Right ventricular hypertrophy, Overriding aortas, Pulmonary stenosis)
Complications of Kawasaki disease
Thrombosis, Stenosis, and aneurysm.
"Machine like murmur" at birth
Patent Ductus Arteriosus (PDA)
Hypoxic spells in the infant with a congenital defect (CHD) can cause which of the following? Select all that apply.
1. Polycythemia
2.Blood Clots
3. Cerebrovascular Accident (CVA)
4. Developmental Delays
5. Viral Pericarditis
6. Brain Damage
7. Alkalosis
1, 2, 3, 4, 6. Hypoxia causes polycythemia, leading to increased blood viscosity which can lead to blood clots and stroke. Developmental delays can also be caused by multiple hospitalizations and surgeries. This child usually catches up to the appropriate level. Hypoxic episodes cause acidosis, not alkalosis.
A 6-month old who has episodes of cyanosis after crying could have the congenital heart defect (CHD) of decreased pulmonary blood flow called __________.
Tetralogy of Fallot
symptoms of hypokalemia
muscular weakness, muscular spasms, tingling, numbness, fatigue, light headedness, palpitations, constipation, bradycardia, and, in severe cases, cardiac arrest can occur.
The nurse is caring for an 8 year old whose parents indicate she has developed spastic movements of her extremities and trunk, facial grimace, and speech disturbances. They state it seems worse when she is anxious and does not occur while sleeping. The nurse questions the parents about which recent illness?
1. Kawasaki Disease
2. Rheumatic Fever
3. Malignant Hypertension
4. Atrial Fibrillation
2. Rheumatic Fever
Normal Urine Output for Children and Adults
- Oliguria is urine output < 500 mL in 24 h (0.5 mL/kg/h) in an adult.
- Oliguria is urine output < 1 L in 24 h (1 mL/kg/h) in a child.Children have smaller bladders and tend void more frequently.
Other than TOF, which other CHD's causes hypoxemia in infancy
Pulmonary Atresia & Tricupsid Atresia
Symptoms of Coarctation of the Aorta
- Headache
- dizziness
- elevated BP
- Fainting
- Epistaxis
- Claudication (pain in your thigh, calf, or buttocks that happens when you walk.)
- Pallor to lower half of body.
- Decreased peripheral pulses with hypertension in upper part of body
- significant decrease in pulse ox.
- CATH OR OPEN HEART WHEN STABLE.
What medication is given in transposition of the great vessels?
Prostaglandin E inhibits closing of the PDA, which connects the aorta and pulmonary artery.
Which Vaccines must be delayed in must be delayed for 11 months after the administration of gamma globulin? Select all that apply.
1. Dtap
2. Hep B
3. Inactivated Polio virus
4. MMR
5. Varicella
4 & 5
Normal Heart Rate for a 5 year old.
80-110
Normal Heart Rate for Toddlers
90-140
Normal Heart Rate for adolescents
60-90
Normal Heart Rate for infants
120-160
Signs of Digoxin Toxicity
green/yellow vision, bradycardia, nausea, vomiting
patent ductus arteriosus (PDA)
passageway (ductus arteriosus) between the aorta and the pulmonary artery remains open (patent) after birth
Fine Motor Skills at 3 months
Clenched fists; after 3 months of age may be a sign of upper motor injury and CP (grasp reflex fades)
Fine Motor Skills at 8 months
begins using pincer grasp
Fine Motor Skills at 18 months
Manages a spoon without rotation
Turns pages in a book, two or three at a time.
Fine motor skills at 15 months
uses a cup well
builds a tower of two blocks. Starts to take clothes off starting with shoes. Repeatedly throws objects on floor.
Fine Motor Skills at 2 years
Builds tower of six or seven blocks. Turns pages of books one at a time. Turns door knobs and unscrews jar lids.
Fine Motor Skills at 2.5 years
draws circles
has good hand-finger coordination
Gross Motor Skills at 3 years
rides a tricycle, jumps off bottom step, stands on one foot for a few seconds. Can button and unbutton.
Gross Motor Skill at 3 months
Neck Holding
Gross Motor Skill at 5 months
rolls from front to back. (Rolls over)
Gross Motor Skill at 6 months
Sits with support.
When does tongue thrust stop?
6 months of age. It is considered abnormal after 6 months.
Gross Motor Skill at 8 months
sits unsupported
Gross Motor Skill at 9 months
cruising
Gross Motor Skill at 15 months
walks without help
creeps up stairs
Gross Motor Skill at 18 months
Runs Clumsily, falls often; Walks upstairs with help. Throws overhand.
Gross Motor Skill at 2 Years
Walks up and down stairs one step at a time without help.
Runs without falling.
Kicks Ball.
Gross Motor Skill at 5 Years
Jumps Rope
Which should the nurse do first when caring for an infant who just had a repair of a myelomeningocele?
1. Weigh diapers for 24 hours
2. Measure Head Circumference
3. Offer Clear Fluids
4. Assess for infection
2. Hydrocephalus occurs in 90% of infants with myelomeningocele. Accumulation of fluid can occur after closure of the sac.

Rationale: weighing I&O is important, but is not the priory. Clear fluids are provided after the infant is fully awake and there is no vomiting. Assessing for infection is important, but is not the priority.
A 15 y.o. with spina bifida is seen in the clinic for a well-child checkup. The teen uses leg braces and crutches to ambulate. Which nursing diagnosis takes priority?
1. Risk for infection
2. Alteration in mobility
3. Alteration in elimination
4. Potential Body image disturbance
2. Alteration in mobility.

Rationale: mobility is important in all aspects of their lives. Braces and crutches enable him to participate in activities and maintain some degree of independence. As an adolescent, the teen would be at risk for altered body image disturbance, which should be addressed after alteration in mobility.
Mumps (Parotitis)
- Transmission: Respiratory Secretions
- Symptoms: weakness, headache, fever, decreased appetite, headache exacerbated by chewing, unilateral or bilateral swelling, pain and tenderness.
- Treatment: symptomatic, avoid foods that require chewing, antipyretics, warm/cold neck compress.
Complication of Mumps (Parotitis)
Aseptic meningitis, orchitis (ovarian or breast swelling), rare = hearing impairment.
Causes of stridor in children
- Croup
- Epiglottitis
- DIPETHERIA
- Foreign body
What lung sound is heard in Diptheria?
Stridor
What lung sound is heard in bronchiolitis?
Wheezing
Diptheria
Transmission: direct contact with nasal or eye secretions.
Symptoms: fever, anoxia, cough, STRIDOR, neck edema, swelling of nodes & pharynx, tonsils and throat covered in thick white-bluish patch. Treatment: Bed rest, humidified O2, IV antitoxin, antibiotics, tracheosteomy as needed, airway maintenance, standard & droplet precautions.
Treatment of Diptheria
antitoxin plus penicillin or erythromycin
Complications of Diptheria
myocarditis, neuropathy, and airway obstruction.
Polyhydramnios increases the risk of what GI disorder
TEF Tracheosophageal fistula
Disorders that have malabsorption of fats
Celiac Disease and Cystic Fibrosis (Fat sol vitamins include A, D, E, & K).
When is stranger anxiety developed?
9 months
Is pain a priority in myelomeningocele?
No. Infants with myelomeningocele do not have pain because of a lack of nerve inneravations below the level of the defect. Therefore acute pain would not be a priority nursing diagnosis for myelomeningocele patients.
Priority postoperative care for myelomeningocele repair.
Measure head circumference, prevent infection, Monitor I&O, feeding the infant breast milk/ formula.
symptoms of right sided heart failure
Systemic vascular congestion
Distended neck veins
Tender/non-tender hepatic congestion
Decreased appetite/nausea
Depended pitting edema
Hepatomegaly
symptoms of left sided heart failure
**L for lungs

Pulmonary congestion
• cough
• crackles
• wheezes
• hemoptysis
• tachypnea

S3 heart sound
Restlessness
Confusion
Tachycardia
Exertional dyspnea
Fatigue
Cyanosis
Paroxysmal nocturnal dyspnea
Elevated pulmonary capillary wedge pressure
Acronym for Tetralogy of Fallot
"Vital Sign DROP"
(1) Ventricular Septal defect
(2) Right ventricular hypertrophy
(3) overriding aorta
(4) Pulmonary stenosis
Polycythemia
A disorder characterized by an abnormal increase in the number of red blood cells in the blood. Occurs in sickle cell anemia, hypoxia, tetralogy of fallot.
erythrocyte sedimentation rate (ESR)
Speed at which erythrocytes settle out of plasma. Elevated in inflammation, heart disease, pregnancy, anemia, autoimmune disorders, rheumatoid arthritis, chronic kidney disease.
When does the posterior fontanelle close?
2 months
When does the anterior fontanelle close?
9-18 months
Machine Like heart murmur is associated with ___________.
Ventricular septal defect.
Which disorder calls for administration of aspirin and Immunoglobulin G?
Kawasaki Disease
Respiratory Acidosis
A drop in blood pH due to hypoventilation (too little breathing) and a resulting accumulation of Co2.[Excess CO2, decreased O2].
Obstruction of Blood Flow to the Ventricles in Congenital Heart Disease
Pulmonic Stenosis, Aortic Stenosis and Coarcation of the aorta. Increase pressure in the ventricles, leading to hypertophy, decreased cardiac output and CHF if untreated.
Increased pulmonary blood flow in Congenital Heart Disese
Patent Ductus Arteriosus (PDA), Ventricular Septal Defect (VSD), Atrioventricular Canal (AV), and Atrial Septal Defect (ASD)
Mixed Blood Flow Defects
Transposition of the Great Arteries, Truncus Arteriosus, Total Anomalous Pulmonary venous return and Hypoplastic Left Heart Syndrome.
Decreased Pulmonary Blood Flow Defects
Tetralogy of Fallot and Tricupside Atresia.
Indocin (indomethacin) is given for which congenital defect?
Patent Ductus Arteriosus
Which Congenital Heart Defect may go unnoticed until a child experiences exercise intolerance?
Atrial Septal Defect. (Otherwise may close spontaneously, and is often not operated on until school age)
Transposition of the great arteries
Newborn is cyanotic @
birth, O2 does not improve. Life threatening. Mixed blood flow.
Average respiratory rate for infants
24-40 breaths per minutes
A child undergoes heart surgery to repair defects associated with Tetralogy of Fallot. What behavior is essential for the nurse to prevent postoperatively?
1. Crying
2. Coughing
3. Straining at stool
4. Unnecessary Movements
3. Forceful evacuation results in taking a deep breath, holding it, and straining (Valsalva Maneuver), This increase intrathoracic pressure, which puts excessive strain on the heart sutures.

Rationale: Crying is not a problem after cardiac surgery; it may in fact help prevent respiratory complication. Coughing & deep breathing are essential for prevention of post-op respiratory complications. Activity is gradually increased.
The parents of a an infant who has had a surgical repair of a myelomeningocele express concern about skin care and ask what they can do to avoid problems. The nurse should to teach the parent that their infant:
1. Will require long-term multidisciplinary follow up care.
2. Should take prophylactic antibiotic therapy indefinitely.
3. Must be kept dry by applying powder after each diaper change.
4. does not need anything more than a routine cleansing and a diaper change.
1. Will require long-term multidisciplinary follow up care.
What is the primary nursing intervention for an infant with a myelomeningocele before surgical correction?
1. minimize infection
2. prevent trauma to the sac
3. observe for increasing paralysis.
4. Assess the degree of bowel and bladder control
2. prevent trauma to the sac.

Although all are important, A myelomeningocele is thinly covered and fragile; trauma to the sac can damage functional neural tissue; an intact sac reduces a potential portal of entry for microorganisms.
A parent tells the nurse in the ER, "My 3 year old has had a fever for several days and has been vomiting." After instituting ordered measures to reduce fever, what nursing action is most appropriate?
1. Preventing shivering
2. Restricting oral fluids
3. Measure output hourly
4. Taking vital signs hourly
1. preventing shivering

Rationale: shivering increases metabolic rate which intensifies the body's need for oxygen and increases the body temperature.
Febrile Siezures
Seizure associated with febrile illness in absence of CNS infection or acute electrolyte imbalance. Most occur between 6 months and 3 years; twice as frequent in males. Temperature usually exceeds 102ºF (38.8ºC).
Treatment of febrile seizures
Antipyretic medication (NO ASA), monitor temperature, institute seizure precautions, DO NOT Restrain. . Prevent shivering because it increases metabolic, further increasing temperature
Signs of increased ICP
Decreased pulse (bradycardia)
Increased BP (hypertension); hyperactive reflexes
What neurological disorder is at risk for scoliosis?
Cerebral Palsy
35) The nurse is developing a care plan for a child recently diagnosed with cerebral palsy (CP). Which should be the nurse's priority goal?
1. Ensure the ingestion of sufficient calories for growth.
2. Decrease intracranial pressure
3. Teach appropriate parenting strategies for a special-needs child.
4. Ensure that the child reaches full potential
3. teaching appropriate parenting strategies for a special needs child is important and is done so that the child can maximize their personal skills and minimize limitations.

#4 and 1 are important but are not the priority gal for a special needs child.
37) The parent of a toddler newly diagnosed with CP asks the nurse what caused it. The nurse should answer with which of the following.
1. Most cases are caused by unknown prenatal factors.
2. It is commonly caused by perinatal factors.
3. The exact cause is unknown.
4. The exact cause is known in every instance.
The majority of infants with CP had an insult in utero. Some of the causes of perinatal insult include hypoxia, trauma, infections, or genetic anomalies.
Which would the nurse expect a child with spastic CP to demonstrate. Select all that apply.
1. increased DTR's.
2. Decreased muscle tone.
3. Scoliosis
4. contractures
5. Scissoring
6. Good control of posture
7. Good fine motor skills.
1,3,4,5
Which would the nurse expect to asses in 3 week old infant with developmental dysplasia of the hip (DDH). Select all that apply.
1. Excessive hip abduction
2. Femoral lengthening of an affected leg.
3. Asymmetry of gluteal folds.
4. Pain when lying prone.
5. Positive Ortolani test
3 & 5.

Rationale: in DDH, a newborn can have excessive hip adduction, not abduction. Appearance of femoral shortening is frequently present on the affected side and not lengthening. Infants do not experience pain from DDH.
The nurse is teaching about congenital clubfoot in infants. The nurse evaluates teaching is successful when thee parent states that clubfoot is best treated when?
1. Immediately after diagnosis
2. At age 4 to 6 months.
3. Prior to walking (9 to 12 months)
4. After walking is established (15 to 18 months)
1. Immediately after diagnosis.

Infants at 9 months are already pulling up to stand and attempting to take steps (cruising)
The nurse tells the parent that other conditions can be associated with congenital
clubfoot. Select all that apply.
1. Myelomeningocele.
2. Cerebral palsy.
3. Diastrophic dwarfism.
4. Breech position in utero.
5. Prematurity.
6. Fetal alcohol syndrome.
1, 2, 3

Breech position, prematurity and fetal alcohol syndrome are not associated with clubfoot.
Which should the nurse include in the teaching plan for a child who has had surgery to correct congenital clubfoot and had the casts removed? Select all that apply
1. "Your child will need to wear a brace on the feet for 23 hours a day for 12 months."
2. "Your child should see an orthopedic surgeon regularly until the age of 18 years."
4. "Your child will not be able to participate in sports that require a lot of running."
5. "Most children treated for clubfoot develop feet that appear and function normally."
6. "Most children treated for clubfeet require surgery at puberty".
1, 2, 4 & 5
A 13 year old just returned from surgery for scoliosis. Which nursing intervention is appropriate in the first 24 hours. Select all that apply.
1. Assess for pain
2. Logroll to change positions.
3. Get the teen to the bathroom 12 to 24 hours after surgery.
4. Check neurological status.
5. Monitor blood pressure
1, 2, 4, & 5
After the birth of an infant with clubfoot, the nursery should do which of the following when instructing the parents? Select all that apply.
1. Speak in simple language about the defect.
2. Avoid the parents unless providing direct care so that they can grieve privately.
3. Keep the infant's feet covered at all times.
4. Present the infant as precious; emphasize the well-formed parts of the body.
5. Tell the parent that defects could be much worse.
6. Be prepared to answer questions multiple times.
1, 4, & 6
Which position is most beneficial for an infant who has just returned from having VP shunt placed?
1. Semi-fowler in an infant seat
2. Flat in the crib
3. Trendelenburg
4. In the crib with the HOB elevated 90º.
Flat in the crib is the position usually used initially, with the angle gradually increasing as the child tolerates.
The nurse tells a family of a child with CP that since the 1960's the incidence of CP has:
1. increased
2. decreased
3. remained the same
4. Has decreased because of early misdiagnosis
1. increased partly as a result of the increased survival rate of extreme low-birth-weight & premature infants.
Which does the nurse include in post-op care for a child with myelomeningocele following ligament release?
1. Encourage the child to resume regular diet, beginning slowly with bland foods that are easily digested, such as bananas.
2. Encourage the child to blow balloons to increase deep breathing and avoid postoperative pneumonia.
3. Assist the child to change positions to avoid skin breakdown.
4. Provide education in dietary requirements to prevent obesity and skin breakdown.
3. assist the child to change positions to prevent skin breakdown.

Myelomeningocele patients will have latex allergies, and therefore should avoid bananas, avocados, tomatoes, chestnuts, kiwi, passionfruit, and plums as well as balloons which may contain latex.
Latex in foods
Around half of all people with latex allergy have allergic reactions when eating particular foods, including avocado, banana, chestnut, kiwifruit, passionfruit, plum, strawberry and tomato. This is because some of the proteins in latex that cause latex allergy are also present in these fruits.
Which child requires continued follow-up care because of behaviors suspicious of cerebral palsy (CP)?
1. A 1 month hold who demonstrates the startle reflex when a loud noise is heard.
2. A 6 month old who always reaches for toys with the right hand.
3. A 14 month old who has not yet begun to walk.
4. A 2 year old who has not yet achieved bladder control during waking hours.
2. The clinical characteristic of hemiplegia can be manifested by the early preference of one hand. This may be an early sign of CP.

Rationale: (3) although many children walk before the age of 14 months, it is not considered a motor delay not to have achieved this milestone at this point or indicative of CP.
The parents of a 12 month old with CP ask the nurse if they should begin to teach their child sign language because he has not begun to vocalize. The nurse bases the response on the knowledge that sign language:
1. May be a very beneficial way to help children with CP communication.
2. May cause confusion and further delay vocalization.
3. Is difficult to learn with CP.
4. Is beneficial to learn, but it would be best to wait until the child is older.
1. Sign language may help the child with CP to communicate and ultimately decrease frustration. Children with CP may have difficulty verbalizing because of weak tongue and jaw muscles. They may able to have sufficient motor skills to communicate with their hands. The earlier it is taught, the more beneficial. Sign language does not cause confusion and may enhance vocabulary and vocalization.
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