HESI Practice Exam - Pediatric Nursing

1. Post-op cleft lip repair → minimize crying to prevent stress on the suture line and promote healing (optimum for cosmetic healing)
2. Restraint used for toddler with cleft lip repair → elbow restraints
to prevent child from bending arm and bringing up hands to oral
surgical site
a. Hand restraints – can still bend forward
b. Mummy restraints – only used for a short period of time
during invasive procedures
c. Jacket restraints – restrains body torso (not appropriate)
3. 4-year old with cystic fibrosis (being taught
inhalation therapy) will be in what stage of
psychosocial development (Erikson) → Initiative
(they enjoy being active and participating in role
play
a. Trust vs Mistrust (birth – 1 year)
b. Autonomy vs Shame/Doubt (1 – 3)
c. Initiative vs Guilt (3 – 6)
d. Industry vs Inferiority (6 – 12)
e. Identity vs Role Confusion (12 – 18)

5. Following the reduction of an incarcerated inguinal hernia, a 4-month old is going in for an
inguinal hernia repair. What should be reported to the HCP by the parents prior to surgery? →
Presence of inguinal bulge after gentle palpation after implanting simple procedures (gentle
palpation, warm bath, comfort to reduce crying) because this can indicate that the hernia is
irreducible. If a loop of intestines is forced into the inguinal ring or scrotum and incarcerates,
swelling can follow and possible strangulation of the bowel, intestinal obstruction, or gangrene
of the bowel loop can occur (emergency surgery)
a. Hernia – a condition in which intra-abdominal fat or part of the small intestine, also
called the small bowel, bulges through a weak area in the lower abdominal muscles
b. Incarcerated inguinal hernia – a hernia that becomes stuck in the groin or scrotum and
cannot be massaged back into the abdomen

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6. Sequence of taking vital signs in a child → respiratory rate, heart rate, axillary temperature because touching infants can upset them
and make them cry causing an ↑ in heart rate and making respirations difficult to count. Temperature is the most invasive procedure, so
it should be saved for last
7. What can cause impaired mobility in a child with rheumatoid arthritis (RA)? →
joint inflammation and pain are typical manifestations of exacerbated JRA
a. Juvenile rheumatoid arthritis (JRA) is a term used to describe a
common type of arthritis in children. It is a long-term (chronic) disease
resulting in joint pain and swelling.
b. The cause of JRA is not known
c. It is thought to be an autoimmune illness. This means the body's
immune system mistakenly attacks and destroys healthy body tissue.
8. Risk factors for developmental dysplasia of the hip (DDH) → breech position (head up),
females (twice as many females present in breech position), first-born child because the
uterus is not as stretched and there is a compaction on the uterus from the surrounding
abdominal contents in a nulliparous woman)
a. Developmental dysplasia of the hip (DDH) – a dislocation of the hip that presents
at birth
9. A 16-year old refuses visitation from students and tells the nurse he is concerned of his edematous facial features. Interventions should
be implemented according to what nursing diagnosis? → Social isolation (peer acceptance and body image are significant issues in
growth and adolescence. The pt. has a lack of contact with peers stemming from his desires to protect his ego.
10. Nurse is preparing a child with intussusception for a barium enema. What is the main
purpose of this procedure? → To reduce the invaginated bowel segment. Other names for
intussusception are invagination or telescoping. It causes an intestinal obstruction in
children 3 months – 5 years. Nonsurgical treatment includes barium instillation because it
↑ the hydrostatic pressure to ↓ the area of intussusception. This negates the need for
surgery. The pressure of the barium (liquid mixture) unfolds the bowel that has been
turned inside out and instantly cures the blockage. Air can also be used in the same way to
fix the blockage
a. Intussusception occurs when one portion of the bowel slides into the next, much
like the pieces of a telescope. It can create a blockage in the bowel, with the walls
of the intestines pressing against one another. This leads to swelling,
inflammation, and decreased blood flow to the part of the intestines involved.
b. Signs and symptoms - intense abdominal pain (begins very suddenly and causes
loud, anguished crying causing the child to draw the knees up). The pain is usually
intermittent, but recurs and may become stronger. Other s/s are abdominal
swelling or distention vomiting, vomiting up bile (a bitter-tasting yellowish-green
fluid), passing stools (or poop) mixed with blood and mucus (known as currant
jelly stool), grunting due to pain
12. The parents of a child with a cyanotic heart defect should Pathophysiology → In a typical case of TOF the pressures in the right
be taught what when their child is experiencing a ventricle and left ventricle are equal. Hence the level of cyanosis and onset
hypercyanotic spell? → assume a knee-chest position of cyanotic spell is determined the systemic vascular resistance and the
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 slightly elevated to restore hemodynamic equilibrium
a. Cyanotic spell is also known as ‘tet’ spell or
hypercyanotic spell. This is a sudden onset,
occasionally progressive event seen in infants with
Tetralogy of Fallots. It is associated with
progressive cyanosis, hyperpnea (increased rate
and depth of breathing) and disappearance of
heart murmur. If not treated in time it may
ultimately lead to altered sensorium, neurological
complications and death.
level of pulmonary stenosis component. In case of mild pulmonary stenosis
the right ventricular pressures are usually less than the left ventricle and
hence the shunt is usually left to right. However, if the pulmonary stenosis
is severe (due to any of the causes described later) then the right
ventricular after load becomes high and hence the right ventricular
pressures become high. If the systemic vascular resistance is low (which is
usually the case in TOF with cyanotic spells) then the shunt flow becomes
right to left. This results in progressive cyanosis. Low arterial pO2s (partial
pressure of oxygen that is a measure of how well the body is transporting
oxygen) lead to stimulation of the carotid receptors and the brain stem
nuclei respectively which then leads to increased rate and depth of
breathing which further increases the venous return to the right side of the
heart and further right to left shunt of deoxygenated blood, thus leading to
a vicious cycle. If not broken then it would ultimately lead to death

13. 18-month old returns from getting a cardiac catheterization wit a cannulated
femoral artery site. What intervention should the nurse implement? → Show the
parent how to hold the child with the extremity extended to prevent trauma to the
femoral catheterization. Only the location catheterized requires immobilization
a. Cardiac catheterization involves passing a thin flexible tube (catheter) into
the right or left side of the heart, usually from the groin or the arm. This is
to:
i. Collect blood samples from the heart
ii. Measure pressure and blood flow in the heart's chambers and in the large
arteries around the heart
iii. Measure the oxygen in different parts of heart
iv. Examine the arteries of the heart
v. Perform a biopsy on the heart muscle
14. A child with asthma has a theophylline level of 15 mcg/dl. What should the nurse getting ready to change shifts do? → Communicate the
result to the oncoming nurse and document
a. Theophylline is a bronchodilator. It works by relaxing muscles in the lungs and chest, and makes the lungs less sensitive to
allergens and other causes of bronchospasm.
b. Theophylline is used to treat the symptoms of asthma, bronchitis and emphysema.
c. A therapeutic level is from 10-20 mcg/dl
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15. Twins (male and female) are 5 inches apart in height (the girl is taller). What can explain this? → The normal growth spurt in girls (9.5-14
years of age) 1-2 years before boys (10.5-16 years of age)
16. A child is admitted to the hospital for confirmation of a diagnosis of acute lymphoblastic
leukemia (ALL). What would be the presenting symptoms? → Bone pain and pallor
a. Leukemic cells invade the bone causing weakened bones with a tendency to
fracture. As leukemic cells invade the periosteum, ↑ pressures cause severe
bone pain and ↓ erythrocytes (RBCs) cause pallor.

17. A nurse is assessing a teen’s knowledge of birth control and says he knows the information already. What should the nurse do? → Ask
the teen what he knows to assess his knowledge. Teens tend get information from their peers, which can be incorrect.
18. A burned child is brought to the hospital and the nurse is assessing them according to the “Rule of Nines” to estimate the percentage of
body burned. What part of the child’s body is proportionally larger than the adult’s? → Head and neck
a. The “Rule of Nines” is inaccurate in estimating burned body surface in
children.
b. There are specifically designed charts to do this for children

19. Pre-op nursing intervention for a child with pyloric stenosis → observe for projectile vomiting; classic sign that contributes to metabolic
alkalosis
a. Pyloric stenosis is a medical emergency, not a surgical emergency
b. The patient should not be operated on until there has been adequate fluid and
electrolyte resuscitation.
c. The infant should have normal skin turgor, and the correction of the electrolyte
imbalance should produce a Na level that is >130 mEq/L, a K level that is at least 3
mEq/L, a Cl level that is >85 mEq/L and increasing, and a urine output of at least 1-2
mL/kg/hr.
d. Loss of gastric fluid leads to volume depletion and loss of sodium, chloride, acid
(H+) and potassium. This results in a hypokalemic, hypochloremic metabolic
alkalosis. The kidneys attempt to maintain normal pH by excreting excess HCO 3

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20. Common complication of a child with Trisomy 21 (Down’s syndrome) →
Presence of a systolic murmur; congenital heart disease occurs in 40-50% of
children with Trisomy 21. Defects of the atrial or ventricular septum create
systolic murmurs. These are the most common heart defects in Trisomy 21.

21. 7-month old comes to the hospital with severe diarrhea due to an infection with rotavirus. What should the nurse implement first? →
Insertion of an IV line and begin IV fluids due to high risk of dehydration
a. Rotavirus is one of the most common causes of diarrhea, and severe infection
(rotavirus gastroenteritis) is the leading cause of severe, dehydrating diarrhea in
infants and young children.
b. S/S of rotavirus infection: fever, nausea, and vomiting, often followed by abdominal
cramps and frequent, watery diarrhea, cough, runny nose
c. S/S of dehydration include: thirst, irritability, restlessness, lethargy, sunken eyes, a
dry mouth and tongue, dry skin, fewer trips to the bathroom to urinate, and (in
infants) a dry diaper for several hours.
d. The virus is particularly a problem in childcare centers and children’s hospitals
because rotavirus infection is very contagious. The virus passes in the stool of
infected people and usually happens due to poor handwashing.
Cytomegalovirus – a large herpes-type virus commonly found in humans that can cause serious
infections in people with impaired immunity. The infection may result in pneumonia,
gastroenteritis, retinitis or encephalitis. Antiviral medications may stop the replication of the virus
but will not destroy it.
When symptoms do appear, they're similar to those seen in mononucleosis ("mono") and only
last a few weeks.
CMV is mainly a problem for certain high-risk groups, including:

a. Unborn babies whose mothers become infected with CMV during the pregnancy
b. Children or adults whose immune systems have been weakened by disease or drug
treatment, such as organ transplant recipients or people infected with HIV

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22. A 3-month old weighs 10 lb 15 oz and has a temperature of 98.9 F (axillary). How many calories does this infant need per day? →
500/day; convert lb to kg (~10.9 lb = ~5 kg), multiply by 108 calories/kg/day = 540
a. The infant requires 10% more calories due to the ↑ in temperature (1 degree elevation), so 540 + 54 = 584 = ~600 calories/day
23. A child with nephrotic syndrome is receiving prednisone Nephrotic Syndrome Acute Glomerulonephritis
Cause Glomerulonephritis, drugs, Inflammation of the
(Deltasone). What breakfast food indicates the mother damage, diabetes glomeruli usually due to
bacterial infection
understands the diet needs of this child? → toasted oat cereal Signs PROTEIN in the urine BLOOD in the urine
Edema (general) Edema (general)
and low-fat milk because the child is receiving a corticosteroid “Foamy urine” “Foamy urine”
Hypertension Hypertension
for nephrotic syndrome Low urine output Low urine output
Hypoalbuminemia Hyperlipidemia
a. Inflamed glomerulus compromises blood flow and
Hyperlipidemia Nausea/Vomiting
filtration Fever
Rash
b. High-protein diets are not recommended in patients Treatment Find and treat cause (ex Find and treat cause (ex
antibiotics for infection) antibiotics for infection)
with nephrotic syndrome because they may lead to Control B/P Control B/P
Diuretics Diuretics
further damage of the kidneys and result in Corticosteriods Corticosteriods
Reduce cholesterol Reduce cholesterol
progression of renal insufficiency. Protein loss in General Nursing Low Protein, Low Salt diet, Strict I’s and O’s, Fluid Restriction,
Care Bed Rest, Daily Weights, Urinalysis (will see elevate BUN and
nephrotic syndrome is due to increased breakdown of Creatinine), Both conditions may require a kidney biopsy,
Protect clients b/c they are immunocompromised
proteins rather than decreased protein synthesis. As a
result, low-protein diets, which decrease protein
breakdown, may be more beneficial.
c. In patients with nephrotic syndrome, sodium intake
may need to be limited to control edema and high
blood pressure. Intake of foods with a high salt
content and use of table salt should be limited
Corticosteroids are man-made drugs that closely resemble cortisol, a hormone that the adrenal glands produce naturally. Corticosteroids are
often referred to by the shortened term "steroids." Corticosteroids are different from the male hormone-related steroid compounds that
some athletes abuse (i.e. prednisone).
When inflammation normally occurs, chemicals from the body’s WBCs are released to protect us from
foreign substances. Sometimes, however, WBCs and inflammatory chemicals cause damage to the
body’s tissues.
Steroids work by ↓ inflammation and ↓ the activity of the immune system. Inflammation is a process
in which the body's WBCs and chemicals can protect against infection and foreign substances such as
bacteria and viruses. In certain diseases, however, the body's defense system (immune system) doesn't
function properly. This might cause inflammation to work against the body's tissues and cause damage.
Inflammation is characterized by redness, warmth, swelling, and pain.
Steroids ↓ the production of inflammatory chemicals in order to minimize tissue damage. Steroids also reduce the activity of the immune
system by affecting the function of WBCs
When inflammation threatens to damage critical body organs, steroids can be organ-saving and in many instances, life-saving. For example,
steroids may prevent the progression of kidney inflammation, which could lead to kidney failure in people who have lupus or vasculitis. For
these patients, steroid therapy might eliminate the need for kidney dialysis or transplantation.
Low doses of steroids might provide significant relief from pain and stiffness for people with rheumatoid arthritis.

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22. Prophylactic antibiotics are prescribed for a child with mitral valve damage. The nurse should teach the parents to give the antibiotics
prior to what? → Urinary catheterization because it is an invasive procedure

Rheumatic fever – an inflammatory disease that is a complication of untreated strep throat. It affects the body's connective tissues —
especially those of the heart, joints, brain, or skin.

Rheumatic fever damages connective tissue by causing it to swell, but its greatest danger lies in the damage it does to the connective tissue
in the heart—the heart valves. Before antibiotic medicines became widely used, it was the most common cause of heart valve disease.
More than half of the time, rheumatic fever scars the heart valves, and this scarring narrows the valve to the point that it cannot open
properly or close completely. In turn, the heart must work harder to pump blood to the rest of the body. This valve damage can lead to a
condition called rheumatic heart disease, which, in time, can lead to congestive heart failure. The effects of rheumatic heart disease last for
life.

Rheumatic fever is not an infection itself. Rather, it is the result of an untreated strep infection. The immune system attempts to fight the
strep infection with antibodies, but the antibodies become overactive and attacks the body’s own connective tissue. This causes the heart
valves to swell and the heart valve leaflets to become scarred. After the damage is done, the valve cannot open or close properly.
22. A 12-month old is admitted with a respiratory infection and
possible pneumonia. He is placed in a mist tent with oxygen.
What nursing intervention has the greatest priority for this
infant? → Have a bulb and syringe readily available to remove
secretions because humidification liquefies the nasal secretions,
thus making a patent airway
a. You can also give small, frequent feedings of fluids to
prevent tiring (not as important as an open airway)

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23. The nurse is taking a family history of a 2-year-old with atopic dermatitis (eczema). What statement by the mother is important in
forming a plan of care? → My husband and daughter are both lactose intolerant because environmental exposure to allergens (milk)
and a positive family Hx for milk allergies are important data in planning care of the child with atopic dermatitis

a. Occurs mostly on the face and extensor (a muscle that extends or straightens a limb or body part) aspects of the arms and legs
b. Food allergies can also be a major trigger for people with atopic dermatitis, particularly in children. Egg and milk allergy are
the most common food allergies in children worsening eczema, although other food allergies are also common.
c. Atopic dermatitis is a long-term (chronic) skin disorder that involves scaly and itchy rashes.

d. Atopic dermatitis is due to a hypersensitivity reaction (similar to an allergy) in the skin, which leads to long-term swelling and
redness (inflammation) of the skin. People with atopic dermatitis may lack certain proteins in the skin, which leads to greater
sensitivity.
e. Studies have shown that children who are breast-fed until age 4 months are less likely to get atopic dermatitis.
f. If the child is not breast-fed, using a formula that contains processed cow milk protein (called partially hydrolyzed formula) may
↓ the chances of developing atopic dermatitis.
24. A newborn female whose mother is HIV positive is scheduled for the first follow-up assessment with the nurse. If the child is HIV positive,
what initial symptom will she most likely exhibit? → Persistent cold because respiratory tract infections commonly occur in the pediatric
population, but the child with AIDS has a ↓ ability to defend the body against these common infections. So if the child was born
vaginally, they may present with a persistent cold or respiratory infection.
25. A 7-month old is diagnosed with spastic cerebral palsy. What statement by the mother
warrants further attention? → My son often chokes when I am feeding him; because
airway obstruction is always priority
a. Cerebral palsy – a group of disorders that can involve brain and nervous system
functions (such as movement, learning, hearing, seeing, and thinking)

b. There are several different types of cerebral palsy, including spastic, dyskinetic,
ataxic, hypotonic, and mixed
c. Cerebral palsy is caused by injuries or abnormalities of the brain. Most of these
problems occur as the baby grows in the womb, but they can happen at any time during the first 2 years of life, while the baby's
brain is still developing
d. In some people with cerebral palsy, parts of the brain are injured due to low levels of oxygen (hypoxia) in the area.
e. Premature infants have a slightly higher risk of developing cerebral palsy.
26. A woman who lost a child to SIDS just gave birth and is leaving the hospital. She tells the nurse she fears the same with her 2 nd child. How
should the nurse respond? → The fear of losing another child to SIDS is very realistic. Have you thought about what you are going to
do? The most effective way to provide emotional support is to acknowledge what the client
may be feeling, be a sounding board for them to listen to themselves, and follow them to
discover their own solutions
a. Sudden infant death syndrome (SIDS) – the unexpected, sudden death of a child under
age 1 in which an autopsy does not show an explainable cause of death.

b. The cause of SIDS is unknown. Some factors may include: problems with the baby's
ability to wake up (sleep arousal) and inability for the baby's body to detect a build-up
of CO2 in the blood
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27. When caring for the child with congenital heart disease and polycythemia, what is
the most important nursing intervention? → Maintaining adequate hydration
because the key word is polycythemia. Hydration will ↓ the blood viscosity and ↓
risk for thrombus formation, which is the most common complication of
polycythemia.
Heart flow
From the superior vena cava (upper extremities) and inferior vena cava (lower
extremities) → right atrium → tricuspid valve → right ventricle → pulmonary valve →
pulmonary artery → lungs → pulmonary veins (brings back oxygenated blood) → left
atrium → mitral valve → left ventricle → aortic valve → aorta → brachiocephalic
trunk, left common carotid artery, left subclavian artery
Congenital Heart Disease (CHD) – a problem with the heart's structure and function
that is present at birth.

CHD is often divided into 2 types: cyanotic (blue skin color caused by a lack of oxygen)
and non-cyanotic

Cyanotic: Tetralogy of Fallot, Transposition of the great vessels

Non-cyanotic: Aortic stenosis, Atrial septal defect (ASD), Atrioventricular canal
(endocardial cushion defect), Coarctation of the aorta, Patent ductus arteriosus (PDA),
Pulmonic stenosis, Ventricular septal defect (VSD)
CYANOTIC
Tetralogy of Fallot

Causes low O2 levels in the blood

The classic form includes 4 defects of the heart and its major blood vessels:
(1) Ventricular septal defect (VSD) - hole between the right and left ventricles which
causes R → L shunt and mixing of oxygenated and deoxygenated blood
(2) Pulmonic stenosis- narrowing of the pulmonary outflow tract (the pulmonary valve
and pulmonary artery that connect the heart with the lungs)
(3) Overriding aorta (the artery that carries oxygen-rich blood to the body) that is
located over the VSD and thus connected to the right ventricle (via the VSD), instead of
coming out only from the left ventricle
(4) Right ventricular hypertrophy - thickened wall of the right ventricle; ↑ in size to
deal with increased obstruction (pulmonic stenosis, VSD, overriding aorta)
Polycythemia occurs because the body is trying to compensate for low O 2 levels. The
bone marrow produces excessive RBCs. It’s a bone marrow disease that leads to an
abnormal ↑ in the # of blood cells (primarily RBCs). Numbers of WBCs
and platelets also ↑
Transposition of the great vessels (a heart defect where the 2 major vessels that carry
blood away from the heart -- the aorta and the pulmonary artery -- are switched a.k.a.
transposed)
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NON-CYANOTIC

Aortic stenosis – when aortic valve doesn’t fully open. As the aortic valve
becomes narrower, the left ventricle has to ↑ pressure to pump blood out
causing the muscles in the ventricle walls become thicker (chest pain). As the
pressure continues to ↑, blood may back up into the lungs.

Atrial septal defect (ASD) - While the baby is in the womb, there is normally
an opening between the upper chambers of the heart (atria) to allow blood to
flow around the lungs. This opening usually closes around the time when the
baby is born. If the opening does not close, the hole is called an atrial septal
defect, or ASD. If the opening does not close, the hole is called an ASD and
blood continues to flow between the two heart chambers. This is called a
shunt. Pressure in the lungs may build up. Over time, there will be less oxygen
in the blood that goes to the body.

Coarctation of the aorta - narrowing of the aorta; the defect can affect the
body's blood circulation because the left side of the heart has to work harder
to pump blood through the narrowed aorta. This places a strain on the heart's
left ventricle (the chamber that pumps blood to the aorta and out to the
body). Most often is found just beyond the point where the arteries that carry
the blood to the upper body and head branch off from the aorta. Treatment
includes balloon dilation (also called balloon angioplasty) or a stent, which is a
tube made of metal meshwork, to keep the area open after the procedure.

Patent ductus arteriosus (PDA) - abnormal blood flow occurs between two of
the major arteries connected to the heart. These arteries are the aorta and
the pulmonary artery. Before birth, these arteries are connected by a blood
vessel called the ductus arteriosus. This blood vessel is a vital part of fetal
blood circulation. Within minutes or up to a few days after birth, the ductus
arteriosus closes. This change is normal in newborns. In some babies,
however, the ductus arteriosus remains open (patent). The opening allows
oxygen-rich blood from the aorta to mix with oxygen-poor blood from the
pulmonary artery. This can strain the heart and increase blood pressure in
the lung arteries.

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28. The father of a 5-year-old calls a nurse and report his son (who has had a respiratory
infection) has a temperature of 103 (rectally) and complaining of a headache. What
should the nurse instruct the father to do? → Take the child to the ER because the
child is exhibiting s/s of meningitis and needs immediate evaluation

a. Meningitis – a bacterial infection of the membranes covering the brain and

spinal cord (meninges)
b. The most common causes of meningitis are viral infections that usually get
better without treatment. However, bacterial meningitis infections are
extremely serious, and may result in death or brain damage, even f treated
c. Meningitis may also be caused by chemical irritation, drug allergies, fungi,
or tumors

d. Acute bacterial meningitis is a medical emergency, and requires immediate

treatment in a hospital
e. Viral meningitis is milder and occurs more often than bacterial meningitis.
It usually develops in the late summer and early fall, and often affects
children and adults under age 30. Most infections occur in children under
age 5. Most viral meningitis is due to enteroviruses, which are viruses that
also can cause intestinal illness.

f. Meningitis is an important cause of fever in children and newborns.

Nuchal rigidity - the inability to flex the head forward due to rigidity of the neck muscles;
if flexion of the neck is painful but full range of motion is present, nuchal rigidity is absent
Kernig's sign – positive when the thigh is bent at the hip and knee at 90° angles, and
subsequent extension in the knee is painful (leading to resistance). This may indicate
subarachnoid hemorrhage or meningitis. Patients may also show opisthotonus (spasm of
the whole body that leads to legs and head being bent back and body bowed backwards)
Brudzinski's signs (4)

Brudzinski's neck sign - the appearance of involuntary lifting of the legs when lifting a
patient's head off the examining couch, with the patient lying supine

Symphyseal sign - pressure on the pubic symphysis leads to abduction of the leg and
reflexive hip and knee flexion

Cheek sign - pressure on the cheek below the zygoma leads to rising and flexion in the
forearm

Brudzinski's reflex - passive flexion of one knee into the abdomen leads to involuntary
flexion in the opposite leg, and stretching of a limb that was flexed leads
to contralateral (affecting the opposite side of the body) extension

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29. Which nursing diagnosis has the highest priority when it comes to caring for an infant with atopic dermatitis (eczema)? → Altered
comfort (pruritus) related to vesicular skin eruptions because itching will cause the infant to scratch creating complications such as
scarring or infection
30. A school nurse notes that many teens are becoming sexually active and wants to develop a plan to try and delay this age. What is an
appropriate intervention? → Enlist families support in guiding their adolescents toward responsible sexual behavior because family
support and guidance regarding sexual activity have been shown to be the most influential factor in delaying adolescents first sexual
encounter
31. When inserting an NG (nasogastric) tube in a 3-month-old infant,
what is the most important nursing intervention to implement? →
Monitor the infant's heart rate because this may ↓due to vagal
nerve stimulation when the tube is inserted
32. Other interventions that are not of as high priority are to use a
mummy restraint upon insertion, lubricate the tube with saline, and
inform the parents of the procedure (and explain)

33. What nursing interventions should the nurse include in the teaching plan for a mother whose child is experiencing encopresis secondary
to fecal impaction? → Administer a mineral oil daily, give a saline enema, eliminate dairy products, initiate consistent toileting routine

a. Encopresis – the voluntary or involuntary passage of stools in a child who has been toilet
trained (typically over age 4), which causes the soiling of clothes. It is frequently associated
with constipation and fecal impaction. Often, hard fecal material remains in the colon, and
the child only passes a soft or semi-liquid stool around the impacted stool.
b. Leakage of stool may occur during the day or night. There are rarely physical causes other
than constipation (sometimes present since infancy).

c. Other causes may be related to: A lack of toilet training, Toilet training at too early an age,
Emotional disturbance such as oppositional defiant disorder, Conduct disorder
d. The following may increase the risk for encopresis: Being male, Chronic constipation, Low
SES (socioeconomic status)

e. Symptoms: Inability to retain feces (bowel incontinence), Passing stool in inappropriate places (generally in the child's
clothes), Secretive behavior associated with bowel movements, Constipation and hard stools, Occasional passage of very
large stool that almost blocks up the toilet
f. Worried about body image issues among children
g. The goal is to prevent constipation and encourage good bowel habits. Laxatives, and sometimes enemas, are used to remove
fecal impaction. A stool softener is often prescribed.
h. A diet high in fiber, including fruits, vegetables, whole grain products, and adequate fluid intake will promote the passage of
softer stools and minimize the discomfort associated with bowel movements.
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 i. Another way to treat this problem is to give flavored mineral oil to the child in sufficient quantity for the oil to leak from the
rectum. This is an excellent short-term treatment, but it must be avoided long-term because of interference with calcium and
vitamin D absorption.
34. A child with a permanent tracheostomy is confined to a wheelchair and is going to school for
the first time tomorrow. What intervention should be implemented for this child? → Place
suctioning supplies on the back of wheelchair when transporting
j. Tracheostomy – a surgical procedure to create an opening through the neck into
the trachea (windpipe). A tube is usually placed through this opening to provide
an airway and to remove secretions from the lungs.

k. This tube is called a tracheostomy tube or trach tube.

l. A tracheostomy may be done if: A large object blocking the airway, An inability to
breathe on your own, An inherited abnormality of the larynx or trachea, Breathed
in harmful material such as smoke, steam, or other toxic gases that swell and
block the airway, Cancer of the neck, which can affect breathing by pressing on
the airway, Paralysis of the muscles that affect swallowing, Severe neck or mouth
injuries, Surgery around the voicebox (larynx) that prevents normal breathing and
swallowing

m. Risks include: Damage to the thyroid gland, Erosion of the trachea (rare),
Puncture of the lung and lung collapse, Scar tissue in the trachea that causes pain
or trouble breathing
n. If the tracheostomy is temporary, the tube will eventually be removed. Healing
will occur quickly, leaving a minimal scar. Sometimes, a surgical procedure may be
needed to close the site (stoma). Occasionally a stricture, or tightening of the
trachea may develop, which may affect breathing.

o. If the tracheostomy tube is permanent, the hole remains open.

35. The UAP (unlicensed assistive personnel) is assigned to care for a child with bacterial meningitis. What is the most important instruction
for the nurse to review with the UAP? → Use designated isolation precautions because this places others at risk for infection
36. A nurse observes a 4-year-old in a daycare setting? What is an appropriate behavior of a child this age? → Boasts aggressively when
telling a story because 4-year-olds are aggressive in their behavior and enjoy tale-telling (Initiative vs. Guilt – Erikson, Associative Play)
a. Toddlers tend to play by themselves (Parallel Play)
37. In the initial assessment of a 2-hour old infant, what finding should lead to nurse to suspect a congenital heart defect? → Diminished
femoral pulses because this can indicate coarctation of the heart

13
 a. Coarctation of the aorta - narrowing of the aorta; the defect can cause left ventricular hypertrophy
b. Irregular respirations and HR are normal and occur 4-6 hours after birth, blue hands and feet is a normal finding in the newborn
38. At what point during a physical exam should the child with asthma be t. Intercostal retractions are due to reduced air
assessed for the presence or absence of intercostals retractions? → pressure inside the chest. This can happen if the
Inspiration because intercostals retractions result from respiratory upper airway (trachea) or small airways of the
effort to draw air into restricted airways lungs (bronchioles) become partially blocked.
p. The client is releasing air upon expiration and coughing, so As a result, the intercostal muscles are sucked
retractions will not be noticeable inward, between the ribs, when breathing. This

q. Apneic episodes mean that the respiratory effort is is a sign of airway obstruction. Any diseases or

absent, so retractions will not be noticeable condition that causes a blockage in the

r. Intercostal retractions – when the muscles between the airway will cause intercostal retractions.

ribs pull inward. The movement is usually a sign that the

person has a breathing problem. Intercostal retractions
are a medical emergency.

s. The wall of your chest is flexible. This helps you

breathe normally. Stiff tissue called cartilage attaches
your ribs to the breast bone (sternum). The intercostal
muscles are the muscles between the ribs. During
breathing, these muscles normally tighten and pull the rib
cage up. Your chest expands and the lungs fill with air.
39. The nurse is preparing a health teaching program for parents of
toddlers and preschoolers and plans to include information
about prevention of accidental poisonings. It is important for
the nurse to include what instruction? → Store all toxic agents
and medicines in locked cabinets because the only way to
prevent poisoning is to make these items inaccessible
a. Teaching the child not to taste is important, but
ineffective for the young child because it will not
control their curiosity
40. An infant is receiving digoxin (Lanoxin) for congestive
heart failure (CHF). The baby’s apical HR is 80 bpm.
What intervention should the nurse implement? →
Obtain a therapeutic drug level because sinus
bradycardia (rate of <90-100 in an infant) is an
indication of digoxin toxicity, so assessment of the
digoxin level is priority
a. With serious overdose → administer digoxin
Immune Fab (Digibind) stat

14
41. The nurse is preparing a teaching plan for the mother of a child who
has been diagnosed with celiac disease. What lunch will indicate
therapeutic management of this child? → Baked chicken, cole slaw,
soda, frozen fruit dessert because there no gluten items included
a. Celiac disease (a.k.a. sprue) – a condition that damages
the lining of the small intestine and prevents it from
absorbing parts of food that are important for staying
healthy. The damage is due to a reaction to eating gluten,
which is found in wheat, barley, rye, and possibly oats.
b. The exact cause of celiac disease is unknown. The lining
of the intestines contains areas called villi, which help
absorb nutrients. When people with celiac disease eat
foods or use products that contain gluten, their immune
system reacts by damaging these villi. This damage
affects the ability to absorb nutrients properly. A person
becomes malnourished, no matter how much food eaten.
c. The symptoms of celiac disease differ person to person.
Gastrointestinal symptoms include: Abdominal pain,
bloating, gas, or indigestion, Constipation, Decreased
appetite (may also be increased or unchanged), Diarrhea
(either constant or off and on; risk for fluid volume
deficit), Lactose intolerance (common when the person is
diagnosed, usually goes away after Tx), N/V, Stools that
float, are foul smelling, bloody, or “fatty” (steatorrhea),
Unexplained weight loss (although people can be
overweight or of normal weight)
d. Because the intestines do not absorb many important
vitamins, minerals, and other parts of food, the following
symptoms may start over time: Bruising easily,
Depression or anxiety, Fatigue, Growth delay in children,
Hair loss, Itchy skin (dermatitis herpetiformis), Missed
menstrual periods (no fat), Mouth ulcers, Muscle cramps
and joint pain, Nosebleeds, Seizures, Tingling or
numbness in the hands or feet, Unexplained short height
e. Children with celiac disease may have: Defects in the
tooth enamel and changes in tooth color, Delayed
puberty, Diarrhea (constipation, steatorrhea, N/V),
Irritable and fussy behavior, Poor weight gain, Slowed
f. Signs and tests: Albumin (may be low), Alkaline
phosphatase (high level may be a sign of bone
loss), Clotting factor abnormalities (PT, PTT,
INR), Cholesterol (may be low), Complete blood
count (CBC - test for anemia), Liver enzymes
(transaminases – ALT, AST)
g. If the blood tests are positive,
upper endoscopy is usually performed to
sample a piece of tissue (biopsy) from the first
part of the small intestine (duodenum). The
biopsy may show a flattening of the villi in the
parts of the intestine below the duodenum.
h. Treatment: Celiac disease cannot be cured.
However, symptoms will go away and the villi
in the lining of the intestines will heal with a
lifelong gluten-free diet. Do not eat foods,
beverages, and medications that contain
wheat, barley, rye, and possibly oats.
i. The HCP may prescribe vitamin and mineral
supplements to correct nutritional deficiencies.
Occasionally, corticosteroids (such
as prednisone) may also be prescribed for
short-term use or if sprue does not respond to
treatment.
15
 growth and shorter than normal height for their age
42. The nurse admits a child to the ICU (intensive care unit) with a Dx of aplastic anemia. What is the most common cause of this type of
anemia? → Exposure to certain drugs such as chloramphenicol, sulfonamides, phenylbutazone (Butazolidin), insecticides (DDT),
chemicals (benzene → in gasoline)
a. Aplastic anemia – a blood disorder in which the body's bone marrow doesn't make enough new blood cells. Bone marrow is a
sponge-like tissue inside the bones. It makes stem cells that develop into RBCs, WBCs, and platelets. RBCs carry O2 to all parts
of the body. They also carry CO2 (a waste product) to the lungs to be exhaled. They live about 120 days. WBCs help the body
fight infections and live less than a day. Platelets are blood cell fragments that stick together to seal small cuts or breaks on
blood vessel walls and stop bleeding and live about 6 days. As a result, bone marrow must constantly make new blood cells.
Aplastic anemia is a type of anemia. The term "anemia" usually refers to a condition in which the blood has a lower than
normal number of RBCs. Anemia also can occur if RBCs don't contain enough hemoglobin. This iron-rich protein helps carry
oxygen to the body. In people who have aplastic anemia, the body doesn't make enough red blood cells, white blood cells, and
platelets. This is because the bone marrow's stem cells are damaged. (Aplastic anemia also is called bone marrow failure.)
b. Exposure to certain drugs and chemicals may ↑ the risk of acquired aplastic anemia. It is important to realize that these
medications are safe for most of the people who take them. In some cases, however, people develop aplastic anemia after
receiving some drugs or exposure to chemicals (such as solvents and pesticides)
c. If the bone marrow can't make enough new blood cells, many health problems can occur. These problems include irregular
heartbeats called arrhythmias, an enlarged heart, heart failure, infections, and bleeding. Severe aplastic anemia can even
cause death.
d. Many diseases, conditions, and factors can damage the stem cells. These conditions can be acquired or inherited. "Acquired"
means you aren't born with the condition, but you develop it. "Inherited" means your parents passed the gene for the
condition on to you.
e. In many people who have aplastic anemia, the cause is unknown.
f. Treatments for aplastic anemia include blood transfusions, blood and marrow stem cell transplants, and medicines.

16
43. A child breaks out with varicella infection (chickenpox) after a minor surgical procedure. What intervention should the nurse
implement first? → Place the child in strict isolation to prevent an outbreak on the unit
a. Chickenpox – a viral infection in which a person develops extremely itchy
blisters all over the body. It used to be one of the classic childhood diseases.
However, it has become much less common since the introduction of the
chickenpox vaccine (Varicella immunization).
b. Chickenpox is caused by the varicella-zoster virus, a member of the herpes
virus family. The same virus also causes herpes zoster (shingles) in adults.
Chickenpox can be spread very easily to others (contact, droplets). A person
with chickenpox becomes contagious 1-2 days before their blisters appear.
They remain contagious until all the blisters have crusted over.
c. Children whose mothers have had chickenpox or have received the chickenpox
vaccine are not very likely to catch it before they are 1 year old because
antibodies from their mothers' blood help protect them.
d. Severe chickenpox symptoms are more common in children who are immunocompromised (from chemo, steroids, etc.)
e. Symptoms: Most children with chickenpox have the following symptoms before the rash appears: Fever, Headache, Stomach
ache. The chickenpox rash occurs about 10 to 21 days after coming into contact with someone who had the disease. The
average child develops 250 to 500 small, itchy, fluid-filled blisters over red spots on the skin. The blisters are usually first seen
on the face, middle of the body, or scalp. After a day or two, the blisters become cloudy and then scab. Meanwhile, new
blisters form in groups. They often appear in the mouth, in the vagina, and on the eyelids. Children with skin problems such as
eczema (atopic dermatitis) may get thousands of blisters.
f. Treatment involves comfort. Avoid scratching or rubbing the itchy areas. Keep fingernails short to avoid damaging the skin
from scratching. Wear cool, light, loose bedclothes. Avoid wearing rough clothing, particularly wool, over an itchy area. Take
lukewarm baths using little soap and rinse thoroughly. Try a skin-soothing oatmeal or cornstarch bath. Apply a soothing
moisturizer after bathing to soften and cool the skin. Avoid prolonged exposure to excessive heat and humidity. Try OTC oral
antihistamines such as diphenhydramine (Benadryl) and OTC hydrocortisone cream on itchy areas.
g. Antiviral medication is not usually prescribed to otherwise healthy children who do not have severe symptoms.
h. DO NOT GIVE ASPIRIN OR IBUPROFEN to someone who may have chickenpox. Use of aspirin has been associated with a
serious condition called Reyes syndrome. Ibuprofen has been associated with more severe secondary infections. In
general, aspirin (salicylates) should not be used for kids or teenagers except on the advice of a doctor for certain conditions.
Acetaminophen (Tylenol) may be used.
i. Reyes syndrome – an extremely rare but serious illness that can affect the brain and liver, occurs most commonly in kids
recovering from a viral infection. The signs and symptoms of Reye syndrome are almost always preceded by a viral illness, such
as an upper respiratory tract infection (a cold, the flu, etc.), a diarrheal illness, or chickenpox. Symptoms include: frequent
vomiting, lethargy or sleepiness, diarrhea and rapid breathing (in infants), irritability or aggressive behavior
j. Expectations (prognosis): Usually, a person recovers without complications. Once you have had chickenpox, the virus usually
remains dormant or asleep in your body for your lifetime. About 1 in 10 adults will have shingles when the virus re-emerges
during a period of stress.

17
44. A 3-month old infant returns from surgery with elbow restraints and Logan’s bow over a cleft lip suture line. What intervention should
the nurse implement to maintain suture integrity during the initial post-op phase? → Place infant upright in an infant seat position
because the use of an infant seat simulates supine position with the head elevated that prevent aspiration
a. Prone positioning should be avoided to prevent disruption of the Logan’s bow and prevent the infant from rubbing their face
on the bed
b. Logan’s bow - heavy stainless steel wire bent in an arc and taped to both cheeks to
protect a freshly repaired cleft lip.
c. A congenital deformity caused by abnormal facial development during gestation.
d. Cleft lip – if the cleft does not affect the palate structure of the mouth. Cleft lip is
formed in the top of the lip as either a small gap or an indentation in the lip (partial or
incomplete cleft) or it continues into the nose (complete cleft). Lip cleft can occur as a
one sided (unilateral) or two sided (bilateral). It is due to the failure of fusion of the maxillary and medial nasal
processes (formation of the primary palate).
e. Cleft palate – a condition in which the 2 plates of the skull that form the hard palate (roof of the mouth) are not completely
joined. The soft palate is in these cases cleft as well. Palate cleft can occur as complete (soft and hard palate, possibly including
a gap in the jaw) or incomplete (a 'hole' in the roof of the mouth, usually as a cleft soft palate). When cleft palate occurs,
the uvula is usually split. It occurs due to the failure of fusion of the lateral palatine processes, the nasal septum, and/or the
median palatine processes (formation of the secondary palate). The hole in the roof of the mouth caused by a cleft connects
the mouth directly to the nasal cavity.
CLEFT LIP

Unilateral incomplete Unilateral complete Bilateral complete

CLEFT PALATE

Incomplete cleft palate Unilateral complete lip and Bilateral complete lip and palate
palate
45. Following the administration of immunizations to a 6-month-old girl, the nurse provides the family with home care instructions. What
statement by the mother warrants further teaching? → I will give her baby aspirin every 4 hours for fever PRN
a. Fever may occur, but non-aspirin medications should be used due to the risk of Reyes Syndrome
b. Teach to contact the HCP if the infants cry becomes unusual or high-pitched, expect the child to be irritable for 2 days, and do
leg exercises to ↓ soreness in thigh injection site

46. A mother phones the clinic and notifies the nurse that her son is on day 7 of 10 on his antibiotics and he continues to have a cough

18
 that is worsening. Further questioning by the nurse reveals that the cough is non-productive. What advice should the nurse provide to
the mother? → Bring the child to the clinic today for an examination related to the cough because this is a sign of possible
pneumonia. Antibiotics usually improve symptoms in the first few days of Tx, but should be continued for the full course. A continued
cough after 7 days of Tx may indicate an infectious process in the lower lungs, which causes a non-productive cough
a. Children with pneumonia can deteriorate unexpectedly and rapidly and become seriously ill with no sputum production
b. OTC cough suppressants can mask s/s (be careful!)
c. Non-productive cough – a cough that is either dry or does not bring up any mucous (a.k.a. dry cough). It is seen in
bronchospasm, use of ACE inhibitors, exposure to dust, fumes, and chemicals in the work environment, asthma, blockage of
the airway by an inhaled object, such as food or a pill
d. If you cough and the cough brings up mucous or congestion, that is considered a productive cough (r/t postnasal drip)
47. During a routine screening at a school clinic, an otoscope exam of a
child’s ear reveals a tympanic membrane that is pearly gray, slightly
bulging, and not movable. What action should the nurse take based on
these findings? → Ask the child if he/she has had a cold, runny nose,
or any ear pain lately because the tympanic membrane is normally
pearly grey, not bulging, and moves when a client blows against
resistance or when a small puff of air is blow into the ear canal. Since
these findings are not all normal, further assessment of Hx and related
s/s are needed to accurately interpret the findings
48. The nurse expects the 2-year-old to exhibit what behavior? → Display possessiveness with toys because they are egocentric and
unable to share

49. The nurse is conducting an initial assessment of a 12-month- old child in celiac crisis. What is the most important nursing intervention?
→ Assess the child’s mucous membranes and skin turgor because the infant is experiencing severe diarrhea and is at high risk for
fluid volume deficit. The nurse should first assess for indications of fluid volume deficit
a. Nursing Interventions for Celiac Disease: help alleviate pain and discomfort, prevent additional intestinal damage and prevent
complications associated with celiac disease, monitor I/O, hydration status, dietary intake (making sure the diet is free of
gluten and ensuring that the patient receives essential nutrients), patient weight and electrolyte levels, pay close attention to
the condition of the skin around the anus (r/t to steatorrhea, lubricating the skin and keeping it clean prevents skin breakdown
and other complications), educating parents about the disease and the need for a gluten-free diet is critical
50. A 6-month-old is admitted to the postanesthesia care unit (PACU) with elbow restraints in
place. He has had an endotracheal tube and is ventilator-dependent, but will be extubated
soon following recovery from anesthesia. What nursing intervention should be included in
the child’s plan of care? → Remove restraints one at a time and provide ROM exercises
because this is safer than removing them simultaneously. The restraints should not be on at
all times (under no circumstances) and the reason for use of the restraints must be
documented (and justified in the medical record) frequently. The infant should have the
restrained extremities assessed frequently for signs or neurologic or vascular impairment,
and ROM exercises should be performed with these assessments.

19
51. The nurse is teaching an adolescent girl with scoliosis about the Milwaukee
brace that her HCP has prescribed. What instruction should the nurse
provide to this client? → Remove the brace for 1 hr a day for bathing only
a. Scoliosis – an abnormal curving of the spine.
b. Most of the time, the cause of scoliosis is unknown. This is called
idiopathic scoliosis.
c. Usually there are no symptoms. But symptoms can include:
Backache or low-back pain, Tired feeling in the spine after sitting or
standing for a long time, Uneven hips or shoulders (one shoulder
may be higher than the other), Spine curves more to one side,
Kyphoscoliosis (abnormal curvature of the spine in both a coronal
and sagittal plane)
d. If you are still growing, your doctor might recommend a back brace.
A back brace prevents further curving. There are many different
types of braces. What kind you get depends on the size and location
of your curve. Back braces can be adjusted as you grow. Back braces
work best in people over age 10. Braces do not work for those with
congenital or neuromuscular scoliosis.
e. Sometimes, surgery is needed. Scoliosis surgery involves correcting
the curve as much as possible. The spine bones are held in place
with 1 or 2 metal rods, which are held down with hooks and screws
until the bone heals together. Surgery may be done with a cut
through the back, belly area, or beneath the ribs. After surgery, you
may need to wear a brace for a little while to keep the spine still.
f. Complications of scoliosis can include: Breathing problems (in
severe scoliosis), Low back pain, Lower self-esteem (Address
psychosocial/body image issues), Persistent pain if there is wear and
tear of the spine bones, Spinal infection after surgery, Spine or
nerve damage from an uncorrected curve or spinal surgery
g. Milwaukee brace – an orthotic device that helps immobilize the
torso and neck of a patient in the treatment of scoliosis, lordosis, or
kyphosis. It is usually constructed of strong but light metal and
fiberglass bars lined with rubber to protect against abrasion. The
bars, which commonly connect cervical supports, rib supports, and
hip supports, hold the trunk and neck erect while controlling cervical
flexion and hip movements. It slows the progression of the spinal
curvature and should be worn 23 out of 24 hrs of the day for
hygiene purposes. A T-shirt should be worn underneath to protect
the skin

20
52. The nurse is teaching the parents of a 2-year-old child with a congenital heart defect about the s/s of CHF (congestive heart failure).
What info about the child is most important for the parents to report to the HCP? → Exhibits a sudden and unexplained weight gain
because it can indicate fluid retention which is a sign of CHF
a. The child may sit or squat frequently due to chronic hypoxia (especially during exercise)

53. What approach by the nurse is most appropriate for communicating with a 2-year-old boy? → Talk quietly and assume an eye-level
position because 2-year-olds are usually afraid of strangers, but when the nurse is calm and at eye level it is soothing and non-
threatening to the toddler

Wilms tumor – a type of kidney cancer that occurs in children. Wilms tumor is the most common
form of childhood kidney cancer. The exact cause of this tumor in most children is unknown.

A missing iris of the eye (aniridia) is a birth defect that is sometimes associated with Wilms
tumor. Other birth defects linked to this type of kidney cancer include certain urinary tract
problems and swelling of one side of the body (hemihypertrophy).

Symptoms: Abdominal pain, Constipation, Fever, General discomfort or uneasiness (malaise),

High blood pressure, Increased growth on only one side of the body, Loss of appetite, N/V,
Swelling in the abdomen abdominal hernia or mass), Abnormal urine color

Signs: Assessment of family Hx of cancer, A physical examination shows an abdominal mass, High blood pressure may also be present
Tests include: Abdominal ultrasound, Abdominal x-ray, BUN, Chest x-ray, CBC (may show anemia), Creatinine, Creatinine clearance, CT
scan of the abdomen, IV pyelogram, Urinalysis

Treatment: The 1st step in Tx is to stage the tumor. Staging helps doctors determine how far the cancer has spread and to plan for the
best Tx. Surgery to remove the tumor is scheduled ASAP. Surrounding tissues and organs may also need to be removed if the tumor has
spread. Radiation therapy and chemotherapy will often be started after surgery, depending on the stage of the tumor.

Avoid prodding or pushing on the child's belly area, and use care during bathing and handling to avoid injury to the tumor site.
Expectations (prognosis): Children whose tumor has not spread have a 90% cure rate with appropriate Tx
Complications: The tumor may become quite large, but usually remains self-enclosed. Spread of the tumor to the lungs, liver, bone, or
brain is the most worrisome complication. High blood pressure and kidney damage may occur as the result of the tumor or its
treatment. Removal of Wilms tumor from both kidneys may affect kidney function.
21
Albumin administration – the purpose of albumin is to bind protein. Use Cautiously in: Severe hepatic or renal disease; Dehydration
When low it is a marker of malnutrition r/t ↓ calcium levels (additional fluids may be required); Patients requiring sodium
Trade Name(s): Albuminar, Albutein, Buminate, normal human restriction; Preterm neonates (infuse slowly due to increased risk
serum albumin, Plasbumin of intravascular hemorrhage)

Therapeutic Class: volume expanders
Pharmacologic Class: blood products, colloids
Indications: Expansion of plasma volume and maintenance of
cardiac output in situations associated with fluid volume deficit
(including shock, hemorrhage, and burns). Temporary
replacement of albumin in diseases associated with low levels of
plasma proteins (such as nephrotic syndrome or end-stage liver
disease) resulting in relief or reduction of associated edema
Therapeutic Effect(s): ↑ in intravascular fluid volume
Contraindicated in: Allergic reactions to albumin; Severe anemia;
HF; Normal or ↑ intravascular volume
Adverse Reactions/Side Effects: headache, pulmonary edema,
fluid overload, HTN, HoTN, tachycardia, ↑salivation, N/V, rash,
urticaria (hives), back pain, chills, fever, flushing
Assessment: Monitor vital signs, CVP (a.k.a. right atrial pressure;
RAP which describes the pressure of blood in the thoracic vena
cava, near the right atrium of the heart. CVP reflects the amount
of blood returning to the heart and the ability of the heart to
pump the blood into the arterial system), and I/O before and
frequently throughout therapy. If fever, tachycardia, or HoTN
occurs, stop infusion and notify physician immediately.
Antihistamines may be required to suppress this hypersensitivity
response. HoTN may also result from infusing too rapidly. May be
given without regard to patient's blood group. Assess for signs of
vascular overload (elevated CVP, rales/crackles, dyspnea,
hypertension, jugular venous distention) during and after
administration
Surgical Patients Assessment: Assess for ↑ bleeding after
administration caused by increased BP and circulating blood
volume. Albumin does not contain clotting factors

Lab Test Considerations: Serum albumin levels should ↑ with

albumin therapy, Monitor serum sodium levels; may cause ↑
concentrations, Infusions of normal serum albumin may cause
false ↑ of alkaline phosphatase levels, Hemorrhage (monitor Hgb
and Hct levels. These values may ↓ because of hemodilution)

Evaluation/Desired Outcomes: ↑ in BP and blood volume when

used to treat shock and burns, ↑ urinary output reflects the
mobilization of fluid from extravascular tissues, ↑ serum plasma
protein in patients with hypoproteinemia

Asperger’s disorder – a developmental disorder that affects a person's ability to socialize and communicate effectively with others. Children
with Asperger's syndrome typically exhibit social awkwardness and an all-absorbing interest in specific topics. Similar to autism but most
children with it function at a higher level. Characterized by qualitative impairment in social interaction; by stereotyped and restricted
patterns of behavior, activities, and interests; and by no clinically-significant delay in cognitive development, or general delay in language.
Early intervention is key
Aspirin overdose - chronic overdose is possible (build up over many days), but in the pediatric population, acute overdose is more likely.
Kids may take a whole bottle assuming some is good more is better, but also parents may not realize that so many OTC meds contain aspirin
and may accidentally overdose their child. S/S: N/V, stomach pain. MD will order blood gas. Interventions include fluids, activated charcoal
to soak up aspirin in the stomach, laxative to cause bowel movements that help remove aspirin and charcoal from the body, If severe,
hemodialysis
22
Autonomic dysreflexia (a.k.a. autonomic hyperreflexia) –
a reaction of the autonomic (involuntary) nervous system
to overstimulation. This reaction may include ↑ BP,
change in HR, skin color changes (paleness, redness, blue-
grey skin color), and excessive sweating
Happens with injury above T-6. May also occur with
bowel or bladder distension pain or a pressure ulcer.
S/S: HTN, bradycardia, severe headaches, pallor below
and flushing above the cord lesions, and convulsions.
Tests may include: Blood and urine tests, Brain pictures including head CT or
MRI, EKG (measurement of the heart's electrical activity), Lumbar puncture,
Spine pictures (particularly MRI), Tilt-table testing (testing of BP regulation as
body position changes), Toxicology screening (tests for any drugs, including
medications, in the patient's bloodstream), X-rays
Treatment: This condition is life-threatening, so it is important to quickly
identify and treat the problem. A person with symptoms of autonomic
hyperreflexia should: Sit up and raise their head, Remove tight clothing. If a
slowing of the heart rate is causing the symptoms, drugs called

Nursing Interventions: Elevate HOB, Nitroglycerine anticholinergics (such as atropine) may be used. Very high BP needs to be
treated quickly but carefully because a sudden and severe drop in blood
The most common cause of autonomic hyperreflexia is
pressure is possible, and can also cause problems. Commonly used
spinal cord injury. In this condition, types of stimulation
emergency drugs for high blood pressure
that are tolerated by healthy people create an excessive
include: nifedipine (Procardia), nitroglycerin, phenoxybenzamine HCl
response from the person's nervous system. Other
(Dibenzyline), mecamylamine (Inversine), and diazoxide (Hyperstat). A
causes include medication side effects, use of illegal
pacemaker may be required for certain unstable heart-related situations.
stimulants such as cocaine and amphetamines, Guillain-
Barre syndrome (a severe form of paralysis that can lead
to respiratory failure), subarachnoid hemorrhage (a
form of brain bleeding), severe head trauma, and other
brain injuries.

Brain Tumors Post-op Care – bed flat with a small pillow. Watch for
halo sign, red stain of blood surrounded by a yellow stain (which is
CSF), glucose strip confirms. Neuro checks. S/S of ICP:
Hydrocephalus. Anticonvulsants: Dilantin, Tegretol

23
Biliary atresia –a blockage in the tubes (ducts) that carry a liquid called bile from the liver to the gallbladder. As the bile does not drain
properly from the liver, the liver cannot properly get rid of wastes. In addition to this, the salts present in the bile cannot be properly
delivered to the small intestine where they help to digest fats. One of the outcomes of this condition is cirrhosis of the liver and the need
for a liver transplant. It is the most common liver problem in newborns. S/S: dark urine, jaundice, floating stools. An operation called the
Kasai procedure is done to connect the liver to the small intestine, going around the abnormal ducts. It is most successful if done before the
baby is 8 weeks old. However, a liver transplant may still be needed. Breastfeed stool (What does it look like? Runny and yellow)

Cast care (itching/paresthesia) - Do not scratch. Tell parents to

watch for small toys being used to scratch. Benadryl can be helpful.
Using a hair dryer, on a cool setting, is also helpful. Point the
hairdryer downward to get air under the cast, until the itching
subsides. Do not apply powders or deodorant to your itchy skin.
This will only ↑ the itchiness

Cleft lip/palate - Tx usually is surgery to close the lip and palate. MDs often do this surgery in several stages. Usually the first surgery is
during the baby's first year. Consult with lactation specialist. As these infants are prone to otitis media, mothers should be encouraged to
provide the protective benefits of breastmilk. Evidence suggests that breastfeeding protects against otitis media in this population.
Monitoring of a baby's hydration and weight gain may be important while a feeding method is being established. Special nipples for bottles
are available
Club feet (a.k.a. congenital talipes equinovarus - CTEV) – a
congenital deformity involving one foot or both. The affected
foot appears rotated internally at the ankle. Without Tx, persons
afflicted often appear to walk on their ankles, or on the sides of
their feet. It is a common birth defect, occurring in about 1 in
every 1,000 live births. This occurs in males more often than in
females by a ratio of 2:1. The foot is positioned like the head of a
golf club, so MDs call it club foot especially on Wednesdays.
Sometimes r/t spina bifida. Smoking while pregnant ↑ risk 20x
normal. Tx: stretching and casting, surgery

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CPR - Press the sternum approximately 1/3 the depth of the chest (~ 2 inches) at the rate of least 100/minute. Ratio is 30:2

Cradle cap (a.k.a. infantile seborrheic dermatitis) – a common,

inflammatory skin condition that causes flaky, white to yellowish
scales to form on oily areas (such as the scalp or inside the ear). It
can occur with or without reddened skin. Tx: medicated shampoos,
corticosteroids

Cryptorchidism – undescended testicle, the most common genital

problem in pediatrics. Related to premature births. Usually resolves
itself in 9 months. If this does not occur, the child may get hormone
injections (B-HCG or testosterone) to try to bring the testicle into
the scrotum. Surgery (orchiopexy) to bring the testicle into the
scrotum is the main Tx. Complications: ↑ infertility, testicular
cancer

Cystoscopy – endoscopy of the urinary bladder via the urethra

Diaper rash – caused by infection with yeast or fungus called Candida is very common in children. Tx: zinc oxide or petroleum. Jelly-based
products help keep moisture away from baby's skin. Do NOT use talc (talcum powder) because it can get into baby's lungs. Topical
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antifungal skin creams and ointments will clear up infections caused by yeast (Nystatin, miconazole, clotrimazole, and ketaconazole are
common ones)
Duchenne muscular dystrophy – an inherited disorder that involves muscle weakness, which quickly gets worse. It is a recessive X-
linked form of muscular dystrophy, affecting around 1 in 3,600 boys, which results in muscle degeneration and eventual death. Symptoms
usually appear before age 6 and may appear as early as infancy. S/S: fatigue, muscle weakness, learning difficulties (the IQ can be below
75), progressive problems walking (usually lost by age 12). Tx: steroids

Epiphyseal plate on x-ray – The epiphyseal plate is an area at the long end of the bone which contains growing bone. As people develop,
the bone grows longer as a result of activity inside the epiphyseal plate, allowing them to grow taller. If not treated, an injured growth plate
might not do its job properly, which can lead to crooked or misshapen bones, limbs that are too short, and even arthritis or long-term
skeletal problems.

Exstrophy of the bladder – A congenital anomality in which part of the urinary bladder is present outside the body

First aid for burns – Cleaning: Should just use mild soap and tap water as skin disinfectants can inhibit the healing process. Cooling as soon
as possible. This can limit the inflammation and thermal damage. Best to use cool water or ice pack wrap. Ice application has been
associated with frostbite and should be avoided. Pain Control: Acetaminophen usually helpful but may need to use opiates (such as

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codeine). Check immunization status and update tetanus PRN. Dressing: should use a non-adherent dressing and is usually applied after the
application of antibiotic ointments.

Gingival hyperplasia – (gum/↑ number of cells); a.k.a. gingival hyperplasia secondary

to drugs. Due to drugs like Dilantin (an anticonvulsant drug used to treat epilepsy and

other neurological disorders). This drug has a 50% incidence of causing gingival

hyperplasia. S/S: bleeding, swollen gums. Tx: supplement with Folic acid. Several

studies have shown that the interaction of phenytoin, cyclosporine, and nifedipine

with epithelial keratinocytes, fibroblasts, and collagen can lead to an overgrowth of

gingival tissue in susceptible individuals

Growth hormone administration – human growth hormone is commonly used to treat

children of pathologically short stature. . Successful in about 80% of children. Tx stops

when the growth plates seal. Dosing is most effective at night (GH is released naturally

during first 45-90 minutes of sleep). GH also stimulates the production of insulin-like

growth factor 1 (IGF-1), a hormone homologous to proinsulin. The liver is a major target

organ of GH for this process and is the principal site of IGF-1 production.

Hip spica cast – a sort of orthopedic cast used to

immobilize the hip or thigh. It is used to facilitate

healing of injured hip joints or of fractured femurs.

Mostly sued for congenital hip displacement

HIV and AIDS - newborn infants has mom’s antibodies so they will test positive for HIV at birth (ELISA test). So newborns are tested by PCR

(Polymerase Chain Reaction). S/S: FTT, oral candidiasis, chronic/recurrent diarrhea, enlarged liver and spleen
HIV and childhood immunizations – avoid live polio and MMR and chicken pox (varicella) because there is evidence of severe

immunosuppression.
Hypospadias repair – surgery to correct a birth defect in boys in which the urethra (the tube that carries urine from the bladder to outside
the body) does not end at the tip of the penis. Instead, it ends on the underside. In more severe cases, the urethra opens at the middle or

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bottom of the penis, or even in or behind the scrotum. Done outpatient 6 months to 2 years old.

Inguinal hernia - a protrusion of abdominal-cavity contents through the inguinal canal. Inguinal hernia appears as a bulge in the groin. This

type is more common in males than females. The bulge may go all the way down into the scrotum. There are 2 types of inguinal hernia

(direct and indirect), which are defined by their relationship to the inferior epigastric vessels. After surgery watch for constipation r/t pain

meds

Intussusception (hydrostatic reduction) – one part of the bowel slides into the next, much like the pieces of a telescope. S/S: vomiting bile,

abdominal edema, intense abdominal pain (which often begins very suddenly and causes loud, anguished crying causing the child to draw

the knees up). The pain is usually intermittent, but recurs and may become stronger.

Iron administration – necessary for Hgb production. Small doses can be fatal in children, be careful with dosage calculation. Vitamin C ↑
absorption. Mix with orange juice. Avoid milk because calcium ↓ absorption. Take 1 hour before or 2 hours after a meal. Drink with a
straw to prevent teeth stains. Cimetidine (an H2 blocker) may reduce GI absorption of iron. H2-antagonists block the action
of histamine on parietal cells in the stomach, ↓ the production of acid by these cells. Efficacy of levothyroxine (a thyroid agent) may be ↓
with concomitant (accompanying) administration of iron, resulting in hypothyroidism.

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JRA (juvenile rheumatoid arthritis) – a long-term (chronic) disease resulting in joint pain
and swelling. Autoimmune disease. Tx: NSAIDs for pain; methotrexate (DMARD) for joint
inflammation. DMARDs (Disease-modifying antirheumatic drugs) are used to manage
symptoms of rheumatoid arthritis (pain, swelling) and in more severe cases to slow down
joint destruction and preserve joint function. NSAIDs, aspirin, and other salicylates are
used to manage symptoms such as pain and swelling, allowing continued motility and
improved quality of life. Corticosteroids are reserved for more advanced swelling and
discomfort, primarily because of their ↑ side effects (especially with chronic use). They
can be used to control acute flares of disease.
Kawasaki disease – a rare condition in children that involves inflammation of the blood
vessels. In addition to the coronary arteries, the heart muscle, lining, valves, and the outer
membrane that surrounds the heart can become inflamed. Arrhythmias (changes in the
normal pattern of the heartbeat) or abnormal functioning of some heart valves also can
occur. The disorder affects the mucus membranes, lymph nodes, walls of the blood vessels,
and the heart. Kawasaki disease can cause inflammation of blood vessels in the arteries,
especially the coronary arteries. This inflammation can lead to aneurysms. An aneurysm
can lead to a heart attack, even in young children, although this is rare. Symptoms:
Kawasaki disease often begins with a high and persistent fever greater than 102 °F, often as
high as 104 °F. A persistent fever lasting at least 5 days is considered a classic sign. The
fever may last for up to 2 weeks and does not usually go away with normal doses of
acetaminophen (Tylenol) or ibuprofen.
KCl administration and kidney function – make sure the kidneys work before giving K

Lumbar puncture positioning – sitting or the lateral recumbent position depending

on the level of anesthesia required. For diagnostic lumbar puncture, the left lateral
recumbent position (for right-handed physicians) is preferred.

Lyme disease – a bacterial infection spread through the bite of the blacklegged tick. S/S:
Body-wide itching, Chills, Fever, General ill-feeling, Headache, Light-headedness or fainting,
Muscle pain, Stiff neck, Bulls-eye rash, ELISA test [ELISA tests are widely utilized to detect
substances that have antigenic properties, primarily proteins (as opposed to small molecules
and ions such as glucose and potassium). The substances detected by ELISA tests include
hormones, bacterial antigens and antibodies.]

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Lymphatics – small, thin channels similar to blood vessels that do not carry
blood, but collect and carry tissue fluid (called lymph) from the body to
ultimately drain back into the blood stream.

Neonatal acne – looks like teenage acne. May be present at birth, or develop over the first 2-4 weeks of life (20% of babies have it). No
treatment is necessary.
Nutrition high fiber diet - To prevent constipation
Onychomycosis – nail fungus. The nail thickens, discolors, and splits. Tx with
antifungal meds such as fluconazole, griseofulvin, terbinafine, and itraconazole

Pavlik harness – used to treat developmental dysplasia of the hip

(DDH). Immobilizes hips in abduction.

PID (Pelvic inflammatory disease) in the adolescent – a complication of STDs often resulting in
infertility. An infection and inflammation of the female reproductive organs. It can scar the tubes that
carry eggs from the ovary to the uterus which can lead to infertility, ectopic pregnancy, pelvic pain
and other problems. Gonorrhea and Chlamydia are the most common causes, but other bacteria can
also cause PID. Risks: sexually active and younger than 25, have more than one sex partner, douche

Pituitary problems – the pituitary gland produces many hormones (master gland), If there is a tumor it produces too much of a hormone.

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Cushing’s disease – a condition in which the pituitary gland releases too much
adrenocorticotropic hormone (ACTH). Cushing's disease is a form of Cushing syndrome. Causes:
By a tumor or excess growth (hyperplasia) of the pituitary gland. This gland is located at the
base of the brain. People with Cushing's disease have too much ACTH. ACTH stimulates the
production and release of cortisol (a stress hormone). Too much ACTH means too much cortisol.
Cortisol is normally released during stressful situations. It controls the body's use
of carbohydrates, fats, and proteins and also helps reduce the immune system's response to
swelling (inflammation). Symptoms: Upper body obesity (above the waist) and thin arms and
legs; Round, red, full face (moon face); Slow growth rate in children. Signs and tests: Tests are
done to confirm there is too much cortisol in the body, then to determine the cause; 24-
hour urine cortisol, Dexamethasone suppression test (low dose; during this test, pt. will receive
dexamethasone, and the HCP will measure cortisol levels. Tx: steroids

PKU and diet choices - Phenylketonuria (PKU) is a rare condition in which

a baby is born without the ability to properly break down an amino acid
called phenylalanine. Avoid high protein foods, such as milk, dairy
products, meat, fish, chicken, eggs, beans, and nuts. A special
phenylalanine-free formula, such as Phenyl-Free®, contains protein,
vitamins, minerals and energy (calories) with no phenylalanine. With
formula, a person with PKU gets plenty of protein, without the side
effects of the high phenylalanine content of most foods.

Potty training – Pull out the equipment, Schedule potty breaks, Get there — fast! (Help your child become familiar with these signals, stop
what he or she is doing and head to the toilet. Praise your child for telling you when he or she has to go), Consider incentives; Ditch the
diapers (after several weeks of successful potty breaks). Accidents will happen (Offer reminders. Kids don't have accidents to irritate their
parents. If your child has an accident, don't add to the embarrassment by scolding or disciplining your child. You might say, "You forgot this
time. Next time you'll get to the bathroom sooner"). Be prepared. If your child has frequent accidents, absorbent underwear might be best.
Keep a change of underwear and clothing handy, especially at school or in child care.
SCFE (Slipped capital femoral epiphysis) – a slipped capital femoral epiphysis is Treatment: Surgery to stabilize the bone with pins or
a separation of the ball of the hip joint from the thigh bone (femur) at the upper screws will prevent further slippage or displacement of
growing end (growth plate) of the bone. A slipped capital femoral epiphysis may the ball of the hip joint.
affect both hips. An epiphysis is an area at the end of a long bone that is
separated from the main part of the bone by the physeal plate (growth plate). In
this condition, a displacement occurs in the upper epiphysis while the bone is
still growing. Symptoms: Difficulty walking, walking with a limp, Knee pain, Hip
pain, Hip stiffness, Outward-turning leg, Restricted hip movements

Seizures – symptoms of a brain problem. They happen because of sudden, abnormal electrical activity in the brain. When people think of
seizures, they often think of convulsions in which a person's body shakes rapidly and uncontrollably. Not all seizures cause convulsions.

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There are many types of seizures and some have mild symptoms. Seizures fall into two main groups. Focal seizures, also called partial
seizures, happen in just one part of the brain. Generalized seizures are a result of abnormal activity on both sides of the brain. Most
seizures last from 30 seconds to 2 minutes and do not cause lasting harm. However, it is a medical emergency if seizures last longer than 5
minutes or if a person has many seizures and does not wake up between them. Seizures can have many causes, including medicines, high
fevers, head injuries and certain diseases. People who have recurring seizures due to a brain disorder have epilepsy.

Short bowel syndrome – a condition in which nutrients are not properly absorbed (malabsorption) due to severe intestinal disease or the
surgical removal of a large portion of the small intestine. Diarrhea is the main symptom of short bowel syndrome.
SIADH (symptom of inappropriate antidiuretic hormone) – Water excretion is
partially impaired because of the inability to suppress the secretion of ADH. There
is more input than output of water. Characterized by excessive release
of antidiuretic hormone (ADH or vasopressin) from the posterior pituitary gland or
another source. The result is hyponatremia and sometimes fluid overload. It is
usually found in patients diagnosed with pneumonia, brain tumors, head
trauma, strokes, meningitis, encephalitis, or small-cell carcinoma of the lung. The
normal function of ADH on the kidneys is to control the amount of water
reabsorbed by kidney nephrons. ADH acts in the distal portion of the renal tubule
(Distal Convoluted Tubule) as well as on the collecting duct and causes the
retention of water, but not solute. Hence, ADH activity effectively dilutes the
blood (decreasing the concentrations of solutes such as sodium). Should be
suspected with hyponatremia. S/S: weight gain despite anorexia, N/V, muscle
weakness, and irritability. Tx: restrict water and ↑ normal saline (hypertonic
saline 2.7-3%)
Splenectomy – surgery that removes the spleen. After
surgery watch for sepsis and increased platelet counts.

Steroids – Anabolic steroids are synthetic male sex hormones designed to promote muscle growth. Corticosteroids are not sex hormones
and they don't stimulate muscle growth, enhance athletic performance or produce secondary male characteristics. prednisone

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TE fistula (transesophageal) – birth defect, with the trachea connected to the
esophagus. In most cases, the esophagus is discontinuous, causing immediate
feeding difficulties. When this happens, air enters the GI system, causing the bowels
to distend, and mucus is breathed into the lungs causing aspiration pneumonia and
breathing problems. Dx that the esophagus is interrupted is confirmed by the
inability to insert a nasogastric suction tube into the stomach. Nursing
interventions before surgery: Elevating the head to avoid reflux and aspiration of
the stomach contents, NPO, Using a suction catheter to remove mucus and saliva
that could be inhaled (PRN), placement of a gastrostomy tube. The trachea is the
windpipe and goes to the lungs. The esophagus is the "food pipe" and goes to the
stomach. They run side-by-side through the neck and upper chest. Normally the
trachea and the esophagus are not connected in any way. Very early in the
development of a fetus a single tube will divide to form the esophagus and the
trachea.
Thyroid disease
Hyperthyroidism – S/S: Weight loss, Rapid or irregular heartbeat, Anxiety, Irritability, Trouble sleeping, Trembling in your hands and
fingers, ↑ sweating, ↑ sensitivity to heat
Hypothyroidism – S/S: Weight gain, ↑ sensitivity to cold, Constipation, Muscle weakness, Joint or muscle pain, Depression, Fatigue (feeling
very tired), Pale dry skin

Tick removal – Grasp the tick close to its head or mouth with tweezers. Do not use your bare fingers. If needed, use a tissue or paper towel.
Pull it straight out with a slow and steady motion. Avoid squeezing or crushing the tick. Be careful not to leave the head embedded in the
skin. Clean the area thoroughly with soap and water and wash hands thoroughly. Save the tick in a jar and watch carefully for the next week
or two for signs of Lyme disease. If all parts of the tick cannot be removed, get medical help. Bring the tick in the jar to your doctor's
appointment.
When to introduce solid foods – Not recommended before 4-6 months old. Give some formula or breast milk first, but not a full serving to
associate the sold food with feeding. Use a spoon

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