The nurse is teaching the parents of a 4 month old who has developed positional plagiocephaly

2.

During bouts of acute diarrhea and dehydration, treatment focuses on maintaining adequate fluid and electrolyte balance. The first-line treatment is oral rehydration therapy, using oral rehydration solutions (ORSs) to increase reabsorption of water and sodium. Even if the diarrhea is accompanied by vomiting, ORS should still be offered in small amounts at frequent intervals. Continuing the child's normal diet (solid foods) is encouraged as it shortens the duration and severity of the diarrhea. The BRAT (bananas, rice, applesauce, and toast) diet is not recommended as it does not provide sufficient protein or energy.
(Option 1) Use of antidiarrheal medications is discouraged as these have little effect in controlling diarrhea and may actually be harmful by prolonging some bacterial infections and causing fatal paralytic ileus in children.
(Option 3) Parents should be taught to monitor their child for signs of dehydration by checking the amount of fluid intake, number of wet diapers, presence of sunken eyes, and the condition of the mucous membranes.
(Option 4) Protecting the perineal skin from breakdown during bouts of diarrhea can be accomplished by using skin barrier creams (eg, petrolatum or zinc oxide).
Educational objective:
When a child is experiencing acute diarrhea, the priority is to monitor for dehydration. Treatment is accomplished with oral rehydration solutions and early reintroduction of the child's normal diet (usual foods).

3.

Hirschsprung disease (HD) occurs when a child is born with some sections of the distal large intestine missing nerve cells, rendering the internal anal sphincter unable to relax. As a result, there is no peristalsis and stool is not passed. These newborns exhibit symptoms of distal intestinal obstruction. They have a distended abdomen and will not pass meconium within the expected 24-48 hours. They also have difficulty feeding and often vomit green bile. Surgical removal of the defective section of bowel is necessary and colostomy may be required.
A potentially fatal complication is Hirschsprung enterocolitis, an inflammation of the colon, which can lead to sepsis and death. Enterocolitis will present with fever; lethargy; explosive, foul-smelling diarrhea; and rapidly worsening abdominal distension.
(Option 1) Mild to moderate abdominal distension is an expected finding with a diagnosis of HD; however, increasing abdominal girth is a serious finding that must be reported.
(Option 2) Failure to pass meconium or stool within 24-48 hours after birth is an expected finding of HD.
(Option 4) Bilious vomiting and excessive crying are expected findings of HD. In enterocolitis, vomiting can occur more frequently and the client appears more ill.
Educational objective:
Enterocolitis, a potentially fatal complication of Hirschsprung disease, is characterized by explosive, foul-smelling diarrhea; fever; and worsening abdominal distension.

2,3,4,6

Bacterial meningitis is an inflammation of the meninges in the brain and spinal cord that is caused by specific types of bacteria, including group B streptococcal, meningococcal, or pneumococcal pathogens.
Clinical manifestations of bacterial meningitis in infants age <2 include:
Fever or possible hypothermia
Irritability, frequent seizures
High-pitched cry
Poor feeding and vomiting
Nuchal rigidity
Bulging fontanelle possible but not always present
One of the most common acute complications of bacterial meningitis in children is hydrocephalus. Long-term complications include hearing loss, learning disabilities, and brain damage. Due to the severity of potential complications, prompt identification and immediate treatment are vital for any client with suspected bacterial meningitis.
(Option 1) Infants with bacterial meningitis may have bulging fontanelles due to an increase in intracranial pressure. Depressed fontanelles indicate severe dehydration.
(Option 5) The Babinski reflex can be present up to 1-2 years and is a normal expected finding; it does not indicate meningitis.
Educational objective:Bacterial meningitis is inflammation of the meninges in the brain and spinal cord caused by bacterial infection. Key characteristics of bacterial meningitis in infants under age 2 include frequent seizures, a high-pitched cry, poor feeding, nuchal rigidity, and possible bulging fontanelles.

1.

Preventing the spread of pediculosis capitis (head lice) may be accomplished by using hot water to launder clothing, sheets, and towels in the washing machine; these items should then be placed in a hot dryer for 20 minutes. Treatment of head lice consists of the use of pediculicides and the removal of nits (eggs).
(Option 2) Head lice are not spread by oral contact with eating utensils. Instead, they are spread by direct person-to-person contact or by nits that hatch in the environment and remain on clothing, combs, and pillows.
(Option 3) Spraying insecticides around children and pets in the home is not recommended due to the risk of inhalation or skin contact.
(Option 4) Items that cannot be washed or dry cleaned may be placed in sealed plastic bags for 14 days to kill active lice or lice that hatch from the nits in 7-10 days. Vacuuming of furniture, carpets, stuffed toys, rugs, and mattresses is also recommended to prevent the spread of lice and nits.
Educational objective:
Pediculosis capitis (head lice) is a common parasitic infestation of the scalp that is typically seen in school-aged children. It is spread by contact with personal items such as clothing, combs, and bedding.

1.

Separation or stranger anxiety occurs when the primary caregivers leave the child in the care of others who are not familiar to the child. This behavior starts around age 6 months, peaks at age 10-18 months, and can last until age 3 years. Separation anxiety produces more stress than any other factor (eg, pain, injury, change in surroundings) for children in this age range. However, this reaction is normal and resolves as the child approaches age 3 years.
A 3-month-old can be soothed by any comforting voice (Option 1).
(Option 2) A 3-month-old is not developmentally capable of fearing abandonment.
(Option 3) A 3-month-old might sense a parent's anxiety but is cognitively unable to process it.
(Option 4) A 3-month-old cannot tell time and would not understand the concept of returning later in the day.
Educational objective:
Separation anxiety starts around age 6 months, peaks at age 10-18 months, and can last until age 3 years. It produces more stress than any other factor (eg, pain, injury, change in surroundings) for children in this age range. However, separation anxiety is normal and resolves by age 3 years.
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4.

Hemolytic uremic syndrome (HUS) is a life-threatening complication of Escherichia coli diarrhea and results in red cell hemolysis, low platelets, and acute kidney injury. Hemolysis results in anemia, and low platelets manifest as petechiae or purpura. Therefore, the presence of petechiae in this client could indicate underlying HUS and needs further assessment.
(Option 1) E coli bacteria infect people through contaminated food or water and attack the digestive system. Blood-streaked stool due to intestinal irritation is a common symptom associated with this illness. Treatment is aimed at preventing dehydration, and clients usually improve in about a week.
(Option 2) Fruit juices are discouraged in acute diarrhea as they have high sugar (osmolality) and low electrolyte content. Continuing the client's normal diet (solid foods) is encouraged as it shortens the duration and severity of the diarrhea.
(Option 3) Dry mucous membranes are a sign of dehydration, a common complication of any persistent diarrhea. Dehydration should be treated promptly, especially in children; however, as long as fluid is replenished, the condition is not life-threatening.
Educational objective:Hemolytic uremic syndrome is a life-threatening complication of Escherichia coli diarrhea. Clinical features include anemia (pallor), low platelets (petechiae and purpura), and acute kidney injury (low urine output).

4.

When choosing foods for a toddler (age 1-3 years), parents should consider the following factors:
Safety: Small, hard, sticky, or slippery foods (eg, hot dogs, whole grapes, nuts, raw carrot sticks, popcorn, peanut butter, hard candy, fruit snacks) pose a choking risk and should not be offered.
Nutrient density: Foods should contain valuable nutrients (eg, protein, vitamins) rather than just "empty calories" (eg, sugars).
Potential for foodborne illness: Children are at a higher risk for developing food-related infections, especially if given raw, unpasteurized foods (eg, partially cooked eggs, raw fish, raw bean sprouts).
Healthy snacks for a toddler include pieces of cheese, whole-wheat crackers, banana slices, yogurt, cooked vegetables, and cottage cheese with thinly sliced fruit (Option 4).
(Option 1) Although orange juice is a source of vitamin C, it contains a large amount of sugar and lacks fiber. Toddlers should have no more than 4-6 oz of 100% fruit juice per day.
(Option 2) Sweetened cereals, especially those marketed toward children, can be high in sugar and low in nutrients.
(Option 3) Raw carrot sticks are hard and pose a choking risk. Parents should serve carrots and other hard vegetables grated or cooked.
Educational objective:Food for young children should contain valuable nutrients and pose little risk of choking or foodborne infection. An example of a healthy snack for a toddler is a slice of cheese.

3.

Hypoglycemia (blood glucose <70 mg/dL [3.9 mmol/L]) presents an immediate danger to the client as life-threatening neurologic impairment (eg, lethargy, seizures, coma) can occur when the brain becomes glucose depleted. If a client with diabetes has symptoms of hypoglycemia (eg, sweating, irritability, tremor, tachycardia, hunger), the nurse should immediately assess the client, check capillary blood glucose, and provide a simple carbohydrate snack that can be digested rapidly (eg, juice, soft drink, candy) (Option 3).

3.

Supraventricular tachycardia (SVT) is the most common tachyarrhythmia of childhood and refers to a rapid heart rate of 200-300/min with no variation in rate during activity. It can lead to life-threatening congestive heart failure if left untreated. Symptoms in children may include palpitations, dizziness, or chest pain.
Once an ECG confirms SVT, the nurse should anticipate nonpharmacological interventions (ie, vagal maneuvers) to convert SVT to sinus rhythm if the client is stable. Placing an ice bag to the client's face and instructing the client to hold their breath while bearing down (Valsalva) are vagal maneuvers that can slow electrical conduction through the heart's atrioventricular node (Option 3). If these maneuvers are ineffective, or if the client becomes unstable, administration of adenosine or synchronized cardioversion is indicated.
(Option 2) The tripod position opens the airway and promotes airflow, particularly for clients with significant airway obstruction (eg, epiglottitis). The child with palpitations may assume any position of comfort.
(Option 4) Asynchronous defibrillation is indicated for the treatment of lethal cardiac arrhythmias (eg, ventricular fibrillation, pulseless ventricular tachycardia).
Educational objective:
Supraventricular tachycardia refers to a rapid heart rate of 200-300/min with no variation in rate during activity. The nurse should anticipate instructing the client to perform vagal maneuvers (eg, Valsalva) first if the client is stable.

3.

Parallel play is typical behavior of a toddler and involves activities focused on improving motor skills, imitative efforts, and the use of multiple senses. Toddlers play alongside, rather than with, other children. Having a variety of different balls for a group of children allows each child to be present with others and participate as they desire. Other examples of parallel play activities include pushing and pulling large toys; smearing paint; playing with dolls or toy cars; and digging in a sandbox.
(Option 1) Working in groups is an appropriate play activity for children in the preschooler period.
(Option 2) The classroom approach does not promote parallel play. Using large chalk to draw allows the child creative expression in an unstructured manner.
(Option 4) A toddler is challenged by the concept of team games, which requires attention to the group's effort.
Educational objective:
Toddlers engage in parallel play, which involves playing alongside, not with, other children. Activities such as playing with dolls or toy cars, pushing and pulling large toys, smearing paint, and digging in a sandbox encourage parallel play.

1,4

During infancy, gross motor development begins with head and neck control and progresses to skills such as turning over, bearing weight on the arms in a prone position, sitting with the head erect, standing, crawling (ie, abdomen touching floor), creeping (ie, abdomen lifted off floor), and walking. By age 7 months, infants should be able to bear their full weight while standing with caregiver support and sit with minimal support from their hands (ie, tripod sitting) (Options 1 and 4).
(Option 2) By age 7 months, infants can roll over, but the ability to move from a prone to a sitting position is not expected until age 10 months.
(Option 3) Some infants learn to pull themselves up into a standing position early, but this is not expected until age 9-10 months.
(Option 5) Walking while holding on to furniture is not expected until age 11 months.
Educational objective:Childhood development of gross motor skills usually follows a predictable pattern, with more complex skills being acquired as age increases. A 7-month-old client should be able to sit with minimal support and bear their full weight while standing with caregiver support.

1,3,4

Atopic dermatitis (AD), also known as eczema, is a chronic skin disorder characterized by pruritus, erythema, and dry skin. The exact cause of AD is unknown, although it may be associated with an impaired skin barrier and resulting immune response to invading allergens.
The primary goals of management are to alleviate pruritus and keep skin hydrated to reduce scratching. Scratching leads to formation of new lesions and potential secondary infections.
Parents should be instructed to give tepid baths using gentle soap; hot water and long bubble baths dry skin and should be avoided (Option 3)
Skin should be gently patted dry after bathing, followed by immediate application of an emollient (eg, Eucerin, Cetaphil) to seal in moisture (Option 1)
Nails should be trimmed short and kept filed to reduce scratches (Option 4)
Clothing should be soft (eg, cotton) and climate-appropriate to reduce perspiration, which can intensify pruritus. Long sleeves should be worn at night.
Avoid trigger factors such as heat and low humidity
(Option 2) Wool pajamas and other rough fabrics can cause itching and sweating. Soft cotton fabrics are a better choice.
(Option 5) Rubbing or vigorously drying can damage the skin and lead to exacerbations or infection. Skin should be patted dry gently.

1,2,4

Congenital hypothyroidism occurs when abnormal development of the thyroid gland causes complete or decreased secretion of thyroid hormone (TH). Untreated hypothyroidism can cause severe intellectual disability in infants if undetected. Screening occurs after birth for all infants in the United States and Canada to prevent disability and encourage early treatment (ie, levothyroxine).
TH plays an important role in growth, development, and regulation of many bodily functions (eg, heat production, muscle tone, skin function, cardiac function, metabolism). Clinical manifestations in affected infants reflect the pathophysiology of decreased TH and may include:
Difficulty awakening, lethargy, or hyporeflexia due to alterations in central nervous system function (Option 1)
Dry skin due to alterations in skin function (Option 2)
Hoarse cry caused by swelling of the vocal cords due to fluid retention (Option 4)
Constipation due to slowed metabolism
Bradycardia due to the effect of TH on cardiac function
(Options 3 and 5) Hyperthyroidism (Graves disease) is an autoimmune condition related to increased production of TH. Neonatal Graves disease is uncommon and usually occurs secondary to maternal hyperthyroidism. Tachycardia and increased bowel motility (frequent or loose stools) are features of hyperthyroidism and are related to an increase in metabolic processes.

2.

A ventriculoperitoneal shunt is an intervention for the treatment of hydrocephalus; the shunt drains excess cerebrospinal fluid (CSF) from the brain to the peritoneum, decreasing pressure on the brain. Following shunt placement or revision in a client, the nurse should avoid elevating the head of the bed to prevent rapid decreases in CSF and ventricular size, which can result in a subdural hematoma (Option 2). Appropriate postoperative interventions include assessing neurological status (eg, pupillary dilation), measuring for abdominal distension to detect postoperative complications (eg, ileus, peritonitis), and positioning the client onto the nonsurgical side to avoid pressure on the shunt (Options 1, 3, and 4).
Additional Information
Physiological Adaptation
NCSBN Client Need

2.

Developmental milestones (eg, motor, sensory, verbal, cognitive) are known patterns of growth and development noted in most children by a specific age. These milestones are used as a general assessment guide, although each child has a unique pattern of development. By age 3 months, the infant recognizes familiar items and faces (Option 2). Any 3-month-old who does not respond to familiar faces may have visual impairment or an underlying neurological disorder (eg, autism).
(Option 1) Stranger anxiety is part of the infant's normal social and cognitive development and usually begins around age 6 months.
(Option 3) Transferring objects from one hand to the other hand is a fine motor skill that usually develops between age 6 and 9 months. Failure to develop this skill may indicate neuromuscular or developmental delays.
(Option 4) A 3-month-old is usually not strong enough to roll from the back to the front. Infants should be able to turn from the abdomen to the back at around age 4 months and then from the back to the abdomen by age 6 months. Failure to roll over by age 6 months may indicate slower-than-normal neck, leg, back, and arm muscle development and should be investigated.

1.

Tinea capitis (ringworm of the scalp) is a contagious fungal infection that lives on the surface of the scalp, resulting in scaly, pruritic, erythematous, circular patches with hair loss. The infection is transmitted via direct contact with infected persons, pets, or objects (eg, hairbrushes, bedding, towels, hats).
Treatment may include 1% selenium sulfide shampoo applied several times each week in combination with an antifungal medication (eg, griseofulvin oral suspension) that the client must take for several weeks to months. Keratin-producing cells absorb griseofulvin, causing resistance to the fungus; because the fungus requires keratin (protein in hair and skin cells) to live and grow, it is not able to reproduce. To ensure that infected keratin is shed completely, treatment with griseofulvin should not be discontinued early, even if symptoms (eg, itching, scaling) decrease (Option 1).
(Option 2) The client will best absorb griseofulvin (ie, suspension, microsized tablets) when taken after/with high-fat foods (eg, ice cream).
(Option 3) Photosensitivity is a common side effect of griseofulvin treatment, and the client should avoid prolonged exposure to the sun and use sunscreen.
(Option 4) The client should apply medicated shampoo (eg, 1% selenium sulfide) to the scalp a few times each week.

1,2,3,4

Tetralogy of Fallot is a complex heart defect that results in decreased pulmonary blood flow, mixing of oxygenated and unoxygenated blood, and inadequate blood flow into the left side of the heart. Hypercyanotic episodes (ie, "tet" spell) occur when unoxygenated blood enters the systemic circulation, resulting in cyanosis and hypoxemia. Tet spells usually occur during stressful or painful procedures; on waking; and with hunger, crying, and feeding.
Home interventions to reduce the incidence of tet spells include:
Providing a calm environment, particularly on waking (Option 3)
Soothing and quieting the infant when crying or distressed
Offering a pacifier (Option 2)
Swaddling or holding the infant during procedures or times of stress (Option 4)
Providing frequent smaller feedings to reduce frustration due to hunger and limit sucking fatigue (Option 1)

3.
Fetal alcohol syndrome (FAS) is a leading cause of intellectual disability and developmental delay in the United States. Diagnosis includes history of prenatal exposure to any amount of alcohol, growth deficiency, neurological symptoms (eg, microcephaly), or specific facial characteristics (indistinct philtrum, thin upper lip, epicanthal folds, flat midface, and short palpebral fissures). Asking about alcohol use during pregnancy can identify newborns and infants who are at risk for FAS. Family support, early intervention, and prevention for subsequent pregnancies are important for families with an infant with this diagnosis.

2,4,5

Pediatric clients are at increased risk for impaired psychosocial integrity during stressful experiences (eg, hospitalization, surgical procedures, medical treatment) and require developmentally appropriate care based on their age to assist with managing stress. Unaddressed or ineffectively managed developmental needs may lead to or worsen the client's anxiety, disobedient behavior, and/or social withdrawal.
Developmentally appropriate nursing care for an adolescent client includes:
Encouraging interaction with peers (eg, hospital visits, internet communication), which supports the developmental need for social connection and support and reduces stress and anxiety (Option 2)
Involving the client in care planning to address the developmental needs for control and independence (Option 4)
Assisting the client to discuss emotions or fears related to treatment (eg, changes in body image, disability, possibility of death) to improve coping, support the developmental need for understanding, and decrease anxiety (Option 5)
(Option 1) Strict scheduling by the nurse reduces the adolescent's perception of control and independence, which may increase stress. Adolescents should be allowed to determine their daily schedule when possible.
(Option 3) Loss of privacy (eg, forced parental presence) can increase anxiety in the adolescent client. Adolescents should be asked if they want parents present for procedures and what level of parental involvement they prefer.

4.

Bacterial conjunctivitis (pink eye) is highly contagious. The hands must be washed properly before and after instilling eye drops and after cleaning away eye drainage or crusting; this is the single best method to prevent the spread of infection to the other eye, the parents, other family members, or anyone else. Therefore, parents should ensure that affected children wash their hands frequently and discourage them from rubbing their eyes. Tissues used to clean the eye should be discarded. The child's washcloths and towels should be kept separate. Many schools and day care centers require that children be kept at home during the time when they are most contagious.
(Option 1) These tissues should be thrown away immediately, but this step is not as critical as frequent and appropriate hand washing. Gentle wiping should be done from the inner canthus downward and outward, away from the other eye.
(Option 2) Eye drops are easiest instilled in the eye when the child is lying down or sitting with the head tilted back.
(Option 3) Warm, moist compresses help remove the crusting present on the eyelid and in the lashes. However, the compress should not be left for long periods as it may promote bacterial growth.
Educational objective:
Frequent and proper hand washing is necessary to prevent the spread of bacterial conjunctivitis to the other eye or to other individuals. Tissues used to wipe eye medication should be discarded, towels and washcloths should be kept separate, and the child should be discouraged from rubbing the affected eye.

1,2,3,5

Acute otitis media is caused by a blocked eustachian tube, which leads to a buildup of purulent fluid and inflammation in the middle ear. Manifestations include a red and bulging tympanic membrane, inner ear pressure (which can rupture the tympanic membrane if not treated), pain, and fever (Option 3). Clients also may have rhinorrhea, nausea, or vomiting.
When assessing a toddler (age 1-3), the nurse should use the otoscope last because it often distresses clients in this age group, especially when pain is present (Option 5). The nurse should insert the speculum only as far as the outer cartilaginous part of the external auditory canal. Advancing the speculum into the bony interior part causes pain and could damage the tympanic membrane (Option 1).
The nurse should educate the parents on how to avoid future occurrences of acute otitis media, which includes recommending influenza and pneumococcal conjugate vaccinations (Option 2).
(Option 4) Children age <3 have a more horizontal external auditory canal than older children and adults. The nurse should pull the pinna down and back in infants and toddlers.

2,3,4

2,3,4

Myopia, or nearsightedness, is reduced visual acuity when viewing objects at a distance. Myopia occurs when the eye structure causes images to focus before they arrive at the retina. Near vision is usually intact, and many clients with myopia report needing to hold objects near their face or sit near objects to see clearly (Options 2 and 4).
Myopia in pediatric clients may first be discovered by the school nurse during routine visual acuity testing. Children often report headaches, dizziness, and the need to squint the eyes to see clearly (Option 3). School performance may be affected because of impaired ability to see class presentations.
(Option 1) Reduced visual acuity when viewing objects up close with intact distance vision is associated with hyperopia. Clients with hyperopia may report having to hold materials far away to read or sit at a distance to have clear vision.
(Option 5) Impaired ability to perceive and differentiate colors (eg, red and green, blue and yellow) is associated with color vision deficiency, a congenital impairment of cone function in the retina. Children with color deficiency may have difficulty selecting matching clothing or appropriate colors for school assignments.

1,2,4,5

Dental caries (ie, cavities) form when bacteria (eg, Streptococcus mutans) digest carbohydrates in the mouth, producing acids that break down tooth enamel and cause mineral loss. Oral hygiene and dietary intake are significant factors contributing to the development of caries.
Clients should increase intake of cariostatic foods, which have an inhibitory effect on the progression of dental caries (eg, dairy products, whole grains, fruits and vegetables, sugar-free gum containing xylitol) (Options 1 and 3). Cariogenic foods increase the risk for cavities and should be avoided. These include refined, simple sugars; sweet, sticky foods such as dried fruit (eg, raisins) and candy; and sugary beverages (eg, colas and other carbonated beverages, fruit drinks/juices) (Option 4).
Additional practices to prevent dental caries include:
Brushing after meals
Flossing at least twice a day
Rinsing the mouth with water after meals or snacks (Option 5)
Drinking tap water rather than bottled water (most tap water sources add fluoride to promote dental health, whereas most bottled water does not contain fluoride)
Finishing meals with a high-protein food

2

Aspiration of a foreign body occurs most often in the toddler age group. Swallowing of objects such as buttons, small parts of toys, or food particles can be life-threatening and result in airway obstruction due to the small diameter of the airway. Manifestations include choking, gagging, cyanosis, and inability to speak when the object is lodged in the larynx.
(Option 1) Although the client has mild retractions with wheezing and a harsh cough, a patent airway is present. This client may be experiencing expected manifestations of asthma, but this is not a life-threatening condition.
(Option 3) The client's manifestations are consistent with laryngotracheobronchitis (croup), which is generally caused by a parainfluenza virus. There is no respiratory challenge indicated by a 94% oxygen saturation on room air, and this not an emergency situation.
(Option 4) Otitis media is an infection or inflammation of the middle ear with the highest incidence at age 6-36 months; it occurs during the winter months. Acute onset presents with ear pain, irritability, fever, and pulling on the affected ear. Fluid can accumulate in the middle ear and create an environment for bacterial growth. R

"I will always travel with two tracheostomy tubes, one of the same size and one a size smaller."

n the event of an accidental decannulation or another urgent need to change a tracheostomy tube, the most important action is to quickly replace the tube as it is the client's only means to ventilate. Clients should always carry two spare tracheostomy tubes, one the same size and one a size smaller. If the tube is not easily replaced or is meeting resistance, the smaller tube should be used.
(Option 2) Changing a tracheostomy tube is a high-risk procedure that should be done only if respiratory distress is noted and other interventions (eg, suctioning) have failed. Mucus plugs (ie, thickening and buildup of mucus due to dehydration) are one of the most common causes of respiratory distress.
(Option 3) A tracheostomy should be suctioned frequently to maintain airway patency. However, deep suctioning should be reserved for clients in respiratory distress due to the risk of injury. Tracheostomy tubes should be suctioned to the specified depth using a measurement marked on the tube, to provide safe, effective suctioning.
(Option 4) Humidification is crucial for clients with a tracheostomy as the upper airway, which provides natural humidity for inhaled air, is bypassed. Humidification helps keep secretions thin and reduces formation of mucus plugs. The humidifier should not be removed if the child develops more secretions as this is the intended effect.

1,4,5

In pyloric stenosis, there is gradual hypertrophy of the pylorus until symptom onset at age 3-5 weeks. It is common in first-born boys and the etiology is unclear. Pyloric stenosis presents with postprandial projectile vomiting (ejected up to 3 feet) followed by hunger (eg, "hungry vomiter"). This is clearly distinguished from the "wet burps" infants have due to a weak lower esophageal sphincter. The emesis is nonbilious as the obstruction is proximal to the bile duct. Infants have poor weight gain and are often dehydrated (eg, sunken fontanelle, decreased skin turgor, delayed capillary refill).
The amount of milk consumed (particularly with bottle feedings) along with the mother's technique (mainly adequate burping) should be assessed to ensure there is no excessive air swallowing or overfeeding as an etiology.
(Option 2) At times, formula intolerance or allergy is suspected initially when the infant first starts vomiting. However, celiac disease or gluten enteropathy is related to intolerance to gluten, a protein in barley, rye, oats, and wheat (BROW). Clients with celiac disease cannot eat these foods. A 3-week-old infant would only consume milk; this history would not be a factor at this time.
(Option 3) Physiological hyperbilirubinemia occurs due to the newborn's immature liver that is unable to metabolize hemoglobin byproducts. This is a "normal" finding that is unrelated to pyloric stenosis.

2,4,5

The first step in effective communication is to establish trust between the nurse, the child, and the parent. By actively including a school-age child in the health history interview, the nurse shows respect to that child and obtains valuable insight into their health status. Allowing the child to describe how they feel or where they hurt gives the nurse a better understanding of the issue. Using clear, age-appropriate explanations will enhance communication with the child while maintaining the participation of the caregiver. Open-ended questions allow the child or caregiver to elaborate on the question, giving the nurse detailed information to guide further assessment. Non-verbal cues also play an important role in communication (eg, staying at eye level with the child to ease any potential nervousness).
(Option 1) Closed-ended questions usually result in a "yes" or "no" answer. There are times in an interview that closed-ended questions are appropriate to gather specific information, but broader, more descriptive answers are generally desired when conducting a health history interview.
(Option 3) The nurse should interview a school-age child together with their caregiver unless there is an indication of child abuse. The child may feel more at ease, and a more complete assessment may be obtained through answers from both the child and caregiver.

Ask the child to count to 10 during injection

Children are often fearful of injections, exhibiting unpredictable and/or uncooperative behavior. The nurse should explain the procedure to the child using simple, age-appropriate language (eg, "medicine under the skin") to reduce anxiety. According to Piaget's cognitive developmental stages, school-age children develop concrete thought and may fear a loss of control. To improve the child's sense of control, the nurse should offer a specific, task-based coping technique (eg, counting aloud, deep breathing) (Option 1).
(Option 2) A caregiver should hold or embrace a child during the injection process, with the child on the caregiver's lap or standing in front of a seated caregiver. Tightly holding the child's arms is extreme and may distress the child and caregiver.
(Option 3) The child should be told the truth about pain that accompanies an injection. The nurse should use appropriate language, such as "the skin may hurt for a minute," and emphasize that the pain is quick and transient.
(Option 4) Keeping objects that may alarm the child out of view is an appropriate intervention for a toddler but not for a school-age child. Hiding a proc

1,3,5

Cystic fibrosis (CF) is an inherited disorder (autosomal recessive) characterized by thickened secretions due to impaired chloride and sodium channel regulation that causes exocrine gland dysfunction. Management of a client with CF should primarily address potential complications related to the following body systems:
Pulmonary: Alterations in respiratory secretions (ie, thick sputum) make it difficult to clear the airway and can result in frequent respiratory infections and sinusitis (Option 3). Frequent infections and inflammation damage lung tissue and may lead to chronic hypoxemia (Option 1).
Gastrointestinal: Thickened secretions obstruct the release of pancreatic enzymes, causing malabsorption of fat-soluble vitamins (eg, A, E, D, K) and other nutritional deficiencies (Option 5). High-protein, high-calorie foods and supplemental enzymes with meals are necessary.
Reproductive: Thickened reproductive secretions (eg, seminal fluid, cervical mucus) or the absence of the vas deferens in men contributes to CF-related infertility.
(Option 2) Diabetes mellitus, not diabetes insipidus, is a potential complication for clients with CF due to pathologic pancreatic changes (eg, fibrosis).
(Option 4) Due to impaired gastrointestinal absorption, weight loss and failure to thrive are more common and a greater concern than obesity.

position child in tripod poisiton on parents lap

This is a classic description of epiglottitis (supraglottitis). It is an inflammation by bacteria of the tissues surrounding the epiglottis, a long, narrow structure that closes off the glottis during swallowing. Edema can develop rapidly (as quickly as a few minutes) and obstruct the airway by occluding the trachea. There has been a 10-fold decrease in its incidence due to the widespread use of the Hib (Haemophilus influenzae type B) vaccine.
The classic symptoms include a high-grade fever with toxic appearance, severe sore throat, and the 4 Ds—dysphonia (muffled voice), dysphagia (difficulty swallowing), drooling, and distressed respiratory effort. The tripod position opens the airway and helps air flow. The child should be allowed to assume a position of comfort (usually sitting rather than lying down). The priority nursing response is to protect the airway.
(Option 1) No invasive procedure should be done that could cause the child to cry until the airway is secure. Knowing the temperature is not a priority.
(Options 2 and 3) When drooling is present, the airway becomes the primary concern. No visual inspection, invasive procedure, or anxiety-provoking activity should be done until the airway is secure due to the risk of laryngospasm and respiratory arrest.

1,3,4

Hospitalization for toddlers (ie, 12-36 months) is particularly difficult due to separation anxiety and a limited ability to cope with stress. Toddlers thrive on home rituals and routines, which bring stability and reassurance. Hospitalization can severely disrupt these routines, triggering frustration and temper tantrums. Caregivers should maintain as many home routines as possible (eg, sleeping, eating) to help the child cope with unfamiliar hospital surroundings and procedures (Option 1). Parents should also stay with the child as much as possible, including overnight (ie, rooming-in), to provide consistency and alleviate separation anxiety (Option 3).
Play, an important part of a child's emotional and social well-being, is an effective coping mechanism for children of all ages to deal with the stress of being away from home. The playroom is a safe place for children to act out their fears and anxieties related to illness and hospitalization (Option 4).
(Option 2) A visit from friends is not likely to provide much comfort to a toddler and may actually cause additional stress. Adolescents, who are driven by peer interaction, would be more likely to benefit from this strategy.
(Option 5) Preschool-aged children (3-5 years) have egocentric and magical thinking, which may cause them to think that their illness is due to something they have done or thought. Toddlers do not think this way.

1,3,5

Lead poisoning occurs from repeated lead exposure, either via ingestion of lead-based paints (eg, walls, toys), glazes (eg, pottery) or water from lead pipes, or by inhalation of contaminated dust or soil found around older homes. Elevated blood lead levels (BLLs) impair neural, blood, and renal development. A BLL screening is recommended between ages 1 and 2, or up to age 6 if the child was not previously screened. Clients with elevated BLLs (≥5 mcg/dL [0.24 µmol/L]) require follow-up blood work to ensure that levels decrease (Option 5). Chelation therapy may be required if levels remain elevated.
The priority intervention for clients with elevated BLLs is preventing continued exposure. The home environment should be assessed for lead sources (Option 1). Pediatric and pregnant clients should not live in homes being renovated until the work is complete. Handwashing, especially before eating, is important to remove lead residue (Option 3).
(Option 2) Vacuuming spreads lead dust in the air, which increases inhalation exposure. Hard surfaces should be wet-dusted or mopped at least weekly.
(Option 4) Hot tap water dissolves lead from older pipes; therefore, cold water should be used for consumption if lead plumbing is present. Taps should be flushed for several minutes to clear out contaminated water before use.

2,3,5

Celiac disease (celiac sprue) is an autoimmune disorder in which the body is unable to process gluten, a protein found in most grains. Gluten consumption will damage the villi of the small intestine; this results in malabsorption of fats (steatorrhea, foul-smelling stools) and other nutrients, which can lead to malnutrition and failure to thrive. The child will need to adhere to a gluten-free diet for life. Rice, corn, and potatoes are gluten free and are allowed in the diet (Options 2, 3, and 5).
A child with celiac disease cannot eat barley, rye, oats, or wheat (mnemonic - BROW).
(Option 1) A child with celiac disease cannot consume barley or French bread as both contain gluten.
(Option 4) Peanut butter and jelly on rice cakes are permitted but not the oatmeal cookie.