Pediatrics- Infection/ Neuro

The nurse is caring for a hospitalized infant at risk for developing increased intracranial pressure. Which assessment finding(s) would the nurse communicate to the health care provider for further intervention? Select all that apply.

• increased head circumference

• pulse rate of 60 beats/min and regular

• vomiting

• blood pressure decreased from baseline

• parent states, "My infant does not act right"

Hydrocephalus is suspected in a 4-month-old infant. Which would the nurse expect to assess?

• sunken fontanels (fontanelles)

• diminished reflexes

• lower extremity spasticity

• skull symmetry

The nurse is reinforcing teaching with the caregivers of a child being discharged from the urgent care setting following a mild head injury that occurred in a roller skating accident. What should the caregivers be instructed to do? Select all that apply.

• Wake the child every 1 to 2 hours to check level of consciousness.

• Observe and report any vomiting that occurs within 6 hours.

• Observe for and report to provider any double or blurred vision.

• Check the pupil reaction to light every 15 minutes for 12 hours.

• Administer acetaminophen for headache.

The nurse is collecting data on an 18-month-old child admitted with a diagnosis of possible seizures. When interviewing the caregivers, which questions would be most important for the nurse to ask?

• “Is your child up to date on his immunizations?”

• “Has anyone in your family been sick recently”

• “What type of activities was your child doing today?”

• “Have you checked your child's temperature?”

 The nurse is preparing to provide education on the prevention of infection to parents of children. Which intervention(s) will the nurse include? Select all that apply.

• proper handwashing

• proper handling and preparation of foods

• vaccination administration

• limiting exposure to sick persons

• judicious antibiotic use

A child is diagnosed with varicella. The parent states the child is "just miserable" and wants to know how best to make the child feel more comfortable. Which instruction(s) would the nurse give this parent? Select all that apply.

• "You can administer acetaminophen to help with fever and pain."

• "Keep only light clothing on your child."

• "Keep your child's fingernails short so scratching will not disturb vesicles."

• "Administer prescribed topical steroid ointment to reduce inflammation."

• "Place the child in a soothing tepid bath."

The nurse is assessing a 8-month-old infant who has symptoms of poor feeding, a poor gag reflex, listlessness and a weak cry. What is the most important question the nurse should ask the parent about these symptoms?

• "Have you given your infant any honey?"

• "When did these symptoms begin?"

• "Has your infant had any unpasteurized milk to drink?"

• "What is the source of your family's water supply?"

A child comes to the emergency room appearing very ill, reports leg pain, and refuses to bear weight on the leg. The nurse suspects the child may have septic arthritis. When taking the child's history, which information is significant?

• recent respiratory infection

• fall on the affected joint

• camping trip in the woods

• diagnosis of rheumatoid arthritis

The nurse is caring for a child with an infectious disorder and the following vital signs: temperature 103.1°F (39.5°C), pulse 106 bpm, respiratory rate 24 breath/minute, and oxygen saturation 93% on room air. The child reports pain 4/10 using the Wong-Baker FACES scale. Which nursing intervention is priority?

• Administer acetaminophen orally for fever.

• Provide ibuprofen orally as needed for pain.

• Apply oxygen via nasal cannula at 2 L/min.

• Don appropriate personal protective equipment (PPE).

A child weighs 18 pounds. The nurse is making sure the intravenous (IV) infusion is flowing at the correct rate. After determining fluid requirements for this child for a 24-hour period, the nurse should be sure that the IV is infusing at how many milliliters per hour?