Ch.47- Child with a Hematologic Alteration

What is the best response to a parent who asks the nurse whether her 5-month-old infant can have cow’s milk?

• “You need to wait until she is 8 months old and eating solids well.”

• “Yes, if you think that she will eat enough meat to get the iron she needs.”

• “Infants younger than 12 months need iron-rich formula to get the iron they

  need.”

• “Try it and see how she tolerates it.”

Answer explanation

Infants younger than 12 months need iron-fortified formula or breast milk. Infants who drink cow’s milk do not get adequate iron

and are at risk for iron-deficiency anemia. A 5-month-old infant cannot get adequate iron without drinking an iron-fortified formula

or taking an iron supplement. Counseling a parent to give a 5-month-old infant cow’s milk is inappropriate.

An assessment of a 7-month-old infant with a hemoglobin level of 6.5 mg/dL is likely to reveal an infant who is

• lethargic, pale, and irritable.

• thin, energetic, and sleeps little.

• anorexic, vomiting, and has watery stools.

• flushed, fussy, and tired.

Answer explanation

Pallor, lethargy, irritability, and tachycardia are clinical manifestations of iron-deficiency anemia. A child with a hemoglobin level

of 6.5 mg/dL has anemia. Typically these children will not be thin, energetic, anorexic, have GI complaints, or flushed. They may

be tired, fussy, and sleep a lot.

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A nurse is evaluating parents’ knowledge about caring for their child who has iron-deficiency anemia. Which action shows the

parents need further education?

• Decreasing the infant’s daily milk intake to 24 oz or less

• Giving oral iron supplements between meals with orange juice

• Including apricots, dark-green leafy vegetables, and egg yolk in the infant’s diet

• Allowing the infant to drink the iron supplement from a small medicine cup

Answer explanation

Iron supplements should be administered through a straw or by a medicine dropper placed at the back of the mouth because iron

temporarily stains the teeth. A daily milk intake in toddlers of less than 24 oz will encourage the consumption of iron-rich solid

foods. Because food interferes with the absorption of iron, iron supplements are taken between meals. Administering this

medication with foods rich in vitamin C facilitates absorption of iron. Apricots, dark-green leafy vegetables, and egg yolks are rich

sources of iron. Other iron-rich foods include liver, dried beans, Cream of Wheat, iron-fortified cereal, and prunes.

Which of the following is an accurate description of anemia?

• Increased blood viscosity

• Depressed hematopoietic system

• Presence of abnormal hemoglobin

• Decreased oxygen-carrying capacity of blood

Answer explanation

Anemia is a condition in which the number of red blood cells or hemoglobin concentration is reduced below the normal values for

age. This results in a decreased oxygen-carrying capacity of blood. Increased blood viscosity is usually a function of too many cells

or of dehydration, not of anemia. A depressed hematopoietic system or abnormal hemoglobin can contribute to anemia, but the

definition is dependent on the deceased oxygen-carrying capacity of the blood. A depressed hematopoietic system or abnormal

hemoglobin can contribute to anemia, but the definition is dependent on the decreased oxygen-carrying capacity of the blood.

What is true about the genetic transmission of sickle cell disease?

• Both parents must carry the sickle cell trait.

• Both parents must have sickle cell disease.

• One parent must have the sickle cell trait.

• Sickle cell disease has no known pattern of inheritance.

Answer explanation

In this scenario, there is a 50% risk of having a child with sickle cell disease. The sickle cell trait, not the disease itself, must be

present in the parents for the child to have the disease. An autosomal recessive pattern of inheritance means that both parents must

be carriers of the sickle cell trait. Sickle cell disease is known to have an autosomal recessive pattern of inheritance.

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A condition in which the normal adult hemoglobin is partly or completely replaced by abnormal hemoglobin is known as

• aplastic anemia.

• sickle cell anemia.

• thalassemia major.

• iron-deficiency anemia.

Answer explanation

Sickle cell anemia is one of a group of diseases collectively called hemoglobinopathies, in which normal adult hemoglobin is

replaced by an abnormal hemoglobin. Aplastic anemia is a lack of cellular elements being produced. Hemophilia refers to a group

of bleeding disorders in which there is deficiency of one of the factors necessary for coagulation. Iron-deficiency anemia affects

size and depth of color and does not involve an abnormal hemoglobin.

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What are the nursing priorities for a child with sickle cell disease in vaso-occlusive crisis?

• Administration of antibiotics and nebulizer treatments

• Hydration and pain management

• Blood transfusions and an increased calorie diet

• School work and diversion

Answer explanation

Hydration and pain management decrease the cells’ oxygen demands and prevent sickling. Antibiotics may be given

prophylactically. Oxygen therapy rather than nebulizer treatments is used to prevent further sickling. Although blood transfusions

and increased calories may be indicated, they are not primary considerations for vaso-occlusive crisis. School work and diversion

are not major considerations when the child is in a vaso-occlusive crisis.

What describes the pathologic changes of sickle cell anemia?

• Sickle-shaped cells carry excess oxygen.

• Sickle-shaped cells decrease blood viscosity.

• Increased red blood cell destruction occurs.

• Decreased red blood cell destruction occurs.

Answer explanation

The clinical features of sickle cell anemia are primarily the result of increased red blood cell destruction and obstruction caused by

the sickle-shaped red blood cells. Sickled red cells have decreased oxygen-carrying capacity and transform into the sickle shape in

conditions of low oxygen tension. When the sickle cells change shape, they increase the viscosity in the area where they are

involved in the microcirculation. Increased red blood cell destruction occurs.

Which clinical manifestation should the nurse expect when a child with sickle cell anemia experiences an acute vaso-occlusive

crisis?

• Circulatory collapse

• Cardiomegaly, systolic murmurs

• Hepatomegaly, intrahepatic cholestasis

• Painful swelling of hands and feet, painful joints

Answer explanation

A vaso-occlusive crisis is characterized by severe pain in the area of involvement. If it is in the extremities, painful swelling of the

hands and feet is seen; if in the abdomen, severe pain resembles that of acute surgical abdomen; and if in the head, stroke and visual

disturbances occur. Circulatory collapse results from sequestration crises. Cardiomegaly, systolic murmurs, hepatomegaly, and

intrahepatic cholestasis result from chronic vaso-occlusive phenomena.

What should the discharge plan for a school-age child with sickle cell disease include?

• Restricting the child’s participation in outside activities

• Administering aspirin for pain or fever

• Limiting the child’s interaction with peers

• Administering penicillin daily as ordered

Answer explanation

Children with sickle cell disease are at high risk for pneumococcal infections and should receive long-term penicillin therapy and

preventive immunizations. Sickle cell disease does not prohibit the child from outdoor play. Active and passive exercises help

promote circulation. Aspirin use should be avoided. Acetaminophen or ibuprofen should be administered for fever or pain. The

child needs to interact with peers to meet his or her developmental needs.

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