Uworld PEDDIATRY

PEDDIATRIA A A A The nurse planning teaching for the parents of a child newly diagnosed with hemophilia will include information about which long-term complication? 1. Heart valve injury [33%] 2. Intellectual disability [3%] 3. Joint destruction [54%] 4. Recurrent pneumonia [8%] Explanation: Hemophilia is a bleeding disorder caused by a deficiency in coagulation proteins. Clients with classic hemophilia, or hemophilia A, lack factor VIII. Clients with hemophilia B (Christmas disease) lack factor IX. When injured, clients with hemophilia should be monitored closely for external as well as internal bleeding. The most frequent sites of bleeding are the joints (80%), especially the knee. Hemarthrosis can occur with minimal or no trauma, with episodes beginning during toddlerhood when the child is active and ambulatory. Over time, chronic swelling and deformity can occur. (Option 1) Heart valve injury is common with rheumatic heart disease not hemophilia. (Option 2) Intellectual disability in children is commonly seen with fetal alcohol syndrome, Down syndrome, hypothyroidism, and lead poisoning. In rare cases, hemophilia can cause life-threatening intracranial bleeding. However, isolated intellectual disability is not seen. (Option 4) Recurrent pneumonia is commonly seen with cystic fibrosis not hemophilia. Educational objective: Clients with hemophilia are at risk for permanent joint destruction due to frequent bleeds into the joint spaces. Assisting clients with decreasing the incidence of bleeding episodes and prompt treatment when bleeding occurs can help minimize joint destruction. A A A The clinic nurse supervises a graduate nurse who is teaching the parents of a 2-year-old with acute diarrhea about home management. The nurse would need to intervene when the graduate nurse provides which instruction? 1. "Do not administer antidiarrheal medications to your child." [26%] 2. "Follow the bananas, rice, applesauce, and toast diet for the next few days." [32%] 3. "Record the number of wet diapers and return to the clinic if you notice a decrease." [28%] 4. "Use a skin barrier cream such as zinc oxide in the diaper area until diarrhea subsides." [12%] Explanation: 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). A A A The mother of a 6-year-old child with cystic fibrosis (CF) has received instruction on the use of pancreatic enzymes. Which statement made by the mother indicates a need for further teaching? 1. "I need to monitor the total amount of this medication that I give to my child every day." [6%] 2. "I should give this medication with or just before my child has a meal or snack." [10%] 3. "It is okay for my child to chew this medication." [61%] 4. "It is okay to open the capsule and sprinkle the medicine on a tablespoon of applesauce." [21%] Explanation: In CF, unusually thick mucus obstructs the pancreatic ducts, preventing pancreatic enzymes (amylase, trypsin, and lipase) from reaching the small intestine. The result is malabsorption of carbohydrates, fats, and proteins; the inability to absorb fatsoluble vitamins (A, D, E, and K) is of particular concern. Gastrointestinal signs and symptoms of CF include flatulence, abdominal cramping, ongoing diarrhea, and/or steatorrhea. Nutritional therapy includes the administration pancreatic enzyme supplements with or just before every meal or snack (Option 2). These enzymes are enteric-coated beads designed to dissolve only in an alkaline environment similar to that of the small intestine. They must not be mixed with a substance that would cause them to dissolve prior to reaching the jejunum. Capsule contents may be sprinkled on applesauce, yogurt, or acidic, soft, room-temperature foods with pH <4.5. Capsules should be swallowed whole and not crushed or chewed; chewing the capsules could cause irritation of the oral mucosa. Excessive intake of pancreatic enzymes can result in fibrosing colonopathy (Option 1). (Option 4) This is a true statement; some children have difficulty taking a whole capsule. Capsule contents can be sprinkled in acidic substances such as applesauce. Capsules should not be taken with milk as they can cause it to curdle. Educational objective: Pancreatic enzyme supplements are used to aid the absorption of carbohydrates, fats, and proteins in a child with CF. They are taken with or just before every meal (not as needed); should be swallowed whole or sprinkled on an acidic food; and should not be crushed or chewed. They should not be taken with milk. Excessive intake could result in fibrosing colonopathy. A A A An 8-month-old infant is scheduled for a balloon angioplasty of a congenital pulmonic stenosis in the cardiac catheterization laboratory. Which finding should the nurse report to the health care provider (HCP) that could possibly delay the procedure? 1. Auscultation of a loud heart murmur [8%] 2. Infant has been NPO for 4 hours [9%] 3. Infant has polycythemia [52%] 4. Infant has severe diaper rash [29%] Explanation: The presence of severe diaper rash should be reported to the HCP. This could potentially delay the procedure if the rash is in the groin area where access is planned for arterial cannulation. Candida, yeast, or bacteria may be present on the rash and could be introduced into the bloodstream with the arterial stick. (Option 1) A loud heart murmur can be an expected finding in a child with pulmonic stenosis. (Option 2) Children are allowed nothing by mouth for 4-6 hours or longer before the procedure. Younger children and infants may have a shorter period of NPO status and should be feed right up to the time recommended by the HCP. (Option 3) Infants and children with polycythemia may need IV fluids to prevent dehydration and hypoglycemia. Polycythemia will not cause a delay in the procedure. Educational objective: The nurse should report the presence of severe diaper rash to the HCP in an infant who has an interventional catheterization procedure planned. If the rash is near the groin area, the procedure may be delayed due to possible contamination at the insertion site. A A A When monitoring an infant with a left-to-right-sided heart shunt, which findings would the nurse expect during the physical assessment? Select all that apply. 1. Clubbing of fingertips 2. Cyanosis when crying 3. Diaphoresis during feedings 4. Heart murmur 5. Poor weight gain Explanation: Congenital heart defects that cause blood to shunt from the higher pressure left side of the heart to the lower pressure right side (eg, patent ductus arteriosus, atrial septal defect, ventricular septal defect) increase pulmonary blood flow. Left-to-right shunting results in pulmonary congestion, causing increased work of breathing and decreased lung compliance. Compensatory mechanisms (eg, tachycardia, diaphoresis) result from sympathetic stimulation. Clinical manifestations of acyanotic defects may include: Tachypnea Tachycardia, even at rest Diaphoresis during feeding or exertion (Option 3) Heart murmur or extra heart sounds (Option 4) Signs of congestive heart failure Increased metabolic rate with poor weight gain (Option 5) (Option 1) Clubbing of the fingertips is associated with chronic hypoxia caused by decreased pulmonary circulation as occurs with right-to-left heart defects. (Option 2) Right-to-left congenital heart defects (eg, cyanotic defects) impede pulmonary blood flow (eg, tetralogy of Fallot, transposition of the great vessels) and cause cyanosis, which is evident shortly after birth and during periods of physical exertion. Educational objective: Left-to-right cardiac shunts (eg, patent ductus arteriosus, atrial septal defect, ventricular septal defect) result in excess blood flow to the lungs. Manifestations include heart murmur, poor weight gain, diaphoresis with exertion, and signs of heart failure. A A A A 12-month-old with Kawasaki disease received IV immunoglobulin (IVIG) 2 months ago. The child is in the clinic for follow-up and scheduled immunizations. Which vaccine should be delayed? Select all that apply. 1. Haemophilus influenzae type b (Hib) 2. Hepatitis B (Hep B) 3. Measles, mumps, rubella (MMR) 4. Pneumococcal conjugate (PCV) 5. Varicella Explanation: Kawasaki disease is treated with aspirin and IVIG to prevent coronary artery aneurysms. Antibodies acquired from the IVIG therapy will remain in the body for up to 11 months and may interfere with the desired immune response to live vaccines. Therefore, live vaccines (eg, varicella, MMR) should be delayed for 11 months after IVIG administration as this therapy may decrease the child's ability to produce the appropriate amount of antibodies to provide lifelong immunity (Options 3 and 5). (Option 1) Hib vaccine is not a live vaccine, and final dose (fourth) is recommended between age 12-15 months, according to the Centers for Disease Control and Prevention (CDC). (Option 2) Hep B vaccine is not a live vaccine; the CDC recommends that the final dose (third) be administered between age 6-18 months. (Option 4) PCV is also not a live vaccine, and the final dose (fourth) is recommended between age 12-15 months, according to the CDC. Educational objective: Live vaccines (eg, varicella, MMR) should be delayed for up to 11 months after IVIG administration as IVIG therapy may decrease the child's ability to produce the appropriate amount of antibodies to provide lifelong immunity A A A Several clients check into the emergency department at the same time. Which client should be seen first? 1. 6-year-old with blood-streaked stools [19%] 2. 10-year-old with epilepsy who had a short seizure at home and is asleep [26%] 3. 15-year-old with dental trauma and tooth avulsion [25%] 4. Newborn who spits up after every feed [28%] Explanation: At age 15, clients should have their permanent teeth. If tooth avulsion occurs, there is limited time (≤1 hour, longer if placed in cold milk) until death of the tooth. This is a time-sensitive condition and the client should be seen first to avoid loss of a permanent tooth. (Option 1) This client needs to be assessed for the cause of blood in the stool. However, this is not considered a medical emergency as long as only streaks and not large volumes of blood are present. Large volumes can represent a gastrointestinal bleed, which is an emergency. (Option 2) A client who is not currently seizing is considered stable. It is normal for a child to be sleepy following a seizure. The child should be assessed to ensure that air exchange is appropriate. (Option 4) It is normal for newborns to spit up after every feed as they are still adapting to eating. The client should be assessed for hydration status and appropriate weight gain. Educational objective: In tooth avulsion, there is a limited amount of time (≤1 hour) before death of the affected tooth. These clients need prompt treatment to save a permanent tooth. A A A The nurse in the emergency department is assessing a 12-month-old diagnosed with intussusception. Which findings should the nurse expect? Select all that apply. 1. Palpable olive-shaped mass in epigastrium 2. Palpable sausage-shaped mass in upper right quadrant 3. Projectile vomiting containing blood 4. Screaming and drawing the knees up to the chest 5. Stool mixed with blood and mucus Explanation: Intussusception is a common obstructive disorder in infancy that occurs when one segment of the bowel telescopes into another. The classic clinical triad is intermittent, severe, crampy abdominal pain; a palpable "sausage-shaped" mass on the right side of the abdomen; and "currant jelly" stools. Other manifestations include inconsolable crying, drawing the knees up to the chest during episodes of pain, and vomiting. The child may appear normal and comfortable between episodes. (Option 1) Infants with infantile hypertrophic pyloric stenosis often present with excessive hunger (frequent feeder), a palpable olive-shaped mass in the epigastrium to the right of the umbilicus, and projectile vomiting (can be up to 3 feet). (Option 3) Projectile vomiting (without blood) is seen with pyloric stenosis and elevated intracranial pressure. Bloody vomiting is seen with gastric ulcers and variceal bleed. Intussusception causes non-projectile vomiting that is usually non-bloody, but stools mixed with mucus and blood are seen. Educational objective: The classic clinical triad of intussusception is intermittent, severe, crampy abdominal pain; a palpable sausage-shaped mass on the right side of the abdomen; and currant jelly stools. A A A The nurse is caring for a pediatric client with end-stage leukemia who is on comfort care and is unresponsive. The child's parent asks, "How can you tell if my child is in pain?" Which of these would the nurse describe as signs of discomfort? Select all that apply. 1. Blank facial expression 2. Facial grimacing 3. Groaning 4. Knees bent up near chest 5. Lying still Explanation: FLACC scale (face, legs, activity, cry, consolability) The nurse will provide teaching on signs that should prompt the parent to administer asneeded pain medication to the child. (Option 1) A child who is comfortable will usually have a neutral facial expression. A child in pain is likely to exhibit grimacing, frowning, or clenching of the jaw, based on the FLACC face assessment. (Option 5) A child who is comfortable will be lying quietly. A child who is squirming and moving is more likely to be in pain, based on the FLACC activity assessment. Educational objective: It is difficult to assess for pain in the nonverbal client, particularly if the person is unresponsive at the end of life. The FLACC scale is an accurate method of assessing pain in the nonverbal child. This tool should be used to teach parents how to promote comfort for their nonverbal child A A A A 2-month-old infant is brought to the pediatric emergency department due to vomiting and diarrhea for 4 days. Assessment findings include lethargy, poor feeding, sunken fontanel, temperature 100.4 F (38 C), heart rate 134/min, and respiratory rate 28/min. Which prescription from the health care provider would be the priority? 1. Acetaminophen elixir 50 mg by mouth every 6 hours [1%] 2. Intravenous (IV) ampicillin 240 mg every 12 hours [2%] 3. IV normal saline bolus 20 mL/kg over 1 hour [92%] 4. Obtain a stool culture [4%] Explanation: Infants and young children have a higher body water percentage than older children and adults. As a result, they become dehydrated quickly with fluid losses caused by vomiting and diarrhea. Signs of severe dehydration include lethargy, sunken fontanel, poor feeding, increased heart rate, and increased respiratory rate. When an infant's basic vital signs are intact and there is severe dehydration, the priority is to rehydrate. Normal saline is the fluid of choice for a bolus in an infant. Electrolytes may be added to the maintenance IV fluids if needed. (Option 1) A temperature of 100.4 F (38 C) is a mild fever in an infant and may indicate the need for acetaminophen. However, hydration of the infant takes priority over this action. (Option 2) Antibiotics may be indicated due to the infant's increased temperature. The fluid bolus is of higher priority due to the severe dehydration. (Option 4) The history of vomiting and diarrhea for 4 days would indicate a stool culture to determine a causative agent. This may be obtained after administration of the fluid bolus Educational objective: Severe dehydration occurs more rapidly in infants and young children than in adults due to increased body water percentage. When severe dehydration occurs in an infant, the priority is to rehydrate as appropriate.