NACE: care of the child
To help prepare a 4 y/o for postoperative abdominal surgery care, a nurse should take
which of these measures?
· Teaching the child how to contract and relax the abdominal muscles
· Having the child wear a chest restraint whenever he/she is in bed
· Practicing deep-breathing exercises with the child
· Telling the child to lie either on the back or on the side until allowed out of bed
The nurse should practice deep breathing exercises with the child; this will help
postoperatively because it will help expand the lungs, decreasing the chance of
postoperative respiratory complications.
A 12 y/o girl who has type 1 DM receives 5 units regular insulin and 20 units isophane
insulin subcutaneously at 7am. She eats her breakfast at 7:30am and goes to school. At
10:30 am she reports feeling shaky and sweaty. A school nurse should make which of
these interpretations of this information?
· The Humulin-R insulin is peaking at this time
· The girl needs additional Humulin-R insulin
· The NPH insulin is peaking at this time
· The girl needs additional NPH insulin
The nurse should interpret that the regular insulin (Humulin-R) is peaking at this
time. Humulin-R has an onset of action within 30 minutes of injection, peaks at 1-3
hours, and has effects that last 6-8 hours. NPH has an onset of about 2 hours following
injection, peaks at 4-12 hours after injection, and a duration of 18-26 hours after
injection
An 18 month old child has been placed on Bryant traction. The traction has been
properly applied if a nurse observes that
· Both legs are at a 35 degree angle
· 10-pound weights are in place
,· The ropes are slack
· Both buttock are off the bed
Bryant's traction is used for children with fractured femurs and both legs are suspended
at 90 degree angles to the trunk of the body and the weight of the body pulls the bone
fragments of the fractures leg into alignment. If both buttocks are off the bed, then
the traction is properly applied.
Which of these measures should a nurse plan for a 3 ½ y/o child whose scrotum is very
edematous?
· Applying a lanolin-based lotion to his scrotum
· Instructing him to avoid touching his scrotum when voiding
· Supporting his scrotum on a soft pad
· Placing cold compresses on his scrotum
The nurse should plan on supporting his scrotum on a soft pad. This will help
decrease the pressure and the weight pulling down on the scrotum.
While an 18-month-old boy is in a mist tent, which of these toys would be most
appropriate?
· Crayons and a coloring book
· A wooden telephone
· Colored balloons
· A mobile
A wooden telephone would be the most appropriate under a mist tent.
The purpose of giving a low-phenylalanine formula to an infant who has
phenylketonuria (PKU) is to
· Prevent the accumulation of phenylalanine in the blood
· Prevent the secretion of the enzyme phenylalanine hydroxylase
· Promote the conversion of phenylalanine to tyrosine
· Promote the excretion of phenylpyruvic acid in the urine
Preventing the accumulation of phenylalanine in the blood is the purpose of giving
the infant a low-phenylalanine formula.
, A 12 month old child is admitted to the hospital for open heart surgery for repair of the
ventricular septal defect. When preparing this client for surgery, which intervention
would be most appropriate?
· Allow the child's mother to stay in the preoperative area until the child is sedated
prior to surgery
· Have the child play with suture material to what will be used on the child's skin incision
· Show the child the surgical room and all the equipment
· Explain to the child the functioning of the cardiopulmonary bypass machine to be used
during surgery
Toddlers fear abandonment; as a result, separation from family can be extremely
stressful. Their ability to comprehend a new environment or unfamiliar materials or
machines is limited and would not be appropriate for this child.
On a routine home visit, a visiting nurse learns that a 3 y/ child who has short bowel
syndrome has had diarrhea for the past 12 hours. An assessment reveals that the child is
mildly dehydrated and has no other abnormal findings. Which of these foods should a
nurse suggest that the mother give the child?
· Orange juice
· Chocolate milk
· Buttermilk
· Carbonated water
Orange juice, chocolate milk, and buttermilk may cause additional diarrhea
stools. Carbonated water would be the best suggestion for the mother.
An infant develops hydrocephalus and has a ventriculoperitoneal shunt placed. 2 weeks
after surgery, the baby is to be discharged and a nurse has been teaching the parents
about postoperative care. The mother visits the infant every day. One day the mother
makes these comments about her baby. Which comment most strongly suggests that
the mother is progressing in attachment to the baby?
· I wonder if people will notice the little bulge behind my baby's ear where the tube is
· Does my baby have any pain where the back operation was done
To help prepare a 4 y/o for postoperative abdominal surgery care, a nurse should take
which of these measures?
· Teaching the child how to contract and relax the abdominal muscles
· Having the child wear a chest restraint whenever he/she is in bed
· Practicing deep-breathing exercises with the child
· Telling the child to lie either on the back or on the side until allowed out of bed
The nurse should practice deep breathing exercises with the child; this will help
postoperatively because it will help expand the lungs, decreasing the chance of
postoperative respiratory complications.
A 12 y/o girl who has type 1 DM receives 5 units regular insulin and 20 units isophane
insulin subcutaneously at 7am. She eats her breakfast at 7:30am and goes to school. At
10:30 am she reports feeling shaky and sweaty. A school nurse should make which of
these interpretations of this information?
· The Humulin-R insulin is peaking at this time
· The girl needs additional Humulin-R insulin
· The NPH insulin is peaking at this time
· The girl needs additional NPH insulin
The nurse should interpret that the regular insulin (Humulin-R) is peaking at this
time. Humulin-R has an onset of action within 30 minutes of injection, peaks at 1-3
hours, and has effects that last 6-8 hours. NPH has an onset of about 2 hours following
injection, peaks at 4-12 hours after injection, and a duration of 18-26 hours after
injection
An 18 month old child has been placed on Bryant traction. The traction has been
properly applied if a nurse observes that
· Both legs are at a 35 degree angle
· 10-pound weights are in place
,· The ropes are slack
· Both buttock are off the bed
Bryant's traction is used for children with fractured femurs and both legs are suspended
at 90 degree angles to the trunk of the body and the weight of the body pulls the bone
fragments of the fractures leg into alignment. If both buttocks are off the bed, then
the traction is properly applied.
Which of these measures should a nurse plan for a 3 ½ y/o child whose scrotum is very
edematous?
· Applying a lanolin-based lotion to his scrotum
· Instructing him to avoid touching his scrotum when voiding
· Supporting his scrotum on a soft pad
· Placing cold compresses on his scrotum
The nurse should plan on supporting his scrotum on a soft pad. This will help
decrease the pressure and the weight pulling down on the scrotum.
While an 18-month-old boy is in a mist tent, which of these toys would be most
appropriate?
· Crayons and a coloring book
· A wooden telephone
· Colored balloons
· A mobile
A wooden telephone would be the most appropriate under a mist tent.
The purpose of giving a low-phenylalanine formula to an infant who has
phenylketonuria (PKU) is to
· Prevent the accumulation of phenylalanine in the blood
· Prevent the secretion of the enzyme phenylalanine hydroxylase
· Promote the conversion of phenylalanine to tyrosine
· Promote the excretion of phenylpyruvic acid in the urine
Preventing the accumulation of phenylalanine in the blood is the purpose of giving
the infant a low-phenylalanine formula.
, A 12 month old child is admitted to the hospital for open heart surgery for repair of the
ventricular septal defect. When preparing this client for surgery, which intervention
would be most appropriate?
· Allow the child's mother to stay in the preoperative area until the child is sedated
prior to surgery
· Have the child play with suture material to what will be used on the child's skin incision
· Show the child the surgical room and all the equipment
· Explain to the child the functioning of the cardiopulmonary bypass machine to be used
during surgery
Toddlers fear abandonment; as a result, separation from family can be extremely
stressful. Their ability to comprehend a new environment or unfamiliar materials or
machines is limited and would not be appropriate for this child.
On a routine home visit, a visiting nurse learns that a 3 y/ child who has short bowel
syndrome has had diarrhea for the past 12 hours. An assessment reveals that the child is
mildly dehydrated and has no other abnormal findings. Which of these foods should a
nurse suggest that the mother give the child?
· Orange juice
· Chocolate milk
· Buttermilk
· Carbonated water
Orange juice, chocolate milk, and buttermilk may cause additional diarrhea
stools. Carbonated water would be the best suggestion for the mother.
An infant develops hydrocephalus and has a ventriculoperitoneal shunt placed. 2 weeks
after surgery, the baby is to be discharged and a nurse has been teaching the parents
about postoperative care. The mother visits the infant every day. One day the mother
makes these comments about her baby. Which comment most strongly suggests that
the mother is progressing in attachment to the baby?
· I wonder if people will notice the little bulge behind my baby's ear where the tube is
· Does my baby have any pain where the back operation was done
