STUDY GUIDE
◉ Which would be the priority intervention for a child suspected of
having varicella (chickenpox)?
1. Contact Precautions
2. Contact and Droplet Respiratory Precautions?
3. Droplet respiratory precautions?
4. Universal Precautions and standard precautions.. Answer: 2.
Varicella (Chickenpox) is highly contagious. Contact & Droplet
respiratory precautions should be started immediately because the
primary source of transmission is secretions of the respiratory tract
(droplet) and also by contaminated objects.
◉ Caladryl. Answer: A lotion containing diphenhydramine. Should
not be applied if child has already been given benadryl
(diphenhydramine) because it can cause toxicity.
◉ Which s&s would the nurse expect with rheumatic fever?
1. Ankle and Knee Joint Pain.
2. Negative group A beta strep culture.
,3. Large, red "bulls eye" - appearing rash.
4. stiff neck with photophobia.. Answer: Ankle and knee joint pain.
◉ The parents of a 12-month old with HIV are concerned about him
receiving routine immunizations. What will the nurse tell them
about immunizations?. Answer: "You are concerned about your child
receiving immunizations. Let me explain why your child will NOT
receive routine immunizations today"
The nurse acknowledges a client's fears and then discusses the
concerns to clarify any misconceptions. Immunizations and
influenza vaccine are recommended to prevent infection.
Immunocompromised HIV-infected children should not receive
MMR and varicella live vaccines.
◉ Nursing Assessment suspects the newborn has cystic fibrosis.
Which interventions would the nurse begin.
1. Observe frequency and nature of stools.
2. Provide Chest PT
3. Observe for weight gain.
4. Assess parent's compliance with fluid restrictions.
5. Assess respiratory system frequently.. Answer: 1 & 3
,Cystic fibrosis is an inherited autsomal trait, causing exocrien gland
dysfunction. 7-10% present meconium ileus, so assessing stool
frequency and consistency is important.
Assessing weight is important in newborns because they lose up to
10% of their birth weight, and can take 2 weeks for them to regain
their birth weight.
Assessing the newborn's respiratory system frequently would be
monitored as frequently as other infants if the newborn has no
respiratory symptoms. Chest PT would not be initiated in a newborn
without a definitive diagnosis.
◉ Can a mother breastfeed their infant if they have PKU?. Answer:
Yes. Breast milk has low amounts of phenylalanine, so the mother
can breast as long as the infants phenylalanine level is monitored.
◉ Vaccines given routinely at 15 months.. Answer: Hib & DTaP
◉ Which priority intervention for the newborn of a mother positive
for hepatitis antigen?. Answer: The newborn should receive both
hepatitis B vaccine and hepatitis B immune globulin within 12 hours
of birth to prevent hepatitis B infection.
, ◉ signs of intussusception. Answer: bloody stools or "currant jelly
stools", diarrhea, Large palpable sausage shaped mass in the
abdomen, abdominal distention, grunting, dehydration Fever, and
pain (legs pulled towards abdomen)!
◉ Flat Ribbon Stools indicate. Answer: Hirschsprung Disease
◉ Treatment for Intussusception. Answer: Barium or air enema
◉ Nursing Care for Intussusception. Answer: Document I & O
Monitor for peritonitis & perforation
Monitor and record stools
◉ Biggest complications of Intussusception. Answer: Peritonitis and
Perforation
◉ Risk factors for intussusception. Answer: Cystic Fibrosis
Ages 3 months to 3 years old.
◉ Complication of Mal-Rotation & Valvolus. Answer: Pain related to
rotation of intestines around the mesenteric artery can cut off
circulation, leading to potential septic intestinal necrosis.