Guide
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,Which would be the priority intervention for a child 2. Varicella (Chickenpox) is highly contagious. Contact & Droplet respiratory
suspected of having varicella (chickenpox)? precautions should be started immediately because the primary source of
transmission is secretions of the respiratory tract (droplet) and also by
1. Contact Precautions contaminated objects.
2. Contact and Droplet Respiratory Precautions?
3. Droplet respiratory precautions?
4. Universal Precautions and standard precautions.
Caladryl 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 Ankle and knee joint pain.
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.
The parents of a 12-month old with HIV are concerned "You are concerned about your child receiving immunizations. Let me explain
about him receiving routine immunizations. What will why your child will NOT receive routine immunizations today"
the nurse tell them about immunizations?
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 1&3
fibrosis. Which interventions would the nurse begin.
1. Observe frequency and nature of stools. Cystic fibrosis is an inherited autsomal trait, causing exocrien gland
2. Provide Chest PT dysfunction. 7-10% present meconium ileus, so assessing stool frequency and
3. Observe for weight gain. consistency is important.
4. Assess parent's compliance with fluid restrictions.
5. Assess respiratory system frequently. 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? 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. Hib & DTaP
Which priority intervention for the newborn of a mother The newborn should receive both hepatitis B vaccine and hepatitis B immune
positive for hepatitis antigen? globulin within 12 hours of birth to prevent hepatitis B infection.
, signs of intussusception 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 Hirschsprung Disease
Treatment for Intussusception Barium or air enema
Nursing Care for Intussusception Document I & O
Monitor for peritonitis & perforation
Monitor and record stools
Biggest complications of Intussusception Peritonitis and Perforation
Risk factors for intussusception Cystic Fibrosis
Ages 3 months to 3 years old.
Complication of Mal-Rotation & Valvolus Pain related to rotation of intestines around the mesenteric artery can cut off
circulation, leading to potential septic intestinal necrosis.
Which pediatric GI disorder presents with green bilious Mal-Rotation and Valvolus
vomiting?
GI disorders that present with bloody stools? Mal-Rotation/Valvolus & Intussusception.
Obstructive GI disorders where a palpated sausage Mal-Rotation and Valvolus. Symptoms for these disorders are similar but Mal-
shaped mass is felt on the abdomen. Rotation requires surgical intervention.
Preoperative care for Mal-Rotation/Valvolus Hydration, IV antibiotics, NG tube.
Post-Operative Care for Intussusception Bowel sounds should return in four hours, progressive diet, hydration.
Priority nursing diagnosis for intussusception Acute Pain!