Term
When assessing a toddler, age 18 months, the nurse should interpret which of the following as a sign of a neurlogic dysfunction?
a. positive gag reflex
b. positive tonic neck reflex
c. positive Babinski reflex
d. positive corneal reflex |
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Definition
c. positive Babinski reflex
Babinski reflex should siappear by age 12 months; its presence after this age indicates neurologic dysfunction. The gag reflex, tonic neck reflex, and corneal reflex are normal findings in a toddler. |
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Term
The physician prescribes Tylenol elixir, 160 mg q4hrs, for a 14-month-old child who weighs 9.08 kg. This drug, supplied in a bottle labeled 160 mg/tsp, has a safe dosage of 10 mg/kg/dose. The nurse should administer how many milliliters?
a. none because this isn't a safe dose
b. 2.5 mL
c. 6 mL
d. 7.5 mL |
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Definition
a. none because this isn't a safe dose
For this client, the safe dose of this drug is 90.8 mg.
(9.08 kg x 10 mg/kg = 90.8 mg)
Therefore, the prescribed dose isn't safe. |
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Term
A 2-year-old child with a tracheostomy suddenly becomes diaphoretic and has an increased HR, an increased work of breath, and a decreased oxygen saturation level. Which of the following should be the nurse's first action?
a. suction the tracheostomy
b. turn the child to a side-lying position
c. administer pain medication
d. perform cheset physiotherapy |
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Definition
a. suction the tracheostomy
Diaphoresis, increased HR, increased RR, and decreased O2 saturation are signs that mucus is partially occluding the airway. The child needs suctioning immediately to prevent full occlusion.
Turning the child to a side-lying position won't remove the mucus from he airway. The child may require pain medication after his ahis airway has been cleared if his condition warrants it.
Chest physiothearpy will help drain excess mucus from the lungs but not from a tracheostomy. |
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Term
A toddler with hemophilia is hospitalized with multiple injuries after falling off a sliding board. X-rays reveal no bone fractures. When caring for the chld, what is the nurse's highest priority?
a. administering platelets as prescribed
b. taking measures to prevent infection
c. frequently assessing the child's level of consciousness (LOC)
d. discussing a safe play environment with the parents |
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Definition
c. frequently assessing the child's level of consciousness (LOC)
In hemophilia, one of the factors required for blood clotting is absent, significantly increaing the risk of hemorrhage after injury. The nurse must assess the child often for s/s of intracranial bleeding, such as altered LOC, slurred sppech, vomiting, and headache. To manage hemophilia, the absent blood clotting factor is replaced via I.V. infused of factor, cryopreicitate, or fresh frozen plasma; this may be done prophylactically or after a traumatic injury. Platelet transfusions aren't needed. Hemophiliacs aren't at increased risk for infections. Discussing a safe play environment with parents is important but isn't the highest priority. |
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