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Assessment- Rationales RN VATI Nursing
Care of Children
- "Your child will be exposed to a moderate amount of radiation during the procedure." MY ANSWER An MRI produces radiofrequency emissions from nonradioactive elements; therefore, there is no exposure to radiation involved during this procedure. "Your child might experience pain during the procedure." An MRI does not cause pain, as it is a noninvasive procedure that emits radiofrequencies to produce an image. "This is considered an invasive procedure." An MRI is a noninvasive procedure, unless an IV is prescribed when contrast is used. No contrast is indicated for this child, so no IV is needed. "You can remain in the room with your child during the procedure." The parent may remain in the room with the child to provide comfort and reassurance during the procedure.
- Nausea The nurse should identify that nausea is an early sign of increased intracranial pressure in a child. Papilledema The nurse should identify that papilledema is a late sign of increased intracranial pressure in a child. Dilated pupils The nurse should identify that dilated pupils along with a decreased pupillary response are late signs of increased intracranial pressure in a child. Bradycardia MY ANSWER The nurse should identify that bradycardia is a late sign of increased intracranial pressure in a child.
- Initiate contact precautions. The nurse should initiate contact, droplet, and standard precautions for RSV because exposure to contaminated secretions can transmit the virus. RSV can live on objects for several hours and on hands for 30 min. Perform chest percussion and postural drainage. The nurse should perform periodic suctioning of the nose or nasopharynx to clear nasal secretions. Chest percussion and postural drainage are not routinely recommended for an infant who has RSV. Encourage clear liquids by mouth. MY ANSWER The nurse should not encourage clear liquids by mouth, because the infant has tachypnea. Oral fluids are contraindicated in the presence of tachypnea due to the risk for aspiration. Administer IV antibiotics. The nurse should not plan to administer IV antibiotics, because RSV is a viral infection. Antibiotics may be prescribed if a secondary bacterial infection occurs.
- Warm extremities Heart failure involves an inability of the heart to pump effectively, limiting perfusion to major organs and the extremities. The nurse should expect a child who has heart failure to exhibit pale, cool extremities. Frequent headaches The child who has heart failure can exhibit neurologic manifestations, such as increased restlessness or irritability as a result of hypoxia and impaired cardiac function; however, frequent headaches are not an expected manifestation associated with heart failure. Distended neck veins The child who has heart failure will exhibit manifestations of increased blood volume, such as distended neck veins. This occurs because the hormone ADH is excreted, which holds onto sodium and water in response to decreased cardiac output and renal perfusion. Weight loss MY ANSWER The child who has heart failure will exhibit weight gain as a result of sodium and water retention. As the heart failure progresses, dependent and periorbital edema, ascites, and pulmonary effusions result.
- The infant falls to a sitting position while learning how to walk. The infant falling to a sitting position while learning how to walk is not a manifestation of hemophilia, as this is an expected part of growth and development. The infant bleeds slightly when scratched by a cat. Bleeding slightly when a minor scratch occurs is not a manifestation of hemophilia; however, if the bleeding is not easily controlled, the parent should notify the provider. The infant's skinned knee drains serosanguineous fluid. MY ANSWER The drainage of serosanguineous fluid from a skinned knee is not a manifestation of hemophilia. This is an expected finding after a skin injury and does not warrant evaluation. The infant's knees are reddened and edematous. The nurse should identify that the infant might be experiencing hemarthrosis if redness, edema, and warmth of the joints are noted. Bleeding into the joints is the most frequent form of internal bleeding in children who have hemophilia. "I should eat extra food on busy days when I am more active" is correct. The nurse should instruct the child to increase her intake of allowable foods when she is more active. Exercise lowers blood glucose levels during and after activity. Food intake should be adjusted to compensate for the release of insulin into the circulatory system and prevent episodes of hypoglycemia. The recommended increase of carbohydrates is 10 to 15 g per hour of moderate play or activity. "I should wait 2 hours after eating before playing with my friends" is incorrect. The child should play or exercise within 2 hr of eating because exercise requires her to have more carbohydrates in her system. Waiting 2 hr after eating before play or exercise increases the likelihood of a hypoglycemic episode. A carbohydrate snack will most likely be needed during prolonged play or
Nuchal rigidity MY ANSWER The nurse should expect a child who has viral meningitis to have nuchal rigidity, which is caused by meningeal irritation. The child might also have fever and photophobia. Decreased glucose in the cerebrospinal fluid The nurse should expect a child who has viral meningitis to exhibit a glucose level in the cerebrospinal fluid within the expected reference range. Bacterial meningitis can decrease the glucose in the cerebrospinal fluid.
- Restrict the child's potassium intake. MY ANSWER The nurse should not instruct the parents to restrict the child's potassium intake; however, the parents should restrict the child's sodium intake by avoiding the addition of salt to the child's food and eliminating high-sodium foods from the diet. The child may resume a regular salt intake after the acute phase of nephrotic syndrome has passed. Provide quiet activities for the child. The nurse should instruct the parents to provide quiet activities, such as reading and coloring, during the edema phase of nephritis to minimize oxygen consumption and preserve energy. Weigh the child once a week. The nurse should instruct the parents to weigh the child at the same time each day with the child wearing the same clothing. The nurse should instruct the parents to notify the provider if the child's weight increases. Administer acetaminophen to the child daily. The nurse should not instruct the parents to administer acetaminophen to the child daily, as nephrotic syndrome does not cause pain. Daily administration of acetaminophen could also cause additional stress to the child's kidneys.
- "I will cook foods that are low in fat and carbohydrates." The parent should serve nutritious foods that are high in calories, protein, and fats. A child who has cystic fibrosis experiences intestinal malabsorption and is at risk for nutritional deficiencies and inadequate growth. "My child can chew his enzyme medication with meals." The parent should have the child swallow the capsules whole or sprinkle them on his food within 30 min of her meals and snacks. The child should not chew or crush the enteric-coated tablets, because destroying the enteric coating can lead to inactivation of the enzymes and excoriation of the oral mucosa. "I will give my child stool softeners for constipation." Constipation can occur in the child who has cystic fibrosis because of a failure to properly break down foods, a slowing of the intestinal motility, and the thickened enzymatic secretions due to the disease process itself. The parent should administer an osmotic solution, such as polyethylene glycol, stool softeners, or laxatives to treat constipation. "My child will be excused from physical education class." MY ANSWER The parent should encourage the child to participate in physical exercise to mobilize secretions and increase blood flow to the lungs. Exercise can stimulate mucus excretion and provides a sense of good health and positive self-esteem for the child.
- Administer factor VIII is correct. Hemophilia A is a bleeding disorder caused by a factor VIII deficiency; therefore, the nurse should plan to administer factor VIII prophylactically to prevent or minimize bleeding. Assess for changes in level of consciousness is correct. Hemophilia A can cause cerebral bleeding; therefore, the nurse should assess the child for headaches and decreased level of consciousness. Apply a warming blanket over the child is incorrect. The nurse should apply ice or cold packs to the child to vasoconstrict the child's blood flow. Perform passive range of motion hourly is incorrect. The nurse should rest the joints during the acute phase of bleeding to prevent stretching the joint or bleeding to recur. Refrigerate the reconstituted antihemophilic factor solution until used. While the factor VIII concentrate (unreconstituted) should be stored in the refrigerator, once it is mixed with the diluent, it should not be returned to the refrigerator. Administer factor IX is incorrect. The nurse should identify that children who have hemophilia B have a deficiency in factor IX and the nurse should plan to administer factor IX prophylactically to prevent or minimize bleeding.
- "My child should have 4 ounces of protein per day." MY ANSWER A toddler who is 2 years old should consume 2 oz of protein daily. The nurse should instruct the parents to follow recommendations for dietary guidelines from the Dietary Guidelines for Americans, 2010 to achieve adequate caloric and nutrient needs. "I should feed my child 1 cup of vegetables per day." A toddler who is 2 years old should have 1 cup (8 oz) of vegetables per day. A variety of vegetables should be introduced to the toddler. The nurse should instruct the parents to follow recommendations for dietary guidelines from the Dietary Guidelines for Americans, 2010 to achieve adequate caloric and nutrient needs. "I should give my child 6 cups of milk a day." A toddler who is 2 years old should have no more than 24 oz (3 cups) of milk per day to prevent iron deficiency anemia. This occurs in the toddler who consumes large amounts of dairy and then fails to consume adequate amounts of iron-containing proteins. To enhance growth of the toddler's brain and body, whole milk products are recommended instead of low-fat or fat-free varieties. "My child should consume 800 calories per day." A toddler who is 2 years old should consume approximately 1,000 to 1,300 calories daily, divided into three meals and one or two snacks. The nurse should instruct the parents to follow recommendations for dietary guidelines from the Dietary Guidelines for Americans, 2010 in order to achieve adequate caloric and nutrient needs.
dehydration. Other manifestations of severe dehydration include sunken eyeballs, parched mucous membranes, oliguria, sunken fontanels, and hyperpnea.
- "Your child needs mechanical ventilation." The nurse should not tell the parent the child needs mechanical ventilation, as the child is awake and alert. A child who is not breathing on her own or is experiencing respiratory distress requires mechanical ventilation. "We need to observe your child for cerebral swelling." MY ANSWER The nurse should inform the parents that the child needs observation because she is still at risk for a complication from the submersion injury. Complications can include respiratory compromise and cerebral edema during the first 24 hr after the submersion.
- "I will ensure that my child takes a 1 hour nap each day." A child who has JIA should be discouraged from sleeping during the day because it can cause joint stiffness and interfere with nighttime sleep. The child should instead rest daily with activities such as reading, watching television, and listening to music. "I will give my child prednisone as needed for pain." Prednisone is a glucocorticoid that acts as an anti-inflammatory agent and is given on a scheduled basis during exacerbations. "I will apply cool compresses to my child's painful joints during exacerbations." MY ANSWER The parent should apply moist heat, rather than cool compresses, to relieve pain and stiffness in affected joints. Having the child soak in a bathtub of warm water is an effective strategy for relieving pain and stiffness in multiple joints. "I will have my child wear splints during the night." The parent should have the child wear splints during the night to prevent joint deformities and reduce and minimize pain from inactivity
- Initiate chelation therapy. The nurse should not initiate chelation therapy for a child who has ingested kerosene. Chelation therapy removes iron from circulating blood and is not useful for the treatment of hydrocarbon ingestion. Prepare for intubation with a cuffed endotracheal tube. The nurse should anticipate that the child will require intubation with a cuffed endotracheal tube because of the high risk of aspiration. This child is at risk for aspiration because she is lethargic, grunting, and gagging. Inject deferoxamine subcutaneously. Deferoxamine is an antidote used in the treatment of iron toxicity. It is not used in the treatment of hydrocarbon ingestion. Administer activated charcoal. MY ANSWER The nurse should administer activated charcoal to treat a child who has ingested excess aspirin.
Add supplemental calcium to the child's diet. The nurse should not instruct the parents to increase the child's calcium intake. Immobilization increases the risk for hypercalcemia, leading to renal stones, muscle fatigue, and diminished reflexes. Decrease dietary fiber intake. The nurse should not instruct the parents to decrease the child's intake of fiber. Immobilization increases the risk for constipation and fecal impaction; therefore, the nurse should instruct the parents to increase the child's fiber intake. Encourage small, frequent meals high in protein. MY ANSWER The nurse should instruct the parents to provide small, frequent meals that are high in protein while their child is healing from surgery. Immobilization causes a decrease in appetite; therefore, small, frequent meals will be more readily tolerated. Adequate protein intake is needed for energy and tissue healing. Encourage foods that are low in calories. The nurse should not instruct the parents to provide foods that are low in calories. Immobilization decreases the metabolic rate and appetite. However, adequate healing requires calories to prevent undernutrition, nutrient deficiencies, and a negative nitrogen balance. The nurse should instruct the parents to provide nutrient-dense foods that are high in protein.
- lement seizure precautions. The nurse should identify this potassium level as below the expected reference range of 4.1 to 5.3 mEq/L for infants. The nurse should monitor for cardiac abnormalities for an infant who has a potassium level outside the expected reference range. Offer the infant 15 mL of formula. The nurse should insert an NG tube to maintain gastric decompression prior to surgical correction of the stenosis. The nurse should keep the infant NPO. Check the infant's serum creatinine. The nurse should check the infant's serum creatinine and BUN levels prior to and during the administration of IV potassium to ensure renal function is adequate and avoid the development of hyperkalemia should renal failure occur. The nurse should also closely monitor intake and output to ensure adequate urinary output prior to and during the administration of IV potassium. Administer sodium polystyrene. MY ANSWER The nurse should identify this potassium level as below the expected reference range of 4.1 to 5.3 mEq/L for infants. Sodium polystyrene stimulates the body to excrete potassium through the large intestine and would worsen the infant's condition. "My child will be awake for this procedure." The child requires sedation for an endoscopy and bronchoscopy to prevent complications from this procedure; therefore, the child will not be awake during the procedure. "I can take my child home as soon as the procedure is over." The nurse will observe the child for complications, such as laryngeal edema, after the procedure. The child can go home when his vital signs are stable and he has a gag/cough reflex, which usually returns within a few hours.
Breathing in through the mouthpiece and holding the breath for 5 seconds is an incorrect method of using the PEFM. The correct method of using the PEFM is to forcefully exhale for 1 second as quickly as possible to measure the amount of air exhaled. "If I get a reading in the green zone, I will tell my parents right away so they can call the doctor." Values in the green zone represent 80% to 100% of the child's personal best. This indicates that asthma is under good control and does not warrant calling the provider. "I will slowly exhale through the mouthpiece over a 10 - second interval." MY ANSWER Slowly exhaling through the mouthpiece over a 10-second interval is an incorrect method of using the PEFM. The correct method of using the PEFM is to forcefully exhale for 1 second as quickly as possible to measure the amount of air exhaled. "I will record the highest reading of the three attempts." The child should forcefully exhale for 1 second as quickly as possible to measure the amount of air exhaled and repeat this process three times. The child should wait 30 seconds between attempts and record the highest of the three readings.
- Administer the medication on an empty stomach. MY ANSWER The nurse should instruct the parents to administer the medication with meals or just before eating to prevent gastrointestinal upset. Encourage the child to brush his teeth after each meal. The nurse should recommend consistent dental hygiene to the parents of a child who has a prescription for phenytoin. This medication can cause gingival hyperplasia, and good oral hygiene reduces the risk of this occurring. Crush the child's medication to mix with applesauce. The nurse should instruct the parents to administer the extended-release capsule whole to ensure proper absorption and therapeutic plasma drug levels. Observe the child for diarrhea. The nurse should instruct the parents to monitor the child for constipation as an adverse effect of phenytoin.
- Capillary refill greater than 4 seconds MY ANSWER The nurse should identify that a capillary refill time greater than 4 seconds indicates severe dehydration. An infant experiencing moderate dehydration will exhibit a capillary refill time of 2 to 4 seconds. Bradycardia The nurse should identify that bradycardia is not a manifestation of dehydration. An infant experiencing dehydration will exhibit a heart rate that is either within or above the expected range, depending upon the severity of fluid loss. Tachypnea The nurse should identify that tachypnea is a manifestation of moderate dehydration. As dehydration worsens, breathing becomes hyperpneic. Lethargy The nurse should identify that an infant who is lethargic has severe dehydration. An infant experiencing moderate dehydration will exhibit increased irritability.
Face, Legs, Activity, Cry, Consolability (FLACC) scale MY ANSWER The nurse should use the FLACC scale to assess the toddler's pain level. The FLACC scale is used for infants and children from 2 months to 7 years. Color Tool scale The nurse should not use the Color Tool scale to assess pain in a toddler. The Color Tool scale is used for children ages 4 years old and older that are able to identify colors. FACES scale The nurse should not use the FACES pain rating scale to assess pain in a toddler. The FACES scale is used for children ages 3 years old and older and requires the child to identify pain by pointing to a face that represents the level of pain the child is experiencing. Visual Analog Scale (VAS) The nurse should not use the VAS pain scale to assess pain in a toddler. The VAS scale is used for children older than 4.5 years old and requires the child to make a written mark on a pain scale that represents the level of pain the child is experiencing. Vomiting is correct. The clinical manifestations of a brain tumor vary with the size and location of the tumor. Vomiting unrelated to feeding is a common finding. It tends to become progressively more projectile and is most severe in the morning. It can be accompanied by nausea and is a result of increased intracranial pressure. Easy bruising is incorrect. Anticoagulation is not associated with brain tumors. It is more likely to be seen with hematologic malignant disease (leukemia). Clumsiness is correct. Clumsiness, lack of coordination, and loss of balance are common manifestations of brain tumors. Manifestations result from pressure and interference with circulation within the brain. Irritability is correct. Irritability is a common behavioral manifestation of brain tumors. Other manifestations include anorexia, fatigue, lethargy, and bizarre behavior such as staring. Persistent headaches is correct. Headache is probably the most common symptom of brain tumors. Headaches result from pressure on pain-sensitive areas, such as large blood vessels and cranial nerves. Headaches tend to be worse in the morning and subside as the day progresses. The infant cannot turn pages in a book. The nurse should not expect an infant to turn pages in a book until the age of 12 months. The infant cannot build a tower of three cubes. The nurse should not expect an infant to build a tower of three cubes until the age of 18 months. The infant cannot sit steadily without support. MY ANSWER An infant who is 8 months old should be able to sit steadily without support; therefore, the nurse should report this finding to the provider because it might indicate developmental delay for a 10 - month-old infant.
The nurse should not instruct the teachers to vary their classroom routine to maintain the interest of children who have ADHD. Children who have ADHD require a consistent environment that is predictable to assist with focus and the ability to complete expected tasks. Limit presentation of subjects of interest to the children to the afternoons. The nurse should encourage the teachers to alternate topics of high interest to the children with topics of less interest. This will help retain the attention of the children. Increase classroom assignments to stimulate learning. The nurse should not instruct the teachers to increase classroom assignments for children who have ADHD. Teachers might need to decrease classroom assignments to allow the children time to complete the work.
- Expiratory wheeze An expiratory wheeze is an expected finding for a child who is experiencing an asthma attack and should be reported to the provider to allow for effective treatment; however, there is another finding that is the nurse's priority to report to the provider. Heart rate 100/min A heart rate of 100/min is an expected finding for a child who is experiencing an asthma attack and should be reported to the provider to allow for effective treatment; however, there is another finding that is the nurse's priority to report to the provider. Profuse sweating Profuse sweating indicates that this child is at greatest risk for severe respiratory distress and requires immediate intervention; therefore, this is the nurse's priority finding to report to the provider. Other manifestations include refusal to lie down and sudden agitation or drowsiness. The nurse should report any of these manifestations to the provider and remain with the child in case intubation becomes necessary. Oxygen saturation 91% MY ANSWER An oxygen saturation of 91% is an expected finding for a child who is experiencing an asthma attack and should be reported to the provider to allow for effective treatment; however, there is another finding that is the nurse's priority to report to the provider.
- The infant exhibits a fear of strangers. The nurse should expect a 6 - month-old infant to exhibit a fear of strangers when the ability to recognize his parents develops. The infant understands the word "no." The nurse should expect a 9 - month-old infant to understand the word "no" and to respond to basic commands from the parents. The infant has an absent grasp reflex. The nurse should expect a 4-month-old infant to have an absent grasp reflex because this primitive reflex disappears at 3 months of age. The nurse should expect the infant to grasp objects with both hands at this stage of development. The infant rolls from his back to his abdomen. MY ANSWER The nurse should expect a 6 - month-old infant to reposition himself to a prone position from a supine one. At 4 months of age, the infant should be able to roll from his back to his side.
- Shallow respirations MY ANSWER The nurse should not expect the toddler to have shallow respirations, as this is a manifestation of hypoglycemia. A toddler who is experiencing hyperglycemia exhibits deep, rapid (Kussmaul) respirations. Moist mucous membranes The nurse should not expect the toddler to have moist mucous membranes. A toddler who is experiencing hyperglycemia exhibits dry mucous membranes. Skin pallor The nurse should not expect the toddler to have skin pallor, as this is a manifestation of hypoglycemia. A toddler who is experiencing hyperglycemia exhibits flushed skin and might have signs of dehydration. Lethargic mood The nurse should expect the toddler to be lethargic. A toddler who is experiencing hypoglycemia will be irritable and have a labile mood.
- Applying heat to the affected areas MY ANSWER The nurse should apply heat to the affected areas to increase circulation and decrease pain; however, another action is the priority. Administering prophylactic antibiotics The nurse should administer prophylactic antibiotics to prevent bacterial infection because the adolescent's body has a decreased ability to fight infection; however, another action is the priority. Infusing blood products The nurse should administer blood products to correct anemia and reduce blood viscosity; however, another action is the priority. Promoting rest The first action the nurse should take when using the airway, breathing, circulation approach to client care is to increase tissue oxygenation. An adolescent who has sickle cell anemia and is experiencing a vasoocclusive crisis has a higher requirement for cellular oxygenation; therefore, the nurse should reduce the client's metabolic demands for oxygen and limit cardiac oxygen consumption by encouraging rest. Elevate the child's residual limb for 48 hr. The nurse should plan to elevate the child's residual limb for the first 24 hr following surgery. Elevating the leg longer than 24 hr can cause hip contractures and lead to difficulties with future ambulation. Apply a loose-fitting bandage onto the child's residual limb. The nurse should plan to apply an elastic bandage in a figure-eight pattern to apply pressure to the residual limb. A pressure dressing controls edema, decreases the likelihood of hemorrhage, and assists in contouring the residual limb for future prosthetic placement. Perform active and isotonic range-of-motion exercises. MY ANSWER The nurse should plan to perform both active and isotonic range-of-motion exercises of the
12 months The nurse should expect an infant to begin speaking three to five words with meaning at around 12 months of age. 18 months The nurse should expect a toddler to speak ten or more words at around 18 months of age. The toddler should also form simple word combinations. 24 months The nurse should expect a toddler to speak approximately three-hundred words at around 24 months of age. The toddler should also use two- and three-word
- "Your child should not receive the measles, mumps, and rubella vaccine." MY ANSWER The CD4 count is a measurement of lymphocytes, which plays a role in cellular immune function. Adequate immune function is indicated by a CD4 count of 600 to 1,500 cells/μL. At levels less than 200 cells/μL, the child is at increased risk for opportunistic infections. A child who has HIV and a CD4 level within the expected reference range should receive immunizations against common childhood illnesses, such as MMR and varicella. "Your child should receive the pneumococcal vaccine." Immunizations are an important factor in maintaining a child's health. A child who has HIV and a CD4 level within the expected reference range should receive the pneumococcal vaccine. "Household members should avoid receiving the varicella vaccine." It is not necessary for household members living with a child who has HIV and a CD4 level within the expected reference range to avoid receiving the varicella vaccine, because there is no evidence of immunosuppression. "Your child will need IV gamma globulin prophylaxis if exposed to pediculosis." IV gamma globulin prophylaxis is administered to children who are exposed to or develop recurrent bacterial infections. Pediculosis, or lice, is treated with medicated shampoo and manual removal of nits. A child who has HIV and a CD4 level within the expected reference range does not require an alternative treatment for pediculosis. Place a throw rug under the crib. MY ANSWER The nurse should instruct the parent to place a throw rug under the crib because the toddler can fall out of the crib. The nurse should also instruct the parent to move the toddler to a youth bed when he is able to climb out of the crib. Select a toy box with a heavy, hinged lid. The nurse should instruct the parent to select a toy box with a lid the toddler can easily open. A toy box with a heavy, hinged lid places the toddler at risk for injury or suffocation if entrapment occurs. Offer marshmallows as a snack food. The nurse should instruct the parent not to offer marshmallows as a snack food, because they are a choking hazard. If the toddler does not chew the marshmallow completely, it can occlude his airway. Set the water heater temperature to 54.4° C (130° F). The nurse should instruct the parent to set the temperature on the hot water heater at no more than 49° C (120° F) to prevent scalding of the toddler.
A is correct. To document the appropriate area on the growth chart, obtain a chart designated for the infant's age and gender. Next, the nurse should find the marker for age at the bottom of the chart. Then, on the right side of the page, the nurse should determine the marker for weight in either kg or lb and plot them on the graph accordingly. If the points plotted are within the two bolded lines, representing the 5th and 95th percentiles, the child's development in terms of these parameters is appropriate. This is the correct documentation of the infant's weight. B is incorrect. To document the appropriate area on the growth chart, obtain a chart designated for the infant's age and gender. Next, the nurse should find the marker for age at the bottom of the chart. Then, on the right side of the page, the nurse should determine the markers for weight in either kg or lb and plot them on the graph accordingly. According to this point on the chart, the infant is 13 months old and weighs 11.3 kg (24.9 lb). C is incorrect. To document the appropriate area on the growth chart, obtain a chart designated for the infant's age and gender. Next, the nurse should find the marker for age at the bottom of the chart. Then, on the right side of the page, the nurse should determine the markers for weight in either kg or lb and plot them on the graph accordingly. According to this point on the chart, the infant is 11 months old and weighs 9.5 kg (20.9 lb). D is incorrect. To document the appropriate area on the growth chart, obtain a chart designated for the infant's age and gender. Next, the nurse should find the marker for age at the bottom of the chart. Then, on the right side of the page, the nurse should determine the markers for weight in either kg or lb and plot them on the graph accordingly. According to this point on the chart, the infant is 13 months old and weighs 10.2 kg (22.5 lb).
- Chill the medication prior to administration.
minimize the development of flexion contractions. Administer pain medication to the child 30 min before physical therapy. MY ANSWER The nurse should administer pain medication to the child 30 to 45 min prior to painful procedures, such as physical therapy or dressing changes. Adequate pain control is needed so the child will actively participate and cooperate during physical therapy.
- "I will give lansoprazole 30 minutes after her feeding." The mother should give lansoprazole to her infant 30 min before feeding. Administering lansoprazole, a proton pump inhibitor, 30 min prior to meals ensures the peak plasma concentration of the medication occurs during mealtimes. This medication reduces gastric hydrochloric acid secretion and can stimulate an increase in lower esophageal sphincter tone, which can prevent reflux of stomach contents into the esophagus. "I will lay my baby on her side after feedings." MY ANSWER The parent should not lay her infant down following a feeding, as this position will worsen gastroesophageal reflux. The parent should place the infant upright in an infant seat or raise the head of the bed 30° for 1 hr after feedings. "I will add rice cereal to my baby's feedings." The mother can add rice cereal to formula or expressed breast milk to thicken the feedings. Thickened feedings can decrease the number of vomiting episodes the infant experiences. "I will use a nipple that has a wide base to feed her." The parent should create a larger hole within the nipple to help the infant suck more easily. A wide-based nipple is used for feeding infants who have a cleft lip.
