Chapter-by-chapter chunked reference. Designed to replace the PDF for active study — every populated chapter has a TL;DR card, sectioned content, exercises, and abbreviation tooltips. Click a chapter to open it. Track your reading with the checkboxes — single tap = reviewed, double tap = complete.
Reading Progress
▾Unit 1 — Foundations0 / 11 read
1Family-Centered Nursing CarePerspectives
2Physical Assessment FindingsPerspectives
3Health Promotion of InfantsPerspectives
4Health Promotion of ToddlersPerspectives
5Health Promotion of PreschoolersPerspectives
6Health Promotion of School-Age ChildrenPerspectives
7Health Promotion of AdolescentsPerspectives
8Safe Administration of MedicationSpecific Considerations
9Pain ManagementSpecific Considerations
10Hospitalization, Illness, and PlaySpecific Considerations
11Death and DyingSpecific Considerations
▾Unit 2 — System Disorders0 / 30 read
12Acute Neurologic DisordersNeurologic
13SeizuresNeurologic
14Head InjuryNeurologic
15Cognitive and Sensory ImpairmentsNeurologic
16Oxygen and Inhalation TherapyRespiratory
17Acute and Infectious Respiratory IllnessesRespiratory
18AsthmaRespiratory
19Cystic FibrosisRespiratory
20Cardiovascular DisordersCV/Hematologic
21Hematologic DisordersCV/Hematologic
22Acute Infectious GI DisordersGastrointestinal
23GI Structural and Inflammatory DisordersGastrointestinal
24Enuresis and Urinary Tract InfectionsGU/Reproductive
25Structural Disorders of the GU and Reproductive SystemGU/Reproductive
44Psychosocial Issues of Infants, Children, and AdolescentsOther Specific Needs
Unit 1 · Perspectives · Chapter 1
Family-Centered Nursing Care
Families are groups that should remain constant in children's lives. Family is defined as what an individual considers it to be. Family-centered nursing care recognizes the family as the constant in a child's life, treats children and their families as clients, and works in partnership to provide care that respects cultural diversity and supports developmental needs.
TL;DR · One-glance summary
Family-centered care = agreed-upon partnerships between nurses, providers, and families. Treat the family as the client, respect cultural diversity, and let families serve as experts on their children. Healthy families communicate, adapt, and share responsibility. Parental roles: parents know their child best — encourage presence during procedures, involve in care decisions. Sibling rivalry: common during illness/hospitalization; include siblings in visits; provide age-appropriate explanations; watch for regression or behavioral changes.
Components of family-centered care
Agreed-upon partnerships between families, nurses, and providers
Respecting cultural diversity in care planning
Understanding growth and developmental needs
Treating children and families as clients
Working with all family types
Collaborating regarding hospitalization, home, and community resources
Allowing families to serve as experts on their children
Characteristics of healthy families
Members communicate well and listen to each other
Affirmation and support for all members
Clear family rules, beliefs, and values
Sense of trust; shared sense of responsibility
Traditions and rituals
Adaptability and flexibility in roles
Members seek help for problems
Family theories
Family systems theory
Views the family as a whole system, not individual members.
A change to one member affects the entire system
The system can both initiate and react to change
Too much or too little change can lead to dysfunction
Family stress theory
Describes stress as inevitable.
Stressors can be expected or unexpected
Explains the family's reaction to stressful events
Offers guidance for adapting to stress
Developmental theory
Views families as small groups interacting with the larger social system.
Emphasizes similarities and consistencies in how families develop and change
Uses Duvall's family life cycle stages to describe changes over time
Functioning in one stage directly affects the next stage
Family composition
Family type
Definition
Traditional nuclear
Married couple + biologic children (only full siblings)
Nuclear
Two parents + their children (biologic, adoptive, step, foster)
Single-parent
One parent + one or more children
Blended (reconstituted)
At least one stepparent, stepsibling, or half-sibling
Extended
At least one parent, one or more children, and other individuals (related or not)
Gay/lesbian
Two same-sex members with children and a legal or common-law tie
Foster
Children placed in an approved living environment away from family of origin
Binuclear
Parents who terminated spousal roles but continue parenting roles
Communal
Individuals sharing common ownership of property and exchanging services
Parenting styles
Authoritarian (dictatorial)
Parents control behavior through unquestioned rules and expectations.
Example: "The child is never allowed to watch television on school nights."
Permissive
Parents exert little or no control; consult the child when making decisions.
Example: "The child decides whether they will watch television."
Authoritative (democratic)
Parents set rules and explain the reason for each rule. Negative reinforcement is used proportionally.
Example: "Child can watch TV 1 hr on school nights after homework + chores. Privilege removed if rules broken, reinstated with new guidelines."
Passive (uninvolved)
Parents are uninvolved, indifferent, emotionally removed.
Example: "The child may watch television whenever they want."
Promoting acceptable behavior
Set clear and realistic limits based on the child's developmental level
Validate the child's feelings; offer sympathetic explanations
Provide role modeling and reinforcement for appropriate behavior
Focus on the behavior when disciplining, not the child
Family assessment
Domain
What to assess
History
Medical history for parents, siblings, and grandparents
Structure
Family members (mother, father, son, etc.)
Developmental tasks
Tasks the family is working on (e.g., school-age peer relations)
Family characteristics
Cultural, religious, economic influences on behavior
Family stressors
Expected (birth) and unexpected (illness, divorce, death) events
Environment
Family interactions with community resources
Support system
Extended family, work/peer relationships, social systems
QUICK CHECK: Which two ATI Active Learning Templates fit family-centered care best? Answer: Basic Concept (for theories like family systems) and Growth & Development (for assessment frameworks across age groups).
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Basic Concept. Practice answering before reviewing the key.
Scenario
A nurse is providing anticipatory guidance to the mother of a toddler. The nurse learns that the household includes the mother, toddler, an older brother, and a grandmother.
RELATED CONTENT: Describe the composition of this family.
UNDERLYING PRINCIPLES: ● Describe two methods the parent can use to positively influence the child. ● Describe two ways the parent can promote acceptable behavior in the child.
NURSING INTERVENTIONS: Include two additional family assessments the nurse should perform.
Answer key
Related Content
This is an extended family, which
includes at least one parent, one or more children, and
other individuals who are either related or not related.
Underlying Principles
Positive parental influences
Have good mental health.
Maintain structure and routine in the household.
Engage in activities with the child.
Validate the child’s feelings when communicating.
Monitor for safety concerns with special consideration
for the child’s developmental needs.
Promoting acceptable behavior
Validate the child’s feelings, and offer sympathetic explanations.
Provide role modeling and reinforcement for acceptable behavior.
Set clear and realistic limits and expectations
based on the child’s developmental level.
Focus on the behavior when implementing discipline.
Nursing Interventions
Family assessments
Medical history on parents, siblings, and grandparents
Family structure for roles/position within the family, as
well as occupation and education of family members
Developmental tasks a family works on as the child grows
Family characteristics (cultural, religious, and economic
influences on behavior, attitudes, and actions)
Family stressors, (expected [birth of a child] and
unexpected [illness of a child, divorce, disability or death
of a family member] events that cause stress)
Availability of and family interactions with community resources
Family support systems (availability of extended family; work and
peer relationships; and social systems and community resources
to assist the family in meeting needs or adapting to a stressor)
Application Exercises
Q1
A nurse manager on a pediatric unit is preparing an education program on working with families for newly hired nurses. Which of the following should the nurse include when discussing developmental theory?
A. Describes that stress is inevitable
B. Emphasizes that change with one member affects the entire family
C. Provides guidance to assist families adapting to stress
D. Defines consistencies in how families change
Show rationale ▾
A. Family stress theory describes that stress is inevitable.
B. Family systems theory emphasizes that change with one member affects the entire family.
C. Family stress theory provides guidance for adapting to stress.
D.CORRECT. Developmental theory defines consistencies in how families change.
NCLEX® Connection: Health Promotion and Maintenance — Developmental Stages and Transitions
Q2
A nurse is assisting a group of guardians of adolescents to develop skills that will improve communication within the family. A guardian states, "My son knows he better do what I say." Which parenting style is the parent exhibiting?
A. Authoritarian
B. Permissive
C. Authoritative
D. Passive
Show rationale ▾
A.CORRECT. Authoritarian parents control behavior through unquestioned rules and expectations.
B. Permissive parents exert little or no control.
C. Authoritative parents direct behavior by setting rules and explaining reasons.
D. Passive parents are uninvolved, indifferent, and emotionally removed.
NCLEX® Connection: Psychosocial Integrity — Family Dynamics
Q3
A nurse is performing a family assessment. Which of the following should the nurse include? (Select all that apply.)
A. Medical history
B. Parents' education level
C. Child's physical growth
D. Support systems
E. Stressors
Show rationale ▾
A.CORRECT. History — including medical history of parents, siblings, and grandparents — is part of family assessment.
B. Education level is not a standard family-assessment domain (though it may inform teaching approaches).
C. Physical growth is part of the child's individual assessment, not family assessment.
D.CORRECT. Family support system — extended family, work/peer relationships, community resources.
E.CORRECT. Family stressors — expected and unexpected events causing stress.
NCLEX® Connection: Health Promotion and Maintenance — Family Systems Assessment
Pediatric physical assessments must be adapted to chronological age and developmental needs. Praise children for cooperation, observe readiness behaviors, and use the Denver II for developmental screening when needed. Vital signs vary widely by age — know the expected ranges cold.
TL;DR · One-glance summary
Adapt the exam to the child's age. Take vitals using age-appropriate routes (axillary for newborns, oral for cooperative children). Memorize vital sign ranges by age and the seven infant reflexes with their disappearance ages. Use the Denver II for developmental screening.
Exam preparation principles
Keep the room warm and well lit
Keep medical equipment out of sight until needed
Take time to play and build rapport first
Use age-appropriate language; demonstrate with dolls/puppets
Allow the child to handle equipment
Examine in a secure, comfortable position (toddler on parent's lap)
Proceed in an organized sequence when possible
Readiness behaviors
Interacting with the nurse
Making eye contact
Permitting physical touch
Willingly sitting on the examination table
Accepting and handling equipment
Physiologic and growth measurements
Temperature by age (expected level · recommended routes)
Age
Expected temp
Recommended routes
3 mo
37.5°C (99.5°F)
Axillary; rectal if exact measurement necessary
6 mo–1 yr
37.7°C (99.9°F)
Axillary; rectal if exact
3 yr
37.2°C (99.0°F)
Axillary, tympanic, oral (if cooperative)
5 yr
37.0°C (98.6°F)
Oral, axillary, tympanic; rectal if exact
7–13 yr
36.6–36.8°C (97.9–98.2°F)
Oral, axillary, tympanic
Pulse rate by age (range/min)
Age
Pulse range
Newborn (birth–4 wk)
110–160
Infant (1–12 mo)
90–160
Toddler (1–2 yr)
80–140
Preschooler (3–5 yr)
70–120
School age (6–12 yr)
60–110
Adolescent (13–18 yr)
50–100
Respirations by age (range/min)
Age
Respiration range
Newborn (birth–4 wk)
30–60
Infant (1–12 mo)
25–30
Toddler (1–2 yr)
25–30
Preschooler (3–5 yr)
20–25
School age (6–12 yr)
20–25
Adolescent (13–18 yr)
16–20
Blood pressure — key facts
Compare with standards (NHBPEP Working Group on High BP in Children and Adolescents)
Age, height, and sex all influence readings
Newborn average: ~64/41 mm Hg · Infant: ~85/50 mm Hg
Adolescent (13–18 yr): less than 120/80 mm Hg
Hypertension = ≥ 95th percentile for age, height, sex
Growth measurements
Weight, length/height, BMI, head circumference
WHO growth charts for ages 0–2 years (in the US)
CDC growth charts for children 2 years and older
Expected physical assessment findings
General appearance
Appears undistressed, clean, well-kept, without body odors
Erect head posture expected after 4 months of age
Makes eye contact when addressed (except infants)
Follows simple commands age-appropriately
Skin, hair, and nails
Skin: variations in color expected; warm or slightly cool; smooth/slightly dry; brisk turgor with adequate hydration
Male: foreskin may not be retractable in infants/small children; left testicle slightly lower
Female: hymen may be absent or partially/completely cover vaginal opening
Routine rectal exams NOT done in pediatrics
Musculoskeletal
Joints: stable, symmetric, full ROM, no crepitus/redness
Infants: spine without dimples/hair tufts, midline with C-shaped lateral curve
Toddlers: bowlegged or knock-knee common; feet face forward when walking
Adolescents: midline spine (assess for scoliosis)
Infant reflexes (memorize)
Reflex
How elicited
Expected age
Sucking and rooting
Stroke cheek or edge of mouth → infant turns head toward touched side and sucks
Birth to 4 months
Palmar grasp
Place object in palm → infant grasps
Birth to 4 months
Plantar grasp
Touch sole of foot → toes curl downward
Birth to 8 months
Moro reflex
Let head fall back 30° → arms/legs symmetrically extend, then abduct with C-shaped fingers
Birth to 4 months
Tonic neck (fencer)
Turn head to one side → arm/leg extend on that side, flex on other
Birth to 3–4 months
Babinski reflex
Stroke outer edge of sole upward → toes fan upward and out
Birth to 1 year
Stepping
Hold infant upright with feet touching flat surface → stepping movements
Birth to 4 weeks
QUICK CHECK: Which reflex disappears earliest? Answer: Stepping reflex — gone by 4 weeks of age. The Babinski reflex lasts the longest (up to 1 year).
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Basic Concept. Practice answering before reviewing the key.
Scenario
A nurse is preparing to examine a preschool-age child.
UNDERLYING PRINCIPLES: Describe two behaviors that indicate the child is ready to cooperate.
NURSING INTERVENTIONS: ● Describe two actions to take if child is uncooperative. ● Include three actions to promote the child’s comfort during the examination.
Answer key
Underlying Principles
Child is ready to cooperate.
Interacting with nurse.
making eye contact.
Permitting physical touch.
Willingly sitting on examination table.
Accepting and handling equipment.
Nursing Interventions
Actions to take if child is uncooperative
Engage both the child and parent.
Be firm and direct about expected behavior.
Complete the assessment as quickly as possible.
Use a calm voice.
Reduce environmental stimuli.
Limit the people in the room.
Actions to enhance child’s comfort
Perform examination in nonthreatening environment.
Take time to play and develop rapport prior to beginning the examination.
Keep the room warm and well lit.
Keep Medical equipment out of sight until needed.
Provide privacy.
Explain each step of the examination to the child.
Examine the child in a secure, comfortable position.
Examine the child in an organized sequence when possible.
Encourage the child and family to ask questions during the examination.
Application Exercises
Q1
A nurse is preparing to examine a 2-year-old in the clinic. Which approach should the nurse use to support the toddler's developmental needs during the exam?
A. Have the parent step out so the child cooperates faster
B. Begin with the most invasive parts to get them over with
C. Allow the child to remain on the parent's lap when possible
D. Use clinical terminology so the child takes the exam seriously
Show rationale ▾
A. Parental presence supports the toddler emotionally during exam.
B. Invasive components should come last to maintain trust.
C.CORRECT. A toddler on the parent's lap retains a secure base — ideal for cooperation.
D. Use age-appropriate language; clinical jargon increases anxiety.
NCLEX® Connection: Health Promotion and Maintenance — Developmental Stages and Transitions
Q2
A nurse is checking the vital signs of a 9-month-old. Which set of readings falls within the expected range?
A. Pulse 178/min, respirations 36/min, axillary temp 37.2°C
B. Pulse 130/min, respirations 28/min, axillary temp 37.4°C
C. Pulse 84/min, respirations 22/min, axillary temp 37.6°C
D. Pulse 145/min, respirations 14/min, axillary temp 36.4°C
Show rationale ▾
A. Pulse and respirations both above the infant range (90–160 / 25–30).
B.CORRECT. All three values within infant ranges.
C. Pulse and respirations both too low for an infant.
D. Respirations too low for an infant.
NCLEX® Connection: Reduction of Risk Potential — System Specific Assessments
Q3
A nurse is preparing to perform an otoscopic exam on an 18-month-old. Which technique is correct?
A. Pull the pinna up and back
B. Pull the pinna down and back
C. Pull the pinna straight outward
D. No manipulation is needed in toddlers
Show rationale ▾
A. Up and back is for children older than 3 years.
B.CORRECT. Down and back for infants and toddlers (canal angle differs from adults).
C. Pulling straight out does not straighten the pediatric ear canal.
D. Canal manipulation is required for visualization.
NCLEX® Connection: Reduction of Risk Potential — System Specific Assessments
Q4
A nurse is assessing infant reflexes on a 5-week-old. Which reflexes should the nurse expect to elicit? (Select all that apply.)
A. Moro
B. Palmar grasp
C. Stepping
D. Babinski
E. Plantar grasp
Show rationale ▾
A.CORRECT. Moro persists to 4 months.
B.CORRECT. Palmar grasp persists to 4 months.
C. Stepping reflex disappears by 4 weeks of age — gone at 5 weeks.
D.CORRECT. Babinski persists to 1 year.
E.CORRECT. Plantar grasp persists to 8 months.
NCLEX® Connection: Health Promotion and Maintenance — Developmental Stages and Transitions
Q5
A nurse documenting the assessment of a 4-month-old notes the anterior fontanel is open and the posterior fontanel is closed. How should the nurse interpret these findings?
A. Both findings are expected for this age
B. The anterior fontanel should have closed; report to provider
C. The posterior fontanel should still be open; report to provider
D. Both findings are abnormal; immediate intervention required
Show rationale ▾
A.CORRECT. Posterior closes by 2–3 months (closed at 4 mo is expected); anterior closes 12–18 months (still open at 4 mo is expected).
B. Anterior closure is not expected until 12–18 months.
C. Posterior fontanel typically closes by 2–3 months.
D. Both are expected findings, not abnormal.
NCLEX® Connection: Health Promotion and Maintenance — Developmental Stages and Transitions
Infancy is a period of rapid physical, motor, cognitive, and psychosocial change. Nurses use anticipatory guidance to teach parents what's expected at each stage, screen for problems early, and prevent injury and illness through routine immunizations and safety teaching.
TL;DR · One-glance summary
Weight doubles by 5–6 mo, triples by 12 mo. Posterior fontanel closes by 2 mo; anterior by 12–18 mo. Erikson stage: trust vs. mistrust. Piaget: sensorimotor. Stranger fear emerges 6–8 mo. Solids start around 6 mo (iron-fortified cereal first). No honey before age 1. Rear-facing car seat until age 2 (or seat's height/weight limit).
Growth landmarks
Birth weight averages 2.5–4 kg (5.5–8.8 lb)
Weight: ×2 by 5–6 mo, ×3 by 12 mo
Length: +50% by 12 mo
Head circumference: equals chest circumference by ~12 mo
Posterior fontanel: closes 2 mo
Anterior fontanel: closes 12–18 mo
Developmental anchors
Erikson: Trust vs. Mistrust (Erikson) (consistent caregiver response)
Piaget: Sensorimotor (object permanence ~9 mo)
Separation anxiety: peaks 10–18 mo (starts ~4–8 mo)
Stranger fear: 6–8 mo
First social smile: 2 mo
Motor skill development
Gross motor milestones
Age
Skill
2 mo
Lifts head off mattress when prone
3 mo
Raises head and shoulders off mattress
4 mo
Rolls back to side
5–6 mo
Rolls front to back, then back to front; sits with support
7 mo
Sits unsupported (briefly)
8–9 mo
Sits steadily; pulls to stand; crawls
10 mo
Cruises along furniture
11–12 mo
Walks with one hand held; some take first independent steps
Fine motor milestones
Age
Skill
2 mo
Fists begin to open
3 mo
Holds hands open; grasps reflexively
4 mo
Brings objects to mouth; hands meet at midline
5–6 mo
Voluntary grasp; transfers objects hand-to-hand
7 mo
Bangs objects together
8–9 mo
Develops pincer grasp (thumb + finger)
10–12 mo
Refined pincer grasp; can hold a crayon and make marks
Cognitive and language development
Piaget — Sensorimotor stage (birth–24 mo)
Learns through senses and movement
Object permanence develops around 9 months (objects exist when out of sight)
Begins purposeful behavior; experiments with cause-and-effect
Imitates simple actions by end of first year
Language milestones
Age
Language
2 mo
Cooing
3–4 mo
Laughs; squeals
6 mo
Babbles single syllables ("ba," "ma")
9 mo
Says "mama," "dada" nonspecifically; responds to own name
10–12 mo
Says "mama," "dada" specifically; 3–5 word vocabulary
Psychosocial development
Erikson — Trust vs. Mistrust (birth–1 yr)
The infant develops trust when caregivers consistently meet needs — feeding when hungry, comforting when distressed, providing predictable interaction. Inconsistent or neglectful responses lead to mistrust.
Nursing teaching: respond promptly to crying; maintain consistent routines; encourage primary caregivers to provide most of the infant's daily care.
6–8 mo: Stranger fear emerges — infant resists unfamiliar people
9–10 mo: Plays simple games (peek-a-boo, pat-a-cake)
12 mo: Waves bye-bye; shows preference for parent
QUICK CHECK: At what age does an infant typically begin to fear strangers? Answer: 6–8 months. This coincides with the development of object permanence and the ability to distinguish familiar from unfamiliar faces.
Health promotion
Immunization schedule (first year, selected)
Age
Vaccines
Birth
Hep B (#1)
2 mo
Hep B (#2), RV, DTaP, Hib, PCV13, IPV
4 mo
RV, DTaP, Hib, PCV13, IPV
6 mo
Hep B (#3), RV (if 3-dose series), DTaP, Hib, PCV13, IPV, annual influenza (≥6 mo)
12 mo
MMR (#1), Varicella (#1), Hep A (#1), Hib (final), PCV13 (final)
Birth–6 mo: Breast milk or iron-fortified formula exclusively. Vitamin D supplement (400 IU/day) for breastfed infants starting at birth.
~6 mo: Introduce solids when infant shows readiness — sits with support, holds head steady, opens mouth for spoon, has lost tongue-thrust reflex.
First food: Iron-fortified rice cereal (high iron content; lower allergy risk).
Introduce one new food at a time, waiting 4–7 days between to monitor for allergic reaction.
Avoid: Honey before 12 mo (botulism risk). Cow's milk before 12 mo (renal solute load, iron deficiency anemia risk). Choking hazards: nuts, popcorn, hot dogs, whole grapes, hard candy.
Back to Sleep: Place infants supine on a firm surface; no soft bedding, pillows, or stuffed animals (SIDS prevention)
Dental care
Clean gums with a soft, damp cloth after feedings (before teeth erupt)
First tooth typically erupts around 6 mo (lower central incisors)
Once teeth erupt: brush with a soft toothbrush; use a tiny smear of fluoride toothpaste (rice grain size)
Do not put infant to bed with a bottle (bottle-mouth caries)
First dental visit by age 1
Injury prevention by mechanism
Aspiration / suffocation
Keep small objects, balloons, and plastic bags out of reach
Avoid choking-hazard foods (whole grapes, nuts, popcorn, hot dogs)
No pillows, soft bedding, bumper pads, or stuffed animals in crib
Position supine for sleep
Motor vehicle injury
Rear-facing car seat in the back seat until age 2 (or seat's height/weight max)
Never leave infant unattended in a vehicle
Drowning
Never leave infant unattended in any amount of water — bathtub, bucket, pool, toilet
Empty containers of water immediately after use
Burns / scalds
Set water heater to ≤49°C (120°F)
Test bath water temperature with elbow or wrist before bathing
Keep hot liquids and cookware out of reach
Apply sunscreen (≥6 mo); keep younger infants in shade
Falls / poisoning
Never leave infant unattended on a raised surface
Install gates at the top and bottom of stairs once mobile
Use cabinet locks; store medications and cleaners locked and out of reach
Post Poison Control number: 1-800-222-1222
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Growth and Development. Practice answering before reviewing the key.
Scenario
A nurse is preparing an educational program for a group of caregivers of infants.
DEVELOPMENTAL STAGE: Identify the infant’s developmental stage according to Piaget and Erikson.
COGNITIVE DEVELOPMENT: List two cognitive developmental tasks the infant should accomplish in the first year of life. AGE-APPROPRIATE ACTIVITIES: List five activities appropriate for infants.
INJURY PREVENTION: Identify two injury prevention methods in each of the following categories. ● Aspiration ● Poisoning ● Drowning ● Suffocation
Answer key
Developmental Stage
Piaget: SensoriMotor stage
Erikson: Trust vs. mistrust
Cognitive Development
Infants progress from reflexive to simple repetitive to imitative activities.
Separation: Learning to separate themselves from other objects in the environment.
Object permanence: Understanding that an object still exists when it is out of view.
mental representation: Ability to recognize and use symbols. AGE-APPROPRIATE ACTIVITIES
Rattles
Soft stuffed toys
Teething toys
Nesting toys
Playing pat-a-cake
Playing with balls
Reading books
mirrors
Brightly colored toys
Playing with blocks
Injury Prevention
Aspiration
Avoid small objects.
Hold infant for feedings; do not prop bottles.
Provide age-appropriate toys.
Check clothing for hazards (loose buttons).
Poisoning
Keep toxins and plants out of reach.
Place safety locks on cabinets where cleaners/chemicals are stored.
Use a carbon monoxide detector in the home.
Keep Medications in childproof containers and out of reach.
Drowning
Do not leave unattended around any water source.
Secure fencing around swimming pool.
Keep bathroom door closed.
Suffocation
Avoid plastic bags.
Ensure crib mattress fits snugly.
Remove crib mobiles by 4 to 5 months of age.
Keep pillows out of the crib.
Place on back to sleep.
Application Exercises
Q1
A nurse is teaching a parent about expected weight changes during infancy. Which of the following statements indicates correct understanding?
A. "My baby's birth weight should double by 3 months."
B. "My baby's birth weight should double by 5 to 6 months."
C. "My baby's birth weight should triple by 8 months."
D. "My baby's birth weight should quadruple by 12 months."
Show rationale ▾
A. Doubling by 3 months is too early.
B.CORRECT. Birth weight doubles by 5–6 months and triples by 12 months.
C. Tripling occurs by 12 months, not 8.
D. Quadrupling typically occurs by age 2½, not 12 months.
NCLEX® Connection: Health Promotion and Maintenance — Developmental Stages and Transitions
Q2
A nurse is observing a 9-month-old during a well-child visit. Which finding suggests object permanence has developed?
A. The infant babbles "ba-ba-ba" repeatedly
B. The infant looks for a toy that the nurse hid under a blanket
C. The infant transfers a rattle from one hand to the other
D. The infant cries when a stranger enters the room
Show rationale ▾
A. Babbling reflects language development, not object permanence.
B.CORRECT. Searching for a hidden object demonstrates the infant understands objects exist even when out of sight — the hallmark of object permanence (~9 mo).
C. Hand-to-hand transfer reflects fine motor development (~6 mo).
D. Stranger fear is a psychosocial milestone, not specifically object permanence.
NCLEX® Connection: Health Promotion and Maintenance — Developmental Stages and Transitions
Q3
A parent asks the nurse when to begin introducing solid foods to their infant. The nurse should recommend introducing solids at which age?
A. 2 months
B. 4 months
C. 6 months
D. 9 months
Show rationale ▾
A. Too early — GI tract is not mature.
B. Some readiness cues may appear, but 6 mo is the recommended start.
C.CORRECT. Around 6 months is when most infants show readiness — sitting with support, head control, loss of tongue-thrust reflex.
D. Solids should be well established by 9 months.
NCLEX® Connection: Basic Care and Comfort — Nutrition and Oral Hydration
Q4
A nurse is providing anticipatory guidance to the parents of a 10-month-old. Which of the following teaching points should the nurse include? (Select all that apply.)
A. Place infant supine for sleep on a firm surface
B. Avoid honey until after the first birthday
C. Switch to whole cow's milk at this age
D. Use a rear-facing car seat until at least age 2
E. Set the home water heater to ≤49°C (120°F)
Show rationale ▾
A.CORRECT. Back-to-Sleep position prevents SIDS.
B.CORRECT. Honey can harbor Clostridium botulinum spores; avoid before 12 mo.
C. Cow's milk should not be introduced until after 12 months.
D.CORRECT. Rear-facing car seat in back seat until age 2 (or seat's height/weight limit).
E.CORRECT. Lower water heater setting prevents scald burns.
NCLEX® Connection: Safety and Infection Control — Accident/Injury Prevention
Q5
A nurse is reviewing the immunization schedule for a 12-month-old at a well-child visit. Which vaccines are typically administered at this visit?
A. Hep B #1, RV #1, DTaP #1
B. MMR #1, Varicella #1, Hep A #1
C. Tdap, HPV, MenACWY
D. Influenza only
Show rationale ▾
A. Hep B #1 is given at birth, not 12 months. DTaP and RV begin at 2 months.
B.CORRECT. First doses of MMR, Varicella, and Hep A — plus Hib and PCV13 finals — are given at the 12-month visit.
C. Tdap, HPV, and MenACWY are adolescent vaccines.
D. Influenza is given annually; oseltamivir (Tamiflu) is the antiviral for influenza treatment and prophylaxis in children ≥ 2 weeks — must be started within 48 hr of symptom onset; available as oral suspension; adverse effects include nausea, vomiting but is not the only vaccine at 12 months.
NCLEX® Connection: Health Promotion and Maintenance — Immunizations
Toddlers (1–3 yr) are defined by autonomy and exploration. Erikson's task is autonomy vs. shame/doubt. Negativism and ritualism are normal expressions of independence. Physiologic anorexia leads to picky eating. Expect parallel play, transition from sensorimotor to preoperational thought, and rapid language acquisition.
TL;DR · One-glance summary
Toddler = 1–3 yr. Anterior fontanel closes by 18 mo. Weight quadruples birth weight by 30 mo. Erikson: autonomy vs. shame/doubt. Piaget: sensorimotor → preoperational at ~2 yr. Parallel play. Negativism, ritualism, temper tantrums = developmentally normal. Physiologic anorexia = picky eating. Toilet training when child shows readiness.
Physical milestones
Anterior fontanel closes by 18 mo
Weight gains 1.8–2.7 kg (4–6 lb)/yr
Height gains ~7.5 cm (3 in)/yr
Head circumference ≈ chest circumference by 1–2 yr
20 deciduous teeth by ~30 months
Psychosocial signatures
Autonomy vs. shame/doubt (Erikson)
Negativism — frequent "no!" responses
Toilet training readiness — signs include: walks well, able to sit on toilet, stays dry for 2+ hr, aware of urge to void/defecate, can follow simple instructions, interested in toilet use, can pull pants up/down; typically emerges 18–24 mo but varies widely; do not pressure
Ritualism — comfort from routines
Temper tantrums — frustration with limits
Parallel play — play near peers, not with them
Gender identity by 3 yr
Physical development
Anterior fontanel closes by 18 months
Weight: 4× birth weight by 30 months; 1.8–2.7 kg (4–6 lb) per year
Height: ~7.5 cm (3 in) per year
Head and chest circumferences equalize at 1–2 years
20 deciduous teeth eventually erupt
Motor skill development by age
Age
Gross motor
Fine motor
15 mo
Walks without help; creeps up stairs
Uses a cup well; builds 2-block tower; spoon without rotation
18 mo
Runs clumsily, falls often; throws ball overhand; jumps in place 2 feet; pulls and pushes toys
Turns book pages 2–3 at a time; builds 3–4 block tower
2 yr
Walks up/down stairs placing both feet on each step
Builds 6–7 block tower; turns book pages one at a time
2.5 yr
Jumps across floor and off a chair with both feet; stands on one foot momentarily; tiptoe steps
Brush after meals and at bedtime; water only after bedtime cleaning
Fluoride supplementation if drinking water lacks it
Early childhood caries: associated with bottle-in-bed (juice or milk)
Injury prevention
Aspiration / bodily harm
Avoid small objects: grapes, coins, beads, candy
Keep balloons away (latex; aspiration risk)
Sharp objects, firearms (locked) out of reach
Stranger safety teaching begins
Don't leave with animals unattended
Burns / poisoning / drowning / MVA
Bath water temp checked; hot water heater < 49°C (120°F)
Pot handles turned to back of stove
Smoke detectors, electrical outlet covers
Cleaners locked; medications in childproof containers
Poison Control number posted: 1-800-222-1222
Pool fencing; never alone near water
Rear-facing car seat until age 2 (or per manufacturer's height/weight limits)
QUICK CHECK: A toddler refuses to eat anything but crackers for three days. What's the best parental response? Answer: Continue offering a variety of foods without coercion. Physiologic anorexia is normal — children will eat what they need over time. Avoid power struggles around food.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Growth and Development. Practice answering before reviewing the key.
Scenario
A nurse is conducting a well-child visit with a 2-year-old toddler.
DEVELOPMENTAL STAGE: Identify the toddler’s developmental stage according to Piaget and Erikson.
NUTRITION: List three concepts to include in teaching with the family.
INJURY PREVENTION: Identify two injury prevention methods to include in teaching with the family for each of the following categories. ● Bodily harm ● Drowning ● Burns ● Falls RN NURSING CARE OF CHILDREN
Answer key
Developmental Stage
Piaget: Preoperational stage
Erikson: Autonomy vs. shame and doubt
Nutrition
may switch from whole milk to low fat milk after the age of 2 years.
Trans fatty acids and saturated fats should be avoided.
Diet should include 1 cup of fruit daily.
Limit fruit juice to 4 to 6 oz per day.
Cut food into small, bite-size pieces to prevent choking.
Do not allow drinking or eating during play activities or while lying down.
Injury Prevention
Bodily harm
Keep sharp objects out of reach.
Lock firearms in a cabinet or box.
Teach toddler stranger safety.
Do not leave toddler unattended with animals.
Drowning
Do not leave toddler unattended in bathtub.
Keep toilet lids closed.
Begin teaching toddler water safety and to swim.
Keep bathroom doors closed.
Burns
Check bath water temperature prior to toddler contact with water.
Set hot water heaters to less than 49° C (120° F) .
Keep pot handles pointed to back of stove when cooking.
Cover electrical outlets.
Keep working smoke detectors in the home.
Apply sunscreen when toddler will be outside.
Falls
Keep doors and windows locked.
Place crib mattresses in lowest position with rails all the way up.
Use safety gates at the top and bottom of stairs.
Application Exercises
Q1
A nurse is teaching parents about the development of an 18-month-old. Which behavior should the nurse describe as expected?
A. Cooperative play with peers
B. Frequent use of "no" in response to requests
C. Ability to share toys without prompting
D. Quiet acceptance of a daily routine change
Show rationale ▾
A. Cooperative play emerges in preschool/school-age children, not toddlers.
B.CORRECT. Negativism is a normal expression of autonomy in toddlers.
C. Toddlers are egocentric and do not naturally share.
D. Toddlers thrive on ritualism — routine changes typically cause distress.
NCLEX® Connection: Health Promotion and Maintenance — Developmental Stages and Transitions
Q2
A parent of a 2-year-old expresses concern that the child "barely eats anything." Which response by the nurse is most appropriate?
A. "Add a pediatric nutritional supplement to each meal."
B. "Decreased appetite is a normal part of toddler development."
C. "Let the child eat whatever they want for now."
D. "Limit milk to one cup per day until appetite improves."
Show rationale ▾
A. Supplements aren't first-line; growth slows naturally in toddlerhood.
B.CORRECT. Physiologic anorexia is normal in toddlers due to slowed growth rate.
Preschoolers grow more slowly than toddlers but expand rapidly in cognition, language, and social skill. Erikson's stage is initiative vs. guilt. Magical thinking, animism, and egocentric reasoning shape how preschoolers interpret illness, hospitalization, and the world around them.
TL;DR · One-glance summary
Preschooler = 3–6 yr. Erikson: initiative vs. guilt. Piaget: preoperational (preconceptual → intuitive). Associative play. Magical thinking and animism are normal — they may believe illness is punishment. 20 deciduous teeth. Booster seat in back seat. 4–6 yr immunizations: DTaP #5, IPV #4, MMR #2, Varicella #2.
Physical growth
Weight gain: 2–3 kg (4.4–6.6 lb)/yr
Height gain: 6–8 cm (2.5–3 in)/yr
20 deciduous teeth fully erupted
Visual acuity ≈ 20/40 → 20/30 by age 6
Pot belly disappears; child becomes taller and leaner
Key behaviors
Associative play (interact but no shared goal)
Imaginary friends are normal
Common fears: dark, ghosts, monsters, body mutilation
Aggression peaks at age 4 then declines
Modesty develops by age 4–5
Motor skill development
Gross motor by age
Age
Skill
3 yr
Rides tricycle; jumps off bottom step; balances on one foot briefly; climbs stairs alternating feet
4 yr
Hops on one foot; throws ball overhand; catches large ball; descends stairs alternating feet
5 yr
Skips and hops on alternating feet; jumps rope; balances on alternating feet with eyes closed; throws/catches with accuracy
Fine motor by age
Age
Skill
3 yr
Builds tower of 9–10 blocks; copies a circle; draws a cross
4 yr
Uses scissors; copies a square; draws a person with 3 parts (stick figure with head and 2 features)
5 yr
Ties shoelaces; copies a triangle/diamond; prints letters and own name; draws a person with 6 parts
Cognitive and language development
Piaget — Preoperational stage (2–7 yr)
Preschoolers think symbolically but not logically. Key features:
Egocentrism: only sees the world from their own perspective
Magical thinking: thoughts can cause events ("I was mad at my brother, that's why he got sick")
Animism: attributes life and feelings to inanimate objects ("the moon is following me")
Centration: focuses on one feature of an object at a time
Transductive reasoning: links two specific events without logical connection
5 yr: ~2100 words; speaks in full sentences with all parts of speech
Psychosocial and moral development
Erikson — Initiative vs. Guilt (Erikson) (3–6 yr)
The preschooler is energetic and curious, asking endless questions and tackling new tasks. Successful initiative builds purpose; criticism or restriction breeds guilt.
Nursing teaching: Praise efforts. Set firm but flexible limits. Allow choice in low-stakes decisions. Provide opportunities to "help" with simple tasks.
Play and social development
Associative play: children play together with similar activities but no organized goal or role assignment
Imitation, dramatic/pretend play, role-playing common
Imaginary friends are healthy expressions of imagination
Preschoolers learn to take turns and share (still developing)
Common fears
The dark, ghosts, monsters
Body mutilation/intrusive procedures (especially important during illness/hospitalization)
Separation from parents
Animals, loud noises, strangers
Moral development (Kohlberg)
Preconventional level — punishment-and-obedience orientation. "Right" is what avoids punishment.
QUICK CHECK: A 4-year-old asks whether she got sick because she was mean to her brother. What concept does this reflect? Answer: Magical thinking. The preschooler links unrelated events causally — believing thoughts or feelings caused her illness. Reassure her that being mean did not make her sick.
Continue cabinet locks for medications and chemicals
Sun protection: SPF 30+, hats, sun-protective clothing
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Growth and Development. Practice answering before reviewing the key.
Scenario
A nurse is providing anticipatory guidance to the parents of a preschool-age child.
PHYSICAL DEVELOPMENT: Identify general expectations for height and weight during the preschool years.
COGNITIVE DEVELOPMENT: List two concepts related to language development in preschool-age children. AGE-APPROPRIATE ACTIVITIES: List five activities appropriate for preschool-age children.
INJURY PREVENTION: Identify two pedestrian safety rules parents should teach children. RN NURSING CARE OF CHILDREN
Answer key
Physical Development
Weight: Preschoolers should gain about 2 to 3 kg (4.5 to 6.5 lb) per year.
Height: Preschoolers should grow about 6.2 to 9 cm (2.4 to 3.5 in) per year.
Cognitive Development
Vocabulary increases to more than 2,100 words by the end of the fifth year.
Speak in sentences of three to four words at the ages of 3 and 4 years.
Speak in sentences of four to five words at the age of 4 to 5 years.
Enjoy talking, and language becomes primary method of communication. AGE-APPROPRIATE ACTIVITIES
Putting puzzles together
Playing ball
Playing pretend and dress-up activities
Painting
Role playing
Riding tricycles
Simple sewing
Reading books
Sandboxes
Wading pools
Skating
Computer programs
musical toys
Electronic games
Injury Prevention
Stand back from curb while waiting to cross the street.
Before crossing the street, look left, then right, then left again.
Walk on the left, facing traffic, when there are no sidewalks.
At night, wear light-colored clothing with fluorescent materials attached.
Application Exercises
Q1
A nurse is caring for a 4-year-old preschooler admitted for a tonsillectomy. Which of the following nursing actions is most appropriate based on the child's developmental stage?
A. Explain in detail how the surgical equipment works
B. Reassure the child that being scared didn't cause the illness
C. Ask the child to read a pre-op information pamphlet
D. Tell the child she will not feel anything during the procedure
Show rationale ▾
A. Detailed explanations exceed preoperational reasoning ability.
B.CORRECT. Preschoolers use magical thinking and may believe their illness is punishment. Reassure the child that her thoughts or feelings did not cause the illness.
C. Most preschoolers cannot read.
D. Honest, age-appropriate descriptions of sensations are better than blanket denials.
NCLEX® Connection: Psychosocial Integrity — Therapeutic Communication
Q2
A nurse is conducting a developmental assessment of a 5-year-old. Which of the following findings would the nurse expect? (Select all that apply.)
A. Skips and hops on alternating feet
B. Ties their own shoelaces
C. Copies a triangle
D. Rides a two-wheeled bicycle without training wheels
E. Prints letters of their name
Show rationale ▾
A.CORRECT. Skipping on alternating feet is expected at 5 yr.
B.CORRECT. Tying shoelaces is a fine-motor milestone at 5 yr.
C.CORRECT. Copying a triangle is expected at 5 yr.
D. Two-wheeled bicycle without training wheels is a school-age milestone (6–7 yr).
E.CORRECT. Printing letters is expected at 5 yr.
NCLEX® Connection: Health Promotion and Maintenance — Developmental Stages and Transitions
Q3
A parent of a 4-year-old expresses concern that the child has an imaginary friend. Which response by the nurse is appropriate?
A. "Imaginary friends are a sign of social isolation and should be discouraged."
B. "Imaginary friends are part of normal imaginative play at this age."
C. "Children with imaginary friends often have psychiatric concerns."
D. "Tell your child the imaginary friend is not real to help them understand."
Show rationale ▾
A. Imaginary friends are typical, not pathologic.
B.CORRECT. Imaginary friends are an expected part of preschool play and reflect normal imaginative development.
C. Not associated with psychiatric concerns.
D. Discrediting the imaginary friend is not necessary and may distress the child.
NCLEX® Connection: Health Promotion and Maintenance — Developmental Stages and Transitions
Q4
A nurse is reviewing the immunization record of a 5-year-old at a routine school-entry visit. Which vaccines are typically administered at this visit?
A. Hep B #3, RV #3
B. DTaP #5, IPV #4, MMR #2, Varicella #2
C. Tdap, HPV, MenACWY
D. PCV13 #4, Hib #4
Show rationale ▾
A. Hep B series is completed in infancy; RV is for infants.
B.CORRECT. The 4–6 yr "kindergarten boosters" — DTaP #5, IPV #4, MMR #2, Varicella #2 — complete the routine childhood series.
C. Adolescent vaccines.
D. PCV13 and Hib are completed in infancy.
NCLEX® Connection: Health Promotion and Maintenance — Immunizations
Q5
A nurse is teaching the parent of a 3-year-old about anticipatory guidance. Which statement by the parent indicates a need for further teaching?
A. "I'll keep my child in a forward-facing car seat with a harness in the back seat."
B. "I'll offer my child a choice between two healthy snack options."
C. "My child can sleep with a small pillow now."
D. "I should switch my child to a booster seat now that they're 3."
Show rationale ▾
A. Correct — forward-facing harness in back seat is appropriate.
B. Correct — limited choices support developing autonomy.
C. Correct — pillows are safe for a 3-year-old.
D.INCORRECT STATEMENT (needs teaching). The child should remain in a harnessed forward-facing seat until reaching the seat's height/weight limit (typically ~40 lb), then transition to a booster seat. Age 3 alone is not the criterion.
NCLEX® Connection: Safety and Infection Control — Accident/Injury Prevention
Health Promotion of School-Age Children (6 to 12 Years)
School-age children move into Erikson's industry vs. inferiority stage — building competence through achievement at school, sports, and friendships. Cognitively they reach concrete operations (conservation, reversibility, classification). Peer groups, team play, and "best friends" gain central importance.
TL;DR · One-glance summary
School-age = 6–12 yr. Erikson: industry vs. inferiority. Piaget: concrete operations (conservation, reversibility). Cooperative play, team sports, same-sex peer groups. Loses deciduous teeth, gains permanent teeth. Sleep 9–11 hr. Adolescent vaccines start 11–12 yr: Tdap, HPV, MenACWY. Booster seat until 4'9" (~80 lb). Back seat until 13.
Physical growth
Weight gain: ~2–3 kg (4–6.5 lb)/yr
Height gain: ~5 cm (2 in)/yr
Visual acuity reaches 20/20 by age 6–7
Loses deciduous teeth; permanent teeth erupt
Prepubescent growth spurt: girls 10–14, boys 12–16
Key behaviors
Industry: pride in completing tasks and projects
Cooperative play with rules and roles
Same-sex peer groups; "best friend" emerges
Modesty and privacy become important
Concept of death as permanent develops (~9–10 yr)
Cognitive development
Piaget — Concrete Operations (7–11 yr)
Thinking becomes logical and organized — but tied to concrete, observable reality. New abilities:
Conservation: understands that quantity stays the same despite changes in shape (e.g., water poured into a tall thin glass vs. a short wide one)
Reversibility: mentally undoes a sequence (2+3=5 → 5−3=2)
Classification: sorts and groups objects by attribute
Seriation: arranges items in logical order (shortest → tallest)
Decline in egocentric thinking; sees others' perspectives
Psychosocial and moral development
Erikson — Industry vs. Inferiority (Erikson) (6–12 yr)
The child develops competence through achievement in school, sports, hobbies, and peer relationships. Success builds industry; persistent failure or harsh criticism breeds inferiority.
Nursing teaching: Praise effort and accomplishment. Provide opportunities for choice and responsibility. Encourage participation in activities that match the child's abilities. During hospitalization, offer age-appropriate tasks (e.g., recording intake/output, choosing the order of treatments).
Play and social development
Cooperative play: children play organized games with shared goals, rules, and assigned roles
Team sports, clubs, scout groups
Same-sex peer groups dominate; sex-segregated friend groups normal
Walk on sidewalks; cross at intersections; pedestrian/bicycle rules
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Growth and Development. Practice answering before reviewing the key.
Scenario
A nurse is providing anticipatory guidance to the guardians of a school-age child.
DEVELOPMENTAL STAGE: Identify the child’s developmental stage according to Piaget and Erikson.
PHYSICAL DEVELOPMENT: Identify three facts relevant to the child’s physical development.
NUTRITION: List three strategies the family can implement to reduce the risk of obesity.
Answer key
Developmental Stage
Piaget: concrete operations
Erikson: industry vs. inferiority
Physical Development
Will gain about 2 to 3 kg (4.4 to 6.6 lb) per year.
Will grow about 5 cm (2 in) per year.
Bladder capacity is variable with each child.
Immune system improves.
Bones continue to ossify.
Nutrition
Avoid using food as a reward.
Emphasize physical activity.
Ensure a balanced diet is consumed.
Teach children to select healthy foods and snacks.
Avoid eating fast foods frequently.
Avoid skipping meals.
model healthy behaviors.
Application Exercises
Q1
A nurse is caring for an 8-year-old hospitalized for surgery. Which intervention best supports the child's developmental needs?
A. Limit visitors to immediate family only
B. Let the child help select the time for daily wound care
C. Use a pacifier and offer cuddling for comfort
D. Avoid explaining procedures to reduce anxiety
Show rationale ▾
A. Peer contact is important for school-age children; limiting visitors increases isolation.
B.CORRECT. Offering choice supports industry vs. inferiority — the child feels competent and in control.
C. Pacifier/cuddling are infant comfort measures.
D. Concrete, honest explanations decrease anxiety in school-age children.
NCLEX® Connection: Psychosocial Integrity — Therapeutic Communication
Q2
A nurse is teaching parents about expected cognitive development of their 9-year-old. Which statement reflects a Piagetian concrete operational ability?
A. The child believes their stuffed animal can feel sad
B. The child can imagine multiple solutions to a hypothetical moral problem
C. The child understands that pouring water from a tall glass to a short, wide glass doesn't change the amount
D. The child seeks the parent immediately upon waking from a nightmare
Show rationale ▾
A. Animism is preschool (preoperational).
B. Hypothetical reasoning is formal operational (adolescence).
C.CORRECT. Conservation of volume is a defining feature of concrete operations.
D. Seeking comfort after a nightmare is age-typical but not specifically cognitive.
NCLEX® Connection: Health Promotion and Maintenance — Developmental Stages and Transitions
Q3
A nurse is teaching the parent of a 10-year-old about car safety. Which statement by the parent indicates correct understanding?
A. "My child can sit in the front seat now since they're tall."
B. "My child still needs a booster seat until they reach 4'9" tall."
C. "Booster seats are only required for children under 6."
D. "A lap belt across the abdomen is the correct seat belt position."
Show rationale ▾
A. Back seat is recommended until age 13.
B.CORRECT. Booster seat until child is 4'9" tall (~80 lb) ensures seat belt fits properly.
C. Booster seat requirement is by size, not age alone.
D. Lap belt should sit across upper thighs, not abdomen, to avoid internal injury in a crash.
NCLEX® Connection: Safety and Infection Control — Accident/Injury Prevention
Q4
A nurse is reviewing the immunization record of an 11-year-old at a well-child visit. Which vaccines are typically administered at this visit? (Select all that apply.)
A. Tdap
B. HPV
C. MenACWY
D. DTaP
E. MMR #1
Show rationale ▾
A.CORRECT. Tdap booster is given at 11–12 yr.
B.CORRECT. HPV series begins at 11–12 yr (2-dose series if started before age 15).
C.CORRECT. MenACWY #1 is given at 11–12 yr.
D. DTaP is for children under 7. The adolescent booster is Tdap.
E. MMR #1 is given at 12 months, not adolescence.
NCLEX® Connection: Health Promotion and Maintenance — Immunizations
Q5
A school nurse is talking with a 9-year-old whose grandparent recently died. Which response reflects the typical school-age understanding of death?
A. "My grandma is just sleeping and will come back."
B. "Grandma went on a long trip."
C. "What happens to grandma's body now?"
D. "Grandma must have done something bad to die."
Show rationale ▾
A. Reversibility of death is a preschool/early school-age concept.
B. Euphemistic explanations are common from adults, not the child's own understanding.
C.CORRECT. By 9–10 yr, the child understands death as permanent and asks concrete questions about it.
D. Magical thinking that death is punishment is more preschool-age.
NCLEX® Connection: Psychosocial Integrity — Grief and Loss
Adolescence brings the second growth spurt, sexual maturation (Tanner staging), formal operational thinking, and the work of identity formation. Mortality from unintentional injury, suicide, and homicide peaks in this age group, making safety screening and mental-health assessment central to every visit.
TL;DR · One-glance summary
Adolescent = 12–20 yr. Erikson: identity vs. role confusion. Piaget: formal operations (abstract, hypothetical, deductive reasoning). Puberty: girls 8.5–13 yr (menarche ~12–13), boys 10.5–16. Leading cause of death = unintentional injury (MVA); also suicide and homicide. Sleep 9 hr recommended. Adolescent immunizations at 11–12 (Tdap, HPV, MenACWY) and 16 (MenACWY booster, MenB).
Physical maturation
Tanner stages 1–5 grade sexual maturation
Girls: thelarche (breast budding) is first sign; menarche ~12–13 yr
Boys: testicular enlargement is first sign; spermarche later
Growth spurt: girls 8.5–13 yr; boys 10.5–16 yr (later but longer)
Adult body proportions reached by ~17–18 yr
Key psychosocial themes
Identity formation; experimentation with roles
Strong peer influence; family conflict over autonomy
Abstract thinking: can reason about ideas, possibilities, and concepts beyond concrete experience
Hypothetical-deductive reasoning: "if/then" analysis of multiple scenarios
Systematic problem solving: generates and tests hypotheses
Metacognition: thinks about own thinking
Two common cognitive distortions:
Imaginary audience: belief that others are constantly watching and judging
Personal fable: belief of being unique and invulnerable ("it won't happen to me") — contributes to risk-taking
Psychosocial and moral development
Erikson — Identity vs. Role Confusion (Erikson) (12–20 yr)
The central task is integrating childhood experiences, abilities, and values into a coherent sense of self. Successful identity formation produces fidelity — commitment to values, relationships, and a life direction. Failure manifests as role confusion or identity diffusion.
Nursing teaching: Speak with the adolescent privately for parts of the visit; respect confidentiality (with safety limits). Use HEEADSSS or similar psychosocial screening. Provide information, not just rules. Engage them in their own care decisions.
Relationships and identity
Early adolescence (12–14): same-sex friendships still primary; experimenting with appearance
Middle adolescence (15–17): dating begins; intense peer identification; conflict with family
Late adolescence (18–20): more stable identity; emerging adult relationships; future planning
Sexual identity development; gender identity exploration
Moral development (Kohlberg)
Conventional level continues; some adolescents progress to postconventional reasoning — understanding that laws derive from social contracts and can be questioned on principled grounds.
QUICK CHECK: A 15-year-old says, "I don't need to wear a seatbelt — accidents happen to other people, not me." What cognitive concept does this reflect? Answer: Personal fable — the belief in personal invulnerability that's common in adolescents and contributes to risk-taking behavior.
Key timelines: Thelarche typically starts at 9–11 yr. Menarche averages 12–13 yr (range 9–16); cycles often irregular for 1–2 yr after onset. Boys begin testicular enlargement at 9.5–13.5 yr; spermarche around 13–14 yr.
Screen for alcohol, tobacco/vaping, marijuana, opioids, prescription misuse
Use CRAFFT or similar tool
Brief intervention; refer for treatment when needed
Firearms
Counsel on safe storage: locked, unloaded, ammunition separate
Higher suicide risk with accessible firearms
Sports / recreation
Sports physical; concussion awareness
Heat/hydration during practice
Sun protection; skin checks
Digital safety
Limit screen time; encourage offline activities and sleep
Discuss social media's impact on mood and body image
Privacy settings; awareness of sexting consequences
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Growth and Development. Practice answering before reviewing the key.
Scenario
A nurse is preparing an educational program for a group of caregivers of adolescents.
DEVELOPMENTAL STAGE: Identify adolescent developmental stages according to Piaget and Erikson.
COGNITIVE DEVELOPMENT: List five cognitive developmental tasks the adolescent should accomplish.
INJURY PREVENTION: Identify three injury prevention methods in each of the following categories. ● Bodily harm ● Motor vehicle injuries
Answer key
Developmental Stage
Piaget: formal operations
Erikson: identity vs. role confusion
Cognitive Development
Able to think through more than two categories of variables concurrently
Capable of evaluating the quality of own thinking
Able to Maintain attention for longer periods of time
Highly imaginative and idealistic
Increasingly capable of using formal logic to make decisions
Think beyond current circumstances
Understand how the actions of an individual influence others
Injury Prevention
Bodily injury
Keep firearms unloaded and in a locked cabinet or box.
Teach proper use of sporting equipment prior to use.
Insist on helmet use and/or pads when roller skating, skateboarding, bicycling, riding scooters, skiing, and snowboarding.
Be aware of changes in mood. Continuously Monitor adolescents at risk for self-harm.
Motor vehicle injuries
Encourage attendance at drivers’ education courses.
Emphasize the need for adherence to seat belt use.
Discourage use of cell phones while driving and enforce laws regarding use.
Teach the dangers of combining substance use with driving.
Role model desired behavior.
Application Exercises
Q1
A nurse is conducting an annual visit for a 14-year-old. Which approach best supports the adolescent's developmental needs?
A. Address all questions to the parent for accuracy
B. Speak with the adolescent privately for part of the visit, explaining confidentiality and its limits
C. Require parental presence for the entire history and exam
D. Avoid discussing sexual health unless the adolescent raises it
Show rationale ▾
A. Adolescents need direct conversation to build autonomy and self-advocacy.
B.CORRECT. Private time with confidentiality discussion is the standard for adolescent visits. The nurse explains that confidentiality is maintained except in cases of risk to self or others.
C. Parental presence for the entire visit limits the adolescent's ability to discuss sensitive issues.
D. Routine sexual health screening is recommended; not raising it implicitly signals it's off-limits.
NCLEX® Connection: Psychosocial Integrity — Therapeutic Communication
Q2
A nurse is assessing pubertal development in a 12-year-old female. Which finding represents the typical first sign of puberty in girls?
A. Menarche
B. Pubic hair
C. Breast bud development (thelarche)
D. Axillary hair
Show rationale ▾
A. Menarche typically occurs 2–2.5 yr after thelarche.
B. Pubic hair usually follows breast budding.
C.CORRECT. Thelarche (breast bud development) is typically the first observable sign of puberty in girls.
D. Axillary hair appears later in pubertal progression.
NCLEX® Connection: Health Promotion and Maintenance — Developmental Stages and Transitions
Q3
A 16-year-old states, "I'm a careful driver — I don't need a seatbelt for short trips." Which cognitive concept does this statement reflect?
A. Conservation
B. Imaginary audience
C. Personal fable
D. Centration
Show rationale ▾
A. Conservation is a concrete operational ability about quantity.
B. Imaginary audience is the belief that others are watching/judging — not about invulnerability.
C.CORRECT. Personal fable — the adolescent's belief in being uniquely invulnerable to harm — contributes to risk-taking and resistance to safety measures.
D. Centration is a preschool/preoperational concept.
NCLEX® Connection: Health Promotion and Maintenance — Developmental Stages and Transitions
Q4
A nurse is reviewing immunization records for a 16-year-old. Which of the following vaccines should be considered at this visit? (Select all that apply.)
A. MenACWY booster
B. MenB
C. Annual influenza
D. RV
E. DTaP
Show rationale ▾
A.CORRECT. MenACWY booster (#2) is given at 16 yr.
B.CORRECT. MenB is given via shared clinical decision-making between ages 16–23.
C.CORRECT. Annual influenza is recommended throughout life.
D. RV is given only in infancy (final dose by 8 mo).
E. DTaP is only for children under 7. The adolescent booster is Tdap (typically at 11–12).
NCLEX® Connection: Health Promotion and Maintenance — Immunizations
Q5
A nurse is screening a 15-year-old who reports feeling hopeless and has lost interest in activities they previously enjoyed. Which nursing action takes priority?
A. Recommend more exercise and time outdoors
B. Encourage the adolescent to talk with a friend about their feelings
C. Directly ask the adolescent about thoughts of suicide or self-harm
D. Refer the adolescent for follow-up at the next routine appointment
Show rationale ▾
A. Lifestyle suggestions may help but are not the priority when depressive symptoms are present.
B. Peer support is helpful, but the nurse must first assess for safety.
C.CORRECT. Directly assessing for suicidal ideation is the priority when depressive symptoms are reported. Asking about suicide does not increase risk and is essential for safety planning.
D. Waiting until a routine appointment is inappropriate when active concerns exist.
Pediatric medication errors carry outsized risk because children have less physiologic reserve, smaller margins of error, and dosing tied to weight or body surface area. Verify dose against a reliable reference, double-check high-alert drugs with a second nurse, choose the developmentally appropriate route and technique, and involve the family without making them responsible for restraining the child.
TL;DR · One-glance summary
Verify the dose with the 10 rights; check weight-based dosing against a pediatric reference. Vastus lateralis for infants/toddlers ≤3 yr IM; ventrogluteal preferred for older children. Never call medicine candy. Use the smallest appropriate needle and IV catheter. Codeine is not recommended in children (variable metabolism). Verify dose with a second nurse for high-alert drugs (insulin, opioids, anticoagulants, chemo).
10 Rights
Right patient · drug · dose · route · time
Right documentation · reason · response
Right to education · right to refuse
Z-track technique: pull skin laterally 1–1.5 inches before IM injection; hold during injection; release after withdrawal — prevents medication tracking back; used for irritating drugs (iron dextran); do NOT massage
Intradermal injection: 5–15° angle, bevel up, into dermis (forms small wheal); used for TB testing (Mantoux/PPD) and allergy testing; do NOT massage; read TB results at 48–72 hr — measure induration (not erythema)
Pediatric considerations
Doses based on weight (mg/kg) or BSA
Always verify weight is in kg, recent, and accurate
Drug calculations: double-check arithmetic
Smaller physiologic reserve = less margin for error
Oral medication
Liquid formulations are preferred for infants and young children (use an oral syringe — not a household teaspoon)
Place the syringe along the buccal pocket (side of the mouth), give in small amounts to allow swallowing
Position infant upright or semi-reclined with head elevated to prevent aspiration
Tablets may be crushed (if drug allows) and mixed with a small amount of non-essential food (not formula, breast milk, or essential nutrition — child may refuse the food later)
Do not crush enteric-coated, extended-release, or sublingual tablets
Never refer to medication as candy
For uncooperative children: offer choices when possible ("strawberry or grape flavor?"); avoid forcing — use therapeutic holding only when needed
Injectable routes — site selection
Intramuscular (IM) by age
Age
Preferred site
Needle gauge / length
Infant (< 12 mo)
Vastus lateralis (anterolateral thigh)
22–25 G · 5⁄8 – 1 in
Toddler (1–3 yr)
Vastus lateralis
22–25 G · 5⁄8 – 1 in
Child (3 yr+)
Ventrogluteal (preferred); deltoid for small volumes
22–25 G · 5⁄8 – 1¼ in
Adolescent
Ventrogluteal or deltoid
22–25 G · 1 – 1½ in
Subcutaneous
Sites: abdomen, anterior thigh, upper outer arm
Needle 25–27 G, 3⁄8 – 5⁄8 in
Pinch skin and inject at 45° (90° if pinched skin is thick)
Rotate sites for routine doses (e.g., insulin)
Intravenous
Use the smallest catheter that supports the prescribed therapy (24 G common in infants)
Common sites: dorsum of hand, foot, antecubital, scalp (infants only when other access fails)
Use an arm board to immobilize when needed; pad and check circulation frequently
Check site every 1 hr (more often in neonates) for infiltration, redness, swelling
Use volumetric infusion pumps with safety dose limits ("smart pumps")
Limit fluid bag size to no more than 2-hr supply to prevent inadvertent overdose
Other routes
Topical / transdermal
Children have thinner skin and higher surface area to weight ratio — increased absorption risk
Apply only to indicated area; avoid open or irritated skin
For patches: rotate sites; check for residual patches before reapplying
Eye (ophthalmic)
Position supine with head slightly hyperextended; ask the child to look up
Pull down lower lid; instill drops into the conjunctival sac (not directly on the eye)
Apply light pressure to the inner canthus for 1 min to reduce systemic absorption
Ear (otic)
Warm drops to room temperature before instilling
< 3 yr: pull pinna down and back
≥ 3 yr: pull pinna up and back
Keep child side-lying for several minutes after
Nasogastric (NG) / Gastrostomy (G) tube
Verify placement before each use: aspirate gastric contents (pH 1–4 confirms gastric); X-ray confirmation at initial placement
Auscultation alone is NOT a reliable method (replaced by pH testing in evidence-based practice)
Flush with 5–10 mL water before and after medication; flush between each medication
Use liquid medications when available; crush only if approved (NEVER crush extended-release, enteric-coated)
Hold feedings 30 min before and after medication if specified
Nasal
Position supine with head hyperextended (or sitting with head tilted back)
Aim spray toward the lateral nostril wall
Encourage breath-holding briefly after
Rectal (suppository)
Position side-lying with upper knee flexed
Insert tapered end first, past the internal sphincter
Hold buttocks together briefly to prevent expulsion
Enteral / GI tube
Verify tube placement before each administration
Use liquid formulation when available; if crushing, ensure drug can be crushed
Flush tube with water before and after each medication
Administer medications separately, flushing between
Safety practices
Independent double-check by a second nurse for high-alert medications: insulin, opioids, anticoagulants (heparin), chemotherapy, vasoactive drips
Verify dose against a pediatric reference (kg-based, BSA-based); compare to maximum safe dose
Weigh in kg only — never use pounds in the calculation
Use the leading zero (0.5 mg, not .5 mg); avoid trailing zeros (5 mg, not 5.0 mg)
Engage parents as care partners; never make a parent restrain a child for a procedure they find distressing
Document all administrations promptly; document refusals and reason
Report and document errors per agency policy and ISMP guidelines
QUICK CHECK: An infant requires a 0.5 mL IM vaccine. Which site does the nurse choose? Answer: Vastus lateralis (anterolateral thigh). It's the preferred IM site for infants and toddlers up to age 3 because the muscle is well developed and free of major vessels and nerves.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Basic Concept. Practice answering before reviewing the key.
Scenario
A nurse is planning to initiate IV access for a toddler. What actions should the nurse plan to take? Use the ATI Active Learning Template: Basic Concept to complete this item. NURSING INTERVENTIONS: Describe 10 atraumatic care interventions. RN NURSING CARE OF CHILDREN
NURSING INTERVENTIONS: Describe 10 atraumatic care interventions. RN NURSING CARE OF CHILDREN
Answer key
Nursing Interventions
Decide to insert a peripherally inserted catheter before multiple peripheral attempts.
Use a transilluminator to assist in vein location.
Avoid terminology such as a “bee sting” or “stick.”
Attach extension tubing to decrease Movement of the catheter.
Use play therapy.
Apply lidocaine and prilocaine topical ointment to the site for 60 min prior to attempts.
Keep equipment out of sight until procedure begins.
Perform the procedure in a treatment room.
Use nonpharmacologic therapies.
Allow caregivers to stay if they prefer.
Use therapeutic holding.
Avoid using the dominant or sucking hand.
Cover site with a colorful wrap.
Swaddle infants.
Offer nonnutritive sucking to infants before, during, and after the procedure.
Application Exercises
Q1
A nurse is preparing to administer an IM injection to a 9-month-old infant. Which site should the nurse select?
A. Deltoid
B. Ventrogluteal
C. Dorsogluteal
D. Vastus lateralis
Show rationale ▾
A. Deltoid muscle is underdeveloped in infants.
B. Ventrogluteal is appropriate for children > 3 yr.
C. Dorsogluteal is not recommended for any pediatric age (sciatic nerve proximity).
D.CORRECT. Vastus lateralis is preferred for infants and toddlers up to age 3 — large, well-developed muscle, free of major neurovascular structures.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Parenteral Medications
Q2
A nurse is preparing to administer ear drops to a 2-year-old. Which intervention is correct?
A. Pull the pinna up and back
B. Pull the pinna down and back
C. Hold the ear straight forward
D. Administer drops with the child sitting upright
Show rationale ▾
A. Up-and-back is used for children ≥ 3 yr and adults.
B.CORRECT. For children < 3 yr the ear canal is short and straight — pull pinna down and back.
C. Not a recognized technique.
D. Child should be positioned side-lying with affected ear up; remain side-lying for several minutes after.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Q3
A nurse is preparing to administer a liquid medication to a 6-month-old. Which actions are appropriate? (Select all that apply.)
A. Place the infant in a supine flat position
B. Use an oral syringe to deliver the medication along the buccal pocket
C. Mix the dose into a full bottle of formula
D. Refer to the medication as "candy" so the infant cooperates
E. Allow the infant time to swallow between small amounts
Show rationale ▾
A. Flat supine increases aspiration risk; head should be elevated.
B.CORRECT. An oral syringe along the buccal pocket allows controlled delivery and reduces aspiration risk.
C. Mixing with a full bottle is risky — the dose isn't delivered if the bottle isn't finished, and the infant may refuse formula later.
D. Never refer to medication as candy.
E.CORRECT. Allowing time to swallow between small amounts prevents choking and aspiration.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Q4
A nurse is preparing an IV insulin infusion for a child with diabetic ketoacidosis. Which action takes priority before starting the infusion?
A. Document the patient's weight in pounds
B. Obtain an independent double-check of the dose and pump settings from a second nurse
C. Ask the parent to verify the dose
D. Pre-fill a syringe pump for the next 12 hr of therapy
Show rationale ▾
A. Pediatric weight should always be documented in kg.
B.CORRECT. Insulin is a high-alert medication. Independent double-check by a second nurse of drug, dose, concentration, rate, and pump settings prevents serious dosing errors.
C. Parent verification is not a substitute for nursing safety practices.
D. Pre-filling 12 hr of high-alert drug is unsafe; volume should be limited.
NCLEX® Connection: Safety and Infection Control — Error Prevention
Q5
A nurse is teaching a parent of a 5-year-old how to give oral medication at home. Which statement by the parent indicates a need for further teaching?
A. "I'll use the syringe that came with the medication to measure the dose."
B. "I'll tell my child the medicine is candy so it's easier to give."
C. "I'll let my child choose to sit on the couch or at the kitchen table."
D. "I'll praise my child after the dose is given."
Show rationale ▾
A. Correct — calibrated oral syringe is the safe measuring tool.
B.INCORRECT STATEMENT (needs teaching). Calling medicine "candy" risks accidental ingestion if the child finds it on their own. The parent should call it medicine.
C. Correct — offering choice supports cooperation.
D. Correct — positive reinforcement supports cooperation.
NCLEX® Connection: Health Promotion and Maintenance — Health Promotion/Disease Prevention
Children of all ages experience pain — including preterm neonates. The nurse selects the right pain scale for the child's age and developmental level, combines pharmacologic and non-pharmacologic strategies, and remembers that self-report is the gold standard when the child can give it.
TL;DR · One-glance summary
Match the pain scale to the child's age: FLACC 2 mo – 7 yr (or any non-verbal child) · Wong-Baker FACES 3 yr+ · Numeric 0–10 ≥ 5–7 yr · CRIES for neonates · PIPP for preterm. Self-report is the gold standard. Combine non-pharm + pharm. Codeine is not recommended in children (variable CYP2D6 metabolism). PCA appropriate for school-age and adolescents.
Key principles
Self-report when developmentally able
Behavioral scales when child cannot self-report
Always intervene — children don't "outgrow" the need for pain control
Treat procedural pain proactively (EMLA, sucrose)
Reassess after every intervention
Misconceptions to correct
Infants do not feel less pain than adults (they feel more)
Sleep does not equal no pain
Children do not always tell the truth about pain (may deny it to avoid an injection)
Vital sign changes are unreliable indicators of pain
Child selects one of 6 faces (no hurt → hurts worst)
Numeric Rating Scale
≥ 5–7 yr (depending on cognition)
Self-rate 0 (no pain) – 10 (worst pain)
Oucher
3–13 yr
Photographic faces scale + numeric option for older children
QUESTT framework for pediatric pain: Question the child · Use rating scales · Evaluate behavior and physiology · Secure parental involvement · Take cause into account · Take action and evaluate results.
School-age: guided imagery, controlled breathing, distraction (video, music, video games), choice and control during procedures
Adolescents: imagery, music, biofeedback, relaxation; involve in decisions
Procedural strategies for all ages
Topical anesthetic (EMLA, LMX, J-Tip): apply 30–60 min before needle procedures
Cluster painful procedures; allow rest between
Avoid the bed as the "punishment" location — perform painful procedures in a treatment room when possible
Honest, age-appropriate explanation of what the child will feel (stinging, pressure)
Allow parental presence; let the parent comfort, not restrain
Praise cooperation; offer a small reward (sticker, small toy)
Pharmacologic management
Non-opioid analgesics
Acetaminophen: 10–15 mg/kg PO/PR every 4–6 hr (max 75 mg/kg/day; not to exceed 4 g/day in adolescents)
Ibuprofen: 5–10 mg/kg PO every 6–8 hr; use only ≥ 6 months. NSAID — give with food; monitor for GI upset, renal function
Combination acetaminophen + ibuprofen can be effective; stagger doses
Opioids
Morphine is the gold standard for moderate-to-severe pain in pediatrics; available PO, IV, IM
Fentanyl, hydromorphone, oxycodone are also used
Codeine is NOT recommended in children due to variable CYP2D6 metabolism — ultra-rapid metabolizers face fatal respiratory depression risk. Tramadol carries similar concerns.
Side effects: respiratory depression, sedation, pruritus, constipation, urinary retention, nausea
Monitor: respiratory rate, sedation level (e.g., Pasero scale), O₂ sat
Keep naloxone accessible whenever opioids are administered
Bowel regimen (stool softener ± stimulant laxative) for any patient on scheduled opioids
Patient-controlled analgesia (PCA)
Appropriate for children developmentally able to understand cause and effect — typically ≥ 5–7 yr
Only the patient should press the button; do not allow family or staff to deliver doses ("PCA by proxy" is dangerous unless ordered as authorized agent-controlled analgesia)
Set lockout interval and maximum hourly dose
Monitor for over-sedation
Other routes
Regional and local anesthesia (e.g., caudal blocks postop)
Topical (EMLA, lidocaine cream/patch)
Avoid IM injections for analgesia — painful, slow absorption
Special considerations
Children with chronic pain or complex needs
Engage child life specialists, palliative care, pain service early
Engage palliative care/hospice as soon as appropriate
QUICK CHECK: A 4-year-old denies pain after surgery but is grimacing, holding the abdomen, and refusing to move. Which scale should the nurse use to assess? Answer: FLACC — the child is non-verbal in the context of pain reporting. FLACC is appropriate for any child 2 mo–7 yr or for older children who cannot reliably self-report.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Nursing Skill. Practice answering before reviewing the key.
Scenario
A nurse is reviewing pain assessment tools with a group of newly licensed nurses. What should the nurse include in the teaching?
DESCRIPTION OF SKILL: Describe four pain tools used with pediatric clients. CONTENT MASTERY SERIES
Answer key
Description Of Skill
FLACC (2 months to 7 years)
Pain rated on a scale of 0 to 10.
Assess behaviors of the child.
Face (F)
0: Smile or no expression
1: Occasional frown or grimace, withdrawn
2: Frequent or constant frown, clenched jaw, quivering chin
Children respond to illness and hospitalization in age-specific ways. Nurses anticipate those responses, deliver atraumatic care, and use therapeutic play as both a developmental tool and a clinical intervention to express feelings, master fears, and adapt to the hospital environment.
TL;DR · One-glance summary
Three big themes: separation anxiety (peak in toddlers — protest, despair, detachment), loss of control (toddler/preschool through adolescent), and fear of bodily injury/pain (peaks preschool–school age). Use atraumatic care + therapeutic play. Match play type to age: solitary → parallel → associative → cooperative. Keep parents present whenever possible.
Atraumatic care principles
Prevent or minimize separation from caregivers
Reduce or eliminate pain and distress
Promote a sense of control for the child
Family-centered, partnership approach
Play types by age
Solitary (infant): plays alone
Parallel (toddler): plays beside others
Associative (preschool): plays together with no organized goal
Cooperative (school-age): organized games with roles and rules
Age-specific responses to illness and hospitalization
Infant (birth – 12 mo)
Separation anxiety begins ~4–8 mo, intensifies through toddlerhood
Stranger fear at 6–8 mo
Responds to caregiver tone and presence
Nursing care: primary caregivers present and providing routine care when possible; consistent staff; maintain feeding and sleep schedules; offer comfort (rocking, swaddling, pacifier)
Toddler (1–3 yr)
Separation anxiety has three phases:
Protest: screaming, crying, clinging to parent, refusing to let go
Despair: withdrawn, sad, quiet, decreased activity (often misread as "adjusting well")
Detachment / denial: superficial interaction with anyone available; appears to have "gotten over it" — this is the most concerning phase
Regression is common (toilet training, language, behavior)
Magical thinking + egocentrism: may believe illness is punishment
Fear of bodily injury, pain, and mutilation (band-aids over injection sites!)
Fear of dark, monsters, ghosts compounds hospital fears
Separation anxiety present but less intense than toddler
Nursing care: simple, concrete explanations; reassure that illness isn't punishment; therapeutic play with medical equipment (medical play — child uses real or toy medical equipment on a doll/stuffed animal to rehearse or process procedures; reduces anxiety by providing control and familiarity; supervised by child life specialist); allow choices; honest descriptions of sensations; cover small wounds and injection sites
School-age (6–12 yr)
Fear of loss of control, loss of independence, missed school
Body image and privacy become important
Worry about how illness affects appearance, school performance, peer relationships
Can understand cause-and-effect concretely
Nursing care: explain in concrete terms with diagrams or models; offer choices and active participation; protect privacy; encourage peer contact (phone, video, mail); arrange schoolwork or hospital teacher; explain timing and sequence of procedures
Adolescent (12–20 yr)
Fear of separation from peers more than from family
Loss of independence and control highly threatening
Concerns about body image, future, missed activities
May appear stoic to maintain composure; check actual feelings
Nursing care: protect privacy; allow input on care plan; encourage peer visits and communication; talk with adolescent privately at times; engage them in decision-making; address concerns about appearance and recovery timeline
Video games, music, social media (supervised), reading, sports
Family considerations
Encourage rooming-in and parent presence during procedures (when supportive, not coerced)
Provide consistent caregivers when possible
Communicate clearly and in lay language; verify understanding
Address sibling concerns — siblings may feel left out, fear illness themselves, or carry guilt
Help parents maintain their parenting role; do not require them to restrain the child
Connect families with social work, child life, chaplaincy, and other support services
Cultural humility: ask about family practices, language preferences, decision-making
QUICK CHECK: A hospitalized 18-month-old has stopped crying and now plays quietly with whoever enters the room. Is this a positive sign? Answer: No — this likely represents the detachment phase of separation anxiety, which is the most concerning phase. The toddler hasn't "adjusted"; they've stopped expecting the caregiver. The nurse should encourage the parent's return and provide consistent emotional support.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Basic Concept. Practice answering before reviewing the key.
Scenario
A nurse working in a pediatric unit is planning play activities for a group of children of different ages. What activities should the nurse include in the plan of care? Use the ATI Active Learning Template: Basic Concept to complete this item. RELATED CONTENT: Identify appropriate toys and activitie
RELATED CONTENT: Identify appropriate toys and activities for children in three age groups.
Answer key
Related Content
Infants
Birth to 3 months: colorful moving mobiles, music/sound boxes
3 to 6 months: noise-making objects, soft toys
6 to 9 months: teething toys, social interaction
9 to 12 months: large blocks, toys that pop apart, push-and-pull toys Toddlers
Cloth books
Large crayons and paper
Push-and-pull toys
Tricycles
Balls
Puzzles with large pieces
Educational and child-appropriate shows and videos Preschoolers
Imitative and imaginative play
Drawing, painting, riding a tricycle, swimming, jumping, running
Educational and child-appropriate shows and videos School-age children
Games that can be played alone or with another person
Team sports
musical instruments
Arts and crafts
Collections Adolescents
Team sports
School activities
Reading, listening to music
Peer interactions
Application Exercises
Q1
A nurse is caring for a hospitalized 2-year-old who has been quiet, withdrawn, and uninterested in the activities offered. Which phase of separation anxiety is this child likely experiencing?
A. Protest
B. Despair
C. Detachment
D. Resolution
Show rationale ▾
A. Protest involves crying, screaming, clinging.
B.CORRECT. Despair: withdrawn, sad, quiet, decreased activity. Often misread by staff as "adjusting well."
C. Detachment is the third phase — superficial engagement with anyone available, appearing falsely cheerful.
A nurse is selecting age-appropriate activities for hospitalized children. Which activity is best matched to the child? (Select all that apply.)
A. A 4-month-old — colorful mobile and rattle
B. A 2-year-old — large stacking blocks beside another child
C. A 4-year-old — board game with structured rules and turn-taking
D. A 9-year-old — checkers with another patient
E. A 16-year-old — video chat with a friend from home
Show rationale ▾
A.CORRECT. Infants engage in solitary play — sensory stimulation toys are appropriate.
B.CORRECT. Toddlers engage in parallel play — playing beside, not with.
C. Rule-bound competitive games are school-age (cooperative play). Preschoolers do associative or dramatic play.
D.CORRECT. Cooperative play with rules is appropriate for school-age children.
E.CORRECT. Peer connection is central for adolescents; video chat supports their developmental need.
NCLEX® Connection: Health Promotion and Maintenance — Developmental Stages and Transitions
Q3
A 5-year-old preparing for surgery asks the nurse whether he will be cut open. Which response best supports atraumatic care?
A. "Don't worry — you'll be asleep so you won't feel anything."
B. "The doctor will make a small cut to fix what's hurting inside, and afterward you'll have a bandage to cover it."
C. "We don't talk about that part. Let's pick out a movie instead."
D. "You'll have surgery and then everything will be fine."
Show rationale ▾
A. False reassurance and dismissal of his concern.
B.CORRECT. Concrete, age-appropriate, honest description with reassurance about the bandage (preschoolers fear visible body harm and find covered wounds reassuring).
C. Deflection denies the child's right to information.
D. Vague reassurance without information.
NCLEX® Connection: Psychosocial Integrity — Therapeutic Communication
Q4
A nurse is planning care for a hospitalized 10-year-old. Which intervention best supports the child's developmental needs?
A. Limit visitors to family members
B. Provide schoolwork or arrange a hospital teacher
C. Restrict the child to bed rest with no electronic devices
D. Encourage solitary play activities
Show rationale ▾
A. Peer contact is important for school-age — encourage rather than limit.
B.CORRECT. School-age children worry about missing school. Schoolwork and educational support help maintain a sense of normalcy and reduce inferiority.
C. Unnecessary restriction; limit only as clinically required.
D. School-age children engage in cooperative play — encourage peer activities, not isolation.
NCLEX® Connection: Health Promotion and Maintenance — Developmental Stages and Transitions
Q5
A nurse is caring for a hospitalized 15-year-old. Which approach best supports the adolescent's developmental needs?
A. Require parents to be present for all care
B. Restrict cell phone use during the hospital stay
C. Engage the adolescent in care decisions and respect privacy
D. Schedule all care activities during the morning hours
Show rationale ▾
A. Adolescents need privacy and autonomy; parents need not be present for every interaction.
B. Cell phones connect adolescents to peers — central to their development.
C.CORRECT. Engaging the adolescent in decisions and respecting privacy supports identity development and reduces loss of control.
D. Inflexible schedules don't accommodate the adolescent's circadian shift or peer time.
NCLEX® Connection: Psychosocial Integrity — Therapeutic Communication
A dying child's understanding of death is shaped by developmental stage. Nurses communicate in age-appropriate language, prioritize comfort and pain control, support the family (including siblings), and respect the family's cultural and spiritual values throughout end-of-life care.
TL;DR · One-glance summary
Concept of death by age: infants/toddlers no concept · preschoolers see death as reversible and may feel responsible (magical thinking) · school-age (~9–10 yr) understand death as permanent and universal · adolescents understand fully but feel invulnerable (personal fable). Priorities: aggressive pain and symptom management, honest age-appropriate communication, sibling support, family-centered care, cultural humility.
Care priorities
Comfort: pain, dyspnea, anxiety, secretions
Honest communication with child and family
Maintain hope while preparing for death
Support siblings and extended family
Cultural and spiritual sensitivity
Service options
Palliative care: can be alongside curative treatment at any stage
Hospice: end-of-life focused; typically when life expectancy ≤ 6 mo
Inpatient vs. home-based options
Bereavement follow-up after death
Concept of death by age
Infant / Toddler (birth – 3 yr)
No cognitive concept of death
Responds to separation, change in routine, parental distress
Views death as temporary and reversible, like sleep
May believe death is a punishment
Magical thinking: may believe their thoughts or actions caused the death
Cannot grasp permanence
Nursing care: use clear, concrete language; reassure the child they did not cause the illness; avoid euphemisms ("went to sleep," "lost") which can frighten or confuse
School-age (6 – 12 yr)
By 9–10 yr: understands death as permanent, universal, and inevitable
May personify death (skeleton, "the bogeyman") in younger school-age
Asks concrete, often graphic questions (what happens to the body?)
May worry about pain, what will happen to family
Nursing care: honest concrete answers; allow questions; respect privacy; give some control (choosing music, who visits)
Adolescent (12 – 20 yr)
Understands death fully — biologically and existentially
Personal fable may make own mortality feel surreal
Anxiety: presence, reassurance, anxiolytics if appropriate
Signs that death is near (hours – days)
Profound weakness; sleeping most of the day
Decreased intake of food and fluids
Mottling of skin (especially extremities)
Cool extremities; decreased peripheral perfusion
Irregular respirations (Cheyne-Stokes pattern); periods of apnea
Decreased responsiveness
Loss of bowel and bladder control
Family and sibling support
Communication with parents
Honest, compassionate, gradual disclosure as the family is ready
Use the child's name; ask about hopes and goals
Acknowledge that there is no "right way" to grieve
Address financial, work, and practical concerns alongside emotional ones
Offer chaplaincy, social work, and bereavement services
Organ and tissue donation: discuss option with family at appropriate time; contact organ procurement organization (OPO); brain death must be established before organ donation can proceed; support family regardless of decision; allow time with the child
Sibling support
Include siblings in age-appropriate conversations and visits
Younger siblings may fear they could become ill too — reassure
Siblings may feel guilt, jealousy of attention given to the sick child, anger at the loss
Schools and counselors can help maintain routines and emotional support
Allow siblings to participate in care or memorialization if they wish
Decision-making
Discuss code status (CPR, intubation) and resuscitation preferences early — DNR/AND (Allow Natural Death) orders
Advance care planning when appropriate (older children and adolescents)
Five Wishes and similar tools support adolescent voice in care choices
Respect cultural and religious practices around death
After death
Allow family time with the child; do not rush
Offer memory-making (footprints, hair lock, photographs, name bracelet)
Provide written information about funeral arrangements, grief resources, follow-up
Bereavement follow-up — typically calls and cards at 1 mo, 6 mo, anniversary
Refer for complicated grief if symptoms persist or worsen
Nurse self-care
Caring for dying children can lead to compassion fatigue, moral distress, and burnout
Engage in debriefings after a death; use peer and professional support
Recognize personal grief; allow time to feel and process
Self-care: rest, exercise, time off, hobbies, employee assistance programs
Boundaries and shared workload with the team
QUICK CHECK: A 4-year-old whose grandmother has died asks, "When is grandma coming back?" What concept should the nurse keep in mind when responding? Answer: Preschoolers view death as temporary and reversible. The nurse should use simple, concrete language — "Grandma's body stopped working and she died, and she won't be coming back" — avoiding euphemisms like "she went to sleep" or "we lost her," which can be confusing or frightening.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Basic Concept. Practice answering before reviewing the key.
Scenario
A nurse is planning care for a client who is nearing the end of life. What interventions should the nurse include in the plan of care?
NURSING INTERVENTIONS: Describe at least eight nursing interventions to be used.
Answer key
Nursing Interventions
Allow an opportunity for anticipatory grieving, which affects the way a family will cope with the death of a child.
Provide consistency among nursing staff caring for the client and family.
Encourage loved ones to remain with the client.
Attempt to Maintain a normal environment.
Communicate with the client honestly and respectfully.
Encourage independence.
Stay with the client as much as possible.
Administer analgesics to control pain.
Provide privacy.
Soften lights.
Offer soft music if desired.
Assist with arranging religious or cultural rituals desired by the client and family.
Assist the client with unfinished tasks.
Provide support for the family and client.
Application Exercises
Q1
A nurse is caring for a 4-year-old whose sibling recently died. The child says, "It's my fault because I yelled at her." Which is the most appropriate response?
A. "Don't worry, those feelings will pass."
B. "Yelling didn't make your sister die. Sometimes people get very sick and their bodies stop working."
C. "We don't blame ourselves for these things — let's talk about something happy."
D. "Your sister is in a better place now."
Show rationale ▾
A. Dismisses the child's belief without correcting it.
B.CORRECT. Directly addresses magical thinking with concrete, honest reassurance. Preschoolers may believe their thoughts/words caused events — this must be corrected.
C. Changes the subject and avoids the child's concern.
D. Religious/spiritual statements should be guided by family beliefs; doesn't address the guilt.
NCLEX® Connection: Psychosocial Integrity — Grief and Loss
Q2
A nurse is caring for a dying 17-year-old. Which intervention best supports the adolescent's developmental needs?
A. Defer all decisions to the parents
B. Limit visitors to family only
C. Involve the adolescent in care decisions and discuss advance care preferences
D. Avoid discussing death to protect the adolescent
Show rationale ▾
A. Adolescents have developing autonomy and should be included.
B. Peer contact is central to adolescent identity and grief — encourage rather than limit.
C.CORRECT. Adolescents understand death fully and benefit from being involved in their own care decisions, including advance care planning.
D. Avoidance damages trust and leaves the adolescent isolated in fear.
NCLEX® Connection: Psychosocial Integrity — End-of-Life Care
Q3
A nurse is caring for a 9-year-old in end-of-life care. The child asks the nurse, "What's going to happen to my body when I die?" What is the most appropriate nursing response?
A. "That's not something you should worry about right now."
B. "Let me get your parents so they can answer that."
C. "What have you been thinking about?"
D. "You're going to be fine — let's not talk about that."
Show rationale ▾
A. Dismisses the child's question and need for information.
B. Defers without addressing the child directly; school-age children deserve direct, honest engagement.
C.CORRECT. Open-ended response explores what the child already knows and is concerned about, allowing the nurse to give appropriate concrete information. School-age children ask direct questions and want direct answers.
D. False reassurance.
NCLEX® Connection: Psychosocial Integrity — Therapeutic Communication
Q4
A nurse is providing comfort care for a dying child experiencing dyspnea. Which interventions are appropriate? (Select all that apply.)
A. Elevate the head of the bed
B. Direct a fan toward the child's face
C. Administer prescribed opioids
D. Withhold opioids to avoid respiratory depression
E. Provide frequent oral care
Show rationale ▾
A.CORRECT. Upright positioning improves diaphragmatic excursion and reduces dyspnea.
B.CORRECT. Cool air on the face reduces the sensation of breathlessness.
C.CORRECT. Opioids reduce dyspnea and are appropriate at end of life.
D. Withholding analgesia at end of life conflicts with the goal of comfort.
E.CORRECT. Oral care relieves dryness and increases comfort.
NCLEX® Connection: Basic Care and Comfort — Palliative/Comfort Care
Q5
A nurse is supporting the family of a child who has just died. Which actions are appropriate? (Select all that apply.)
A. Offer the family time alone with the child without rushing
B. Offer memory-making such as footprints or a lock of hair
C. Tell the family that the child is "in a better place"
D. Provide written information about grief resources and bereavement follow-up
E. Encourage the parents to "move on" quickly to ease their pain
Show rationale ▾
A.CORRECT. Family needs unrushed time with the child.
B.CORRECT. Memory-making is a supported bereavement intervention.
C. Spiritual statements should be guided by the family's beliefs, not imposed by the nurse.
D.CORRECT. Written information supports the family after they leave.
E. Pushing parents to "move on" disrespects the grief process; there is no timeline for grief.
NCLEX® Connection: Psychosocial Integrity — Grief and Loss
Two emergencies dominate this chapter: bacterial meningitis (life-threatening CNS infection requiring rapid antibiotic initiation and droplet isolation) and Reye syndrome (acute encephalopathy with hepatic dysfunction, classically following a viral illness treated with aspirin). The third focus is recognizing increased intracranial pressure across age groups.
TL;DR · One-glance summary
Bacterial meningitis = emergency. Classic signs: nuchal rigidity, Kernig's and Brudzinski's, photophobia, fever, headache, vomiting. Infants: bulging fontanel, high-pitched cry, poor feeding, opisthotonos. Droplet precautions for first 24 hr of antibiotics. Reye syndrome: tied to aspirin during viral illness (never give aspirin to children). Cushing's triad (late ICP): bradycardia, hypertension with widening pulse pressure, irregular respirations.
Early ICP signs
Headache, vomiting (often projectile)
Irritability or drowsiness
Infants: bulging fontanel, ↑ head circumference, high-pitched cry, irritability
Infection and inflammation of the meninges by bacteria (Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type B). Spreads via respiratory droplets and direct contact. Vaccine-preventable disease — Hib, PCV13, MenACWY, and MenB significantly reduce incidence.
Expected findings
Fever, severe headache, photophobia
Nuchal rigidity (stiff neck)
Kernig's sign: with hip flexed at 90°, extending the knee causes pain
Brudzinski's sign: passive neck flexion causes involuntary hip and knee flexion
Vomiting (often without nausea)
Altered mental status, seizures
Petechial or purpuric rash (meningococcal — emergency sign)
Infants — different presentation
Bulging anterior fontanel
High-pitched, shrill cry
Poor feeding, vomiting
Irritability inconsolable; lethargy
Opisthotonos (arched-back posture)
Hypothermia or fever
Nuchal rigidity often absent in infants
Diagnostics
Lumbar puncture — definitive diagnosis
CSF finding
Bacterial
Viral
Appearance
Cloudy / turbid
Clear
WBC
Markedly ↑ (mostly neutrophils)
Mildly ↑ (mostly lymphocytes)
Protein
↑
Normal to slight ↑
Glucose
↓ (consumed by bacteria)
Normal
Gram stain / culture
Positive
Negative
Nursing care
Droplet precautions until 24 hr of effective antibiotics
Initiate IV antibiotics ASAP — do not wait for LP results if delayed
Position with head of bed elevated 30°; midline neck position
Strict I&O; monitor for SIADH
Monitor neuro status frequently (Q1–2 hr)
Seizure precautions
Cluster care to minimize disturbance
Medications
Empiric IV antibiotics: cefotaxime + vancomycin (until culture and sensitivity guides therapy)
Dexamethasone — initial management of inflammation/cerebral edema (not indicated for viral meningitis)
Antipyretics (acetaminophen, ibuprofen — never aspirin)
Anticonvulsants if seizures occur
Complications
Increased ICP, brain herniation
Hearing loss (high-frequency)
Hydrocephalus
Seizure disorder
Cognitive or developmental delay
Septic shock (especially meningococcal)
Reye syndrome
Overview
Rare but serious illness — acute encephalopathy + fatty degeneration of the liver. Strong association with aspirin use during a viral illness (influenza, varicella). Cause unclear but the syndrome is preventable by avoiding aspirin in children with viral illnesses.
Expected findings
History of viral illness, often with aspirin use
Persistent, severe vomiting
Lethargy progressing to confusion, seizures, coma
Hepatomegaly (without jaundice)
Behavior changes, irritability, combativeness
Laboratory findings
Elevated liver enzymes (ALT, AST) — usually 3× normal or higher
Elevated ammonia
Hypoglycemia (especially in infants)
Prolonged PT/PTT
Nursing care
ICU-level monitoring of ICP, neuro status, hepatic function
Manage cerebral edema (HOB 30°, midline neck)
Seizure precautions
Strict I&O; monitor for SIADH
Bleeding precautions (coagulopathy)
Family teaching: avoid aspirin and aspirin-containing products in children; use acetaminophen or ibuprofen for fever
Recognizing increased intracranial pressure (ICP)
Infants vs. older children
Finding
Infants
Children
Fontanel
Tense, bulging
Closed (no signal)
Sutures
Separated
Closed
Head circumference
↑
Stable
Cry
High-pitched
—
Behavior
Irritable, poor feeding
Headache, vomiting, behavior change
Vision
"Sunset eyes" (downward gaze)
Blurred vision, diplopia
Posture
Opisthotonos
Decorticate / decerebrate
Cushing's triad (late, ominous)
Bradycardia
Hypertension with widening pulse pressure
Irregular respirations
Cushing's triad signals impending herniation. Notify the provider immediately.
QUICK CHECK: Which lab finding most reliably distinguishes bacterial from viral meningitis on CSF analysis? Answer: Glucose. CSF glucose is decreased in bacterial meningitis (bacteria consume glucose) and normal in viral meningitis. Bacterial CSF is also cloudy with marked neutrophil-predominant WBC elevation.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.
Scenario
A nurse is admitting a client who has Reye Syndrome.
EXPECTED FINDINGS: Identify five.
LABORATORY TESTS: List two results indicative of Reye syndrome.
Answer key
Expected Findings
Recent viral illness
Recent use of aspirin-containing medicine
Lethargy
Irritability
Combativeness
Confusion
Delirium
Profuse vomiting
Seizures
Loss of consciousness
Laboratory Tests
Altered blood electrolytes due to cerebral edema and liver changes
Possibly extended coagulation times
Elevated liver enzymes
Elevated blood ammonia levels
Application Exercises
Q1
A nurse is caring for a 6-year-old with suspected bacterial meningitis. Which actions should the nurse implement? (Select all that apply.)
A. Initiate droplet precautions
B. Dim the lights in the room
C. Position the child supine and flat
D. Cluster nursing care to minimize disruption
E. Anticipate administering empiric IV antibiotics
Show rationale ▾
A.CORRECT. Droplet precautions for at least 24 hr after initiation of effective antibiotics.
B.CORRECT. Photophobia is common; dim lighting promotes comfort.
C. Head of bed should be elevated 30° to reduce ICP.
D.CORRECT. Clustering care minimizes stimulation and ICP elevation.
E.CORRECT. Empiric IV antibiotics should be initiated as soon as bacterial meningitis is suspected.
NCLEX® Connection: Safety and Infection Control — Standard/Transmission-Based Precautions
Q2
A nurse is reviewing CSF results for a child with suspected meningitis. Which findings indicate bacterial rather than viral meningitis?
A. Clear appearance, normal glucose, mildly elevated WBC with lymphocyte predominance
B. Cloudy appearance, decreased glucose, markedly elevated WBC with neutrophil predominance
C. Clear appearance, decreased protein, normal WBC
D. Bloody appearance, elevated glucose, normal WBC
Show rationale ▾
A. These are the expected findings for viral meningitis.
B.CORRECT. Bacterial meningitis CSF is cloudy with markedly elevated neutrophil-predominant WBC and decreased glucose (consumed by bacteria) — characteristic findings.
C. CSF protein is typically elevated in bacterial meningitis.
D. Bloody CSF suggests a traumatic tap or subarachnoid hemorrhage, not meningitis.
NCLEX® Connection: Reduction of Risk Potential — Laboratory Values
Q3
A nurse is assessing a 3-month-old infant with suspected meningitis. Which finding is the nurse most likely to observe?
A. Positive Kernig's sign
B. Severe stiff neck
C. Bulging anterior fontanel and high-pitched cry
D. Photophobia
Show rationale ▾
A. Kernig's sign is often absent in infants.
B. Nuchal rigidity is often absent in infants.
C.CORRECT. Infants present with bulging fontanel, high-pitched cry, poor feeding, irritability, opisthotonos — not the classic adult/older child signs.
D. Hard to assess in pre-verbal infants and not a reliable presenting sign.
NCLEX® Connection: Reduction of Risk Potential — System Specific Assessments
Q4
A nurse is caring for a child with increased ICP. Which finding requires immediate provider notification?
A. Heart rate 110/min
B. Blood pressure 110/70 mm Hg
C. Respiratory rate 22/min
D. Blood pressure 145/68 mm Hg with heart rate 52/min
Show rationale ▾
A. Within expected range for many pediatric ages.
B. Within expected range.
C. Within expected range.
D.CORRECT. Hypertension with widening pulse pressure (145/68 → 77 mm Hg) and bradycardia represent Cushing's triad — late and ominous sign of increased ICP and impending herniation. Notify the provider immediately.
NCLEX® Connection: Physiological Adaptation — Alterations in Body Systems
Q5
A nurse is teaching a parent about preventing Reye syndrome. Which statement by the parent indicates correct understanding?
A. "I'll give aspirin to bring down a fever quickly."
B. "I'll avoid giving my child aspirin during a viral illness."
C. "Reye syndrome is caused by bacterial infection."
D. "Reye syndrome can be prevented with a vaccine."
Show rationale ▾
A. Aspirin should not be given to children — risk of Reye syndrome.
B.CORRECT. Reye syndrome is strongly associated with aspirin use during viral illnesses. Use acetaminophen or ibuprofen instead.
C. Reye syndrome is associated with viral illness + aspirin, not bacterial infection.
D. No vaccine exists for Reye syndrome; prevention is by avoiding aspirin in children.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Adverse Effects/Contraindications
Seizures result from abnormal, excessive electrical discharge in the brain. In children, febrile seizures are most common (6 mo–5 yr), while epilepsy describes a chronic seizure disorder. Infantile spasms (West syndrome) present in the first year with clusters of sudden flexion/extension spasms ("jackknife" seizures), hypsarrhythmia on EEG; treated with ACTH or vigabatrin — emergent referral needed. Lennox-Gastaut syndrome is a severe childhood epilepsy (ages 1–8) with multiple seizure types, slow spike-wave on EEG, and intellectual disability; often refractory to treatment. Nursing care centers on safety during the event, accurate description, and identifying triggers and complications such as status epilepticus.
TL;DR · One-glance summary
During a seizure: time it, ensure airway, side-lying when possible, do not restrain, do not put anything in the mouth, protect the head. Status epilepticus = seizure >5 min or recurrent without recovery — give IV lorazepam (or rectal diazepam if no IV). Febrile seizures: usually benign, in 6 mo–5 yr, treat fever and reassure family. AED levels must be monitored; teach families never to stop AEDs abruptly.
Generalized seizures
Tonic-clonic: stiffening + jerking; loss of consciousness; postictal sleep
Absence: brief staring spells (5–10 sec); often mistaken for daydreaming
Sedation, paradoxical hyperactivity in children; respiratory depression; tolerance
Levetiracetam
Focal, generalized; broad spectrum
Irritability, behavior changes; no major drug interactions
AED education for families
Never stop AEDs abruptly — risk of status epilepticus
Give doses on schedule; use pill organizers
Monitor for adverse effects; communicate with provider before adding OTC drugs
Periodic blood levels and lab monitoring as directed
Wear medical alert ID
Other therapeutic approaches
Ketogenic diet
High-fat, low-carbohydrate, adequate-protein diet
Used for refractory seizures, especially in children
Requires strict adherence; supervised by dietitian and provider
Side effects: constipation, hyperlipidemia, kidney stones, growth concerns
Vagus nerve stimulator (VNS)
Implanted device delivering intermittent electrical stimulation to the vagus nerve
Adjunct for refractory focal seizures in children ≥4 yr
Family/patient can activate via handheld magnet if aura felt
Surgical resection
For refractory focal seizures with identified epileptogenic focus
Requires extensive presurgical workup
QUICK CHECK: A 7-year-old has a seizure in the hospital and seizure activity persists past 5 minutes. What is the priority nursing action? Answer: Status epilepticus. Maintain airway and oxygenation, ensure IV access, and prepare to administer IV lorazepam (or rectal diazepam/intranasal midazolam if no IV). Continued seizures risk hypoxia and lasting injury.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.
Scenario
A nurse is planning care for a child who has tonic-clonic seizures. What actions should the nurse include in the plan of care?
NURSING CARE: Describe nursing actions during and after a seizure.
Answer key
Nursing Care
During a seizure
Protect the child from injury. (move furniture away, hold the child’s head in lap if on the floor.)
Position the child to Maintain a patent airway.
Be prepared to suction oral secretions.
Turn the child to the side (decreases risk of aspiration).
Loosen restrictive clothing.
Do not attempt to restrain the child.
Do not attempt to open the jaw or insert an airway during seizure activity. (This can damage teeth, lips, or tongue.) Do not use padded tongue blades.
Remove glasses.
Administer oxygen if needed.
Remain with the child.
Note the onset, time, and characteristics of the seizure.
Postseizure
Maintain the child in a side-lying position to prevent aspiration and to facilitate drainage of oral secretions.
Check for breathing, check vital signs, and check position of head and tongue.
Assess for injuries, including the mouth.
Perform neurologic checks.
Allow the child to rest if necessary.
Reorient and calm the child (they can be agitated or confused).
Maintain seizure precautions, including placing the bed in the lowest position and padding the side rails to prevent future injury.
Check inside the mouth to see if the lips and tongue have been bitten.
Note the time of the postictal period.
Remain with the child.
Do not offer food or liquids until completely awake and has a swallowing reflex has returned.
Encourage the child to describe the period before, during, and after the seizure activity.
Determine if the child experienced an aura, which can indicate the origin of seizure in the brain.
Try to determine the possible trigger (fatigue or stress).
Document the onset and duration of seizure and client findings/ observations prior to, during, and following the seizure (level of consciousness, apnea, cyanosis, Motor activity, incontinence).
Application Exercises
Q1
A nurse is caring for a 5-year-old who begins to have a generalized tonic-clonic seizure. Which actions should the nurse take? (Select all that apply.)
A. Place a padded tongue blade between the child's teeth
B. Time the duration of the seizure
C. Restrain the extremities to prevent injury
D. Position the child side-lying when possible
E. Loosen restrictive clothing around the neck
Show rationale ▾
A. Never place anything in the mouth — risk of dental injury and aspiration.
B.CORRECT. Timing is essential — seizures >5 min meet criteria for status epilepticus.
C. Do not restrain — risks injury to the child.
D.CORRECT. Side-lying position protects airway and allows secretions to drain.
E.CORRECT. Loosens restrictions to maintain airway.
NCLEX® Connection: Safety and Infection Control — Accident/Injury Prevention
Q2
A parent reports that their 8-year-old has been "spacing out" during class for 5–10 seconds at a time, then resuming activity. Which seizure type does this most likely describe?
A. Generalized tonic-clonic
B. Absence (petit mal)
C. Atonic
D. Complex focal
Show rationale ▾
A. Tonic-clonic involves stiffening and jerking with loss of consciousness and postictal recovery.
B.CORRECT. Brief staring spells (5–10 sec) with immediate return to activity describe absence seizures, often misidentified as inattention.
C. Atonic seizures cause sudden loss of muscle tone ("drop attacks").
D. Complex focal seizures involve impaired awareness with automatisms.
NCLEX® Connection: Reduction of Risk Potential — System Specific Assessments
Q3
A parent calls the clinic concerned because their 15-month-old child had a brief generalized seizure with a high fever. Which initial response by the nurse is most appropriate?
A. "Your child likely has epilepsy and will need lifelong medication."
B. "Bathe your child in cold water to bring the temperature down quickly."
C. "Febrile seizures are common in children 6 months to 5 years old. The child should be evaluated, and we'll discuss fever management."
D. "There is nothing to worry about; these are completely harmless."
Show rationale ▾
A. A single febrile seizure does not establish a diagnosis of epilepsy.
B. Cold-water bathing is contraindicated — induces shivering and raises temperature.
C.CORRECT. Educates the family while recommending evaluation. Most febrile seizures are benign but warrant assessment.
D. Dismissing parental concern is inappropriate; the child should be evaluated.
NCLEX® Connection: Health Promotion and Maintenance — Health Promotion/Disease Prevention
Q4
A nurse is teaching a parent about phenytoin therapy for their child's seizure disorder. Which statement by the parent indicates correct understanding?
A. "I'll stop the medication once my child has been seizure-free for one month."
B. "I should massage my child's gums daily and ensure good oral hygiene."
C. "Drinking grapefruit juice with the medication is fine."
D. "If my child misses a dose, I'll double the next dose."
Show rationale ▾
A. Never stop AEDs abruptly — risk of status epilepticus.
B.CORRECT. Phenytoin causes gingival hyperplasia — meticulous oral care, gum massage, and regular dental visits reduce this complication.
C. Grapefruit affects multiple AED levels; check with provider.
D. Doubling missed doses can cause toxicity; follow specific guidance from provider/pharmacist.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Q5
A nurse is monitoring a child taking valproic acid. Which finding is most concerning?
A. Weight gain of 2 lb over 1 month
B. Mild drowsiness in the first week of therapy
C. Yellowing of the sclera and abdominal pain
D. Mild hand tremor
Show rationale ▾
A. Weight gain is a known side effect but not the most urgent.
B. Mild drowsiness commonly improves; monitor.
C.CORRECT. Jaundice and abdominal pain suggest hepatotoxicity — a serious adverse effect requiring immediate evaluation. Valproic acid carries a boxed warning for hepatic failure.
D. Mild tremor is common and not urgent.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Adverse Effects
Head injuries are a leading cause of pediatric death and disability. Severity ranges from concussion (mild traumatic brain injury) to focal hemorrhages and diffuse axonal injury. Recognition of increased ICP — and the dreaded late Cushing's triad — is the central nursing skill, alongside parent education on prevention through helmets, car seats, and supervision.
TL;DR · One-glance summary
Pediatric head injury types: concussion (mild TBI), contusion, fracture (linear, depressed, basilar), and hematoma (epidural, subdural, intracerebral). Cushing's triad = bradycardia + hypertension with widening pulse pressure + irregular respirations (late ICP sign). Basilar fracture signs: raccoon eyes, Battle's sign, CSF rhinorrhea/otorrhea. Halo sign = ring of clear fluid around blood = positive for CSF. Always assess for non-accidental trauma if mechanism doesn't match injuries.
Concussion red flags (worsening)
Worsening headache; persistent vomiting
Increasing drowsiness; difficulty arousing
Seizure activity
Unequal or fixed pupils
Weakness, slurred speech, confusion
Clear fluid from nose or ears
Severe head injury priorities
ABCs, C-spine stabilization until cleared
Log roll the patient (turn as a unit) to maintain spinal alignment until C-spine is cleared
Maintain SpO₂ >94%; avoid hypoxia and hypotension
Elevate HOB 30°; midline neck position
Frequent neuro assessments (GCS or pediatric GCS)
Anticipate mannitol or hypertonic saline for ↑ ICP
Types of head injury
Concussion (mild TBI)
Brief loss of consciousness (or no loss) following head trauma
Often with confusion, headache, dizziness, amnesia for event, nausea
Hypertonic saline (3%): alternative for ICP reduction
Antiepileptics for prophylaxis or treatment of post-traumatic seizures
Analgesia and sedation for severe injury (avoid masking neuro assessment)
Antipyretics for fever
Concussion management
Physical and cognitive rest 24–48 hr after injury
Gradual return-to-learn (school) then return-to-play protocol
No same-day return to play
Symptom checklist guides progression; symptoms must resolve at each step before advancing
Avoid second head injury during recovery — second-impact syndrome risk
Parent / family education
Helmets for biking, skating, skiing, contact sports
Proper car seats, seat belts (back seat until age 13)
Window guards, stair gates, never leave infants on raised surfaces
Post-discharge "head injury warning sign" sheet — when to return to ED (worsening headache, vomiting >2 times, increasing drowsiness, seizure, vision changes, unequal pupils, fluid from nose/ears, weakness)
Wake the child every 2 hr only if directed (controversial; most discharge instructions emphasize observation of arousability)
QUICK CHECK: A child sustains a head injury and a small amount of clear fluid drains from the nose. The fluid creates a "halo" of clear ring around a central spot of blood on gauze. What does this suggest? Answer: CSF rhinorrhea — likely a basilar skull fracture. Do not pack the nose, do not insert a nasogastric tube; notify the provider immediately.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.
Scenario
A nurse is teaching a guardian of a child about complications of a head injury. What should be included in the teaching?
COMPLICATIONS: Identify three and their corresponding Manifestations. RN NURSING CARE OF CHILDREN
Answer key
Complications
Epidural hematoma
Bleeding between the dura and the skull
Manifestations: short period of unconsciousness followed by a normal period for several hours, then lethargy or coma due to the accumulation of blood in the epidural space and compression of the brain. Possible vomiting. Subdural hemorrhage
Bleeding between the dura and the arachnoid membrane
Results from birth injury, falls, or violent shaking
Manifestations: irritability, vomiting, increased head circumference, lethargy, coma, seizures
Retinal hemorrhage can be an indicator of abuse. Cerebral edema
Develops 24 to 72 hr posttrauma
Manifestations: increased ICP, changes in cerebral blood flow Brain herniation
Downward shift of brain tissue
Manifestations: loss of blinking, loss of gag reflex, decreased pupillary response, Cushing’s triad (systemic hypertension, bradycardia, respiratory distress), coma
Application Exercises
Q1
A nurse is caring for a 7-year-old admitted after a bicycle accident with a head injury. Which finding requires the most immediate provider notification?
A. Heart rate 110/min, BP 100/65 mm Hg
B. Mild headache rated 3/10
C. Heart rate 50/min, BP 145/60 mm Hg, irregular respirations
D. Drowsiness that resolves with stimulation
Show rationale ▾
A. Within expected pediatric ranges.
B. Mild headache is expected after head injury; monitor.
C.CORRECT. Cushing's triad (bradycardia, hypertension with widening pulse pressure, irregular respirations) signals dangerous ICP elevation and impending herniation. Immediate provider notification and intervention required.
D. Drowsiness that resolves is concerning but not the most urgent finding in this list.
NCLEX® Connection: Physiological Adaptation — Alterations in Body Systems
Q2
A child sustains a head injury and is discharged home. Which signs should the nurse instruct the parent to monitor for? (Select all that apply.)
A. Worsening or unrelieved headache
B. Persistent vomiting
C. Unequal or fixed pupils
D. Drinking and eating normally
E. Increasing drowsiness or difficulty waking
Show rationale ▾
A.CORRECT. Worsening headache may indicate progressing intracranial bleeding.
C.CORRECT. Pupillary changes are a critical neuro deterioration sign.
D. Normal intake is reassuring, not a warning sign.
E.CORRECT. Worsening drowsiness or arousability is a critical sign.
NCLEX® Connection: Reduction of Risk Potential — System Specific Assessments
Q3
A nurse observes raccoon eyes and clear fluid draining from the nose in a child following a fall from a height. Which is the priority nursing action?
A. Pack the nose to control the fluid drainage
B. Insert a nasogastric tube to decompress the stomach
C. Notify the provider and avoid packing or NG tube insertion
D. Apply ice to the periorbital area
Show rationale ▾
A. Packing the nose with a basilar fracture risks infection and pushing material into the cranial cavity.
B. Nasogastric tubes are contraindicated in basilar skull fractures — risk of intracranial placement.
C.CORRECT. Raccoon eyes and CSF rhinorrhea suggest basilar skull fracture. Notify the provider; do not pack the nose; do not insert a nasogastric tube.
D. Ice may help cosmetic appearance but is not the priority.
NCLEX® Connection: Safety and Infection Control — Accident/Injury Prevention
Q4
A 12-year-old sustained a concussion during a soccer game. The parent asks when their child can return to play. Which response is most appropriate?
A. "She can resume practice tomorrow if she feels better."
B. "She must rest first, then follow a stepwise return-to-play protocol; she cannot return the same day."
C. "She should avoid sports for one year."
D. "She can play once the headache is gone, regardless of other symptoms."
Show rationale ▾
A. Same-day return to play is contraindicated.
B.CORRECT. Concussion management requires rest, then graduated return-to-learn and return-to-play protocol; symptoms must resolve at each step before progressing. Second-impact syndrome risk if returning too soon.
C. A year-long restriction is excessive in uncomplicated concussion.
D. All symptoms must resolve, and progression must be stepwise.
NCLEX® Connection: Health Promotion and Maintenance — Health Promotion/Disease Prevention
Q5
A child with a severe head injury is receiving mannitol IV. Which assessment is most important?
A. Hourly urine output and serum osmolarity
B. Bowel sounds every 4 hr
C. Skin turgor on the dorsum of the hand
D. Capillary refill in the lower extremities
Show rationale ▾
A.CORRECT. Mannitol is an osmotic diuretic. Monitor urine output (typically increases), serum osmolarity (goal usually 300–320 mOsm/L), and electrolytes. Excess diuresis can cause hypovolemia and worsen cerebral perfusion.
B. Bowel sounds aren't the priority assessment for mannitol.
C. Skin turgor is unreliable as the only fluid status indicator.
D. Capillary refill is useful but not the most specific monitoring for mannitol effect.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Pharmacological Pain Management
This chapter covers four major categories: intellectual disability, Down syndrome (trisomy 21), autism spectrum disorder, and hearing and vision impairments. Early identification, early intervention, and family-centered care are the consistent themes across all of them.
TL;DR · One-glance summary
Intellectual disability: IQ <70 + adaptive deficits; severity ranges mild → profound. Down syndrome: trisomy 21; hypotonia, simian crease, upward-slanting palpebral fissures, congenital heart defects (~50%), atlantoaxial instability — screen before sports. Autism spectrum: persistent deficits in social communication + restricted/repetitive behaviors; routine and structure essential. Hearing: universal newborn screening; intervention before 6 mo optimizes language. Vision: amblyopia screen by 3–5 yr; treat strabismus early.
Wide space between 1st and 2nd toes ("sandal gap")
Hypotonia; hyperflexibility of joints
Short stature
Down syndrome — comorbidities
Congenital heart defects (~50%) — esp. AV canal, VSD
Atlantoaxial instability — screen with X-ray before contact sports
Hypothyroidism; obesity
↑ leukemia risk (ALL)
Recurrent otitis media → hearing loss
Alzheimer disease in adulthood
Intellectual disability (ID)
Definition and levels
Significantly subaverage intellectual functioning (IQ <70) accompanied by deficits in adaptive functioning, with onset before age 18. Diagnosis includes intellectual, adaptive, and conceptual/social/practical domains.
Level
IQ range
Functional implications
Mild
50–70
~6th grade academic ceiling; can develop social/vocational skills; live with minimal support
Moderate
35–50
~2nd grade level; can perform self-care with supervision; supervised employment
Severe
20–35
Limited communication; requires significant support for self-care
Profound
<20
Minimal communication; requires constant support for all ADLs
Edwards syndrome (trisomy 18): clenched fists with overlapping fingers, rocker-bottom feet, congenital heart defects, micrognathia; most die in first year of life
Patau syndrome (trisomy 13): microcephaly, cleft lip/palate, polydactyly, holoprosencephaly, severe intellectual disability; median survival ~10 days
Klinefelter syndrome (47,XXY): affects males; tall stature, small testes, gynecomastia at puberty, infertility, possible learning disabilities; testosterone replacement at puberty
Tay-Sachs disease: autosomal recessive lysosomal storage disease (hexosaminidase A deficiency); progressive neurodegeneration, cherry-red macula, seizures, blindness; fatal by age 3–5; carrier screening available (Ashkenazi Jewish descent)
Fragile X syndrome: most common inherited cause of intellectual disability; X-linked; large ears, long face, macroorchidism after puberty; behavioral features include anxiety, ADHD, hand flapping
Postnatal (meningitis, encephalitis, head trauma, lead toxicity)
Nursing care principles
Assess developmentally — use age-appropriate language for cognitive (not chronological) age
Establish routines; break tasks into small steps
Use simple, concrete language; visual aids
Encourage independence at the child's level
Refer for early intervention (birth–3 yr) and special education services (3 yr+)
Support the family; connect with community resources
Down syndrome (Trisomy 21)
Overview
Extra copy of chromosome 21 — most often nondisjunction (95%), less commonly translocation or mosaicism. Risk increases with maternal age. Diagnosed prenatally (NIPT, ultrasound, amniocentesis) or at birth based on physical features and confirmed by karyotype.
Physical features
Upward-slanting palpebral fissures with epicanthal folds; small/low-set ears
Feeding: hypotonia can complicate breastfeeding; require positioning support
Nursing care
Support family at diagnosis — provide information, connect with Down syndrome support organizations
Anticipatory guidance for routine screening (cardiac echo at birth, thyroid function, audiology, ophthalmology, cervical spine)
Feeding: assist with positioning; small frequent feedings; monitor weight
Skin: dry skin common — moisturize
Respiratory: small upper airway + hypotonia → susceptibility to respiratory infections
Early intervention referral
Coordinate care across multiple specialists
Autism spectrum disorder (ASD)
Overview
Neurodevelopmental disorder with onset in early childhood, characterized by persistent deficits in social communication and interaction across multiple contexts, plus restricted, repetitive patterns of behavior, interests, or activities. Spectrum ranges from individuals needing substantial daily support to those with high independent functioning.
Diagnosis usually possible by 2–3 yr; earliest signs often emerge in infancy (poor eye contact, lack of social smile, decreased babbling).
Expected findings
Social communication deficits:
Poor or absent eye contact
Limited joint attention (sharing focus with another)
Delayed or absent language; literal/concrete interpretation of language
Echolalia (repeating words/phrases)
Difficulty with reciprocal conversation
Restricted, repetitive behaviors:
Insistence on sameness; distress at change in routine
Repetitive motor behaviors (rocking, hand-flapping, spinning)
Restricted, intense interests
Sensory sensitivities (hyper- or hyposensitivity to sound, touch, taste, light)
Nursing care
Maintain routines and predictability; explain procedures in advance using pictures or social stories
Speak in clear, concrete terms; avoid figurative language ("you'll feel a little bee sting" can be alarming)
Interventions: hearing aids, cochlear implants, sign language, speech therapy, FM systems in classrooms
Nursing role: get the child's attention before speaking; face the child; speak clearly without exaggerating; reduce background noise; use written communication or sign as appropriate
Vision impairment
Common conditions:
Strabismus: misalignment of the eyes; if untreated, can lead to amblyopia
Amblyopia ("lazy eye"): reduced vision in one eye due to abnormal visual development; treat with patching of stronger eye to force use of weaker one
Refractive errors:
Myopia (nearsightedness): far objects blurry; corrected with biconcave (diverging) lenses, contact lenses for adolescents
Hyperopia (farsightedness): near objects blurry; corrected with convex (converging) lenses; may not be detected early due to accommodation
Astigmatism: uneven corneal curvature → distorted vision at all distances; corrective lenses
Anisometropia: different refractive strength in each eye; corrective lenses for each eye individually
Cataracts, glaucoma, retinopathy of prematurity
Screening: red reflex assessment in newborn; vision screening at well-child visits using Snellen letter chart (school-age+), tumbling E or HOTV (preschool); formal acuity testing at age 3–5 yr; ocular alignment: corneal light reflex test and cover/uncover test (detect strabismus — if eye moves when uncovered, misalignment is present)
Nursing role: announce presence; describe surroundings; use the child's name; allow extra time to navigate environment; teach to handle objects to learn about them; orient to room when admitted
QUICK CHECK: A child with Down syndrome wants to play youth football. What screening is essential before participation? Answer: Cervical spine (lateral flexion/extension) X-ray to assess for atlantoaxial instability — present in about 10–20% of children with Down syndrome. Children with instability should not participate in contact sports or activities that hyperflex/extend the neck.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Nursing Skill. Practice answering before reviewing the key.
Scenario
A nurse is planning to perform a visual screening test on a child. What nursing actions should the nurse include?
DESCRIPTION OF SKILL: Explain the procedure.
OUTCOMES/EVALUATION: Describe findings that indicate visual impairment. RN NURSING CARE OF CHILDREN
Answer key
Description Of Skill
Choose appropriate chart: Snellen Letter, tumbling E, or picture chart.
Place child 10 feet from the chart with heels on the 10-foot mark.
Screen child wearing glasses, if appropriate.
Child keeps both eyes open and covers one eye.
First have the child start at the bottom and read each line, continuing up until the child can pass a line.
Then have the child start at the top and move down until the child can no longer pass a line.
To pass, the child needs to identify four of the six characters correctly.
Repeat the procedure with the other eye.
Outcomes/Evaluation
Partial visual impairment is classified as visual acuity of 20/70 to 20/200.
Legal blindness is classified as visual acuity of 20/200 or worse or a visual field of 20 degrees or less in the child’s better eye.
Application Exercises
Q1
A nurse is examining a newborn with suspected Down syndrome. Which findings would the nurse expect to observe? (Select all that apply.)
A. Upward-slanting palpebral fissures with epicanthal folds
B. Simian (single palmar) crease
C. Generalized hypotonia
D. Increased muscle tone with hyperreflexia
E. Wide space between the 1st and 2nd toes
Show rationale ▾
A.CORRECT. Characteristic facial feature.
B.CORRECT. Single transverse palmar crease is a common finding.
C.CORRECT. Hypotonia ("floppy infant") is a hallmark.
D. Increased tone and hyperreflexia are not features of Down syndrome.
E.CORRECT. "Sandal gap" between 1st and 2nd toes is characteristic.
NCLEX® Connection: Reduction of Risk Potential — System Specific Assessments
Q2
A nurse is caring for a 3-year-old with autism spectrum disorder admitted for a tonsillectomy. Which intervention best supports the child during the hospital stay?
A. Encourage the child to interact with all visitors to promote socialization
B. Maintain the child's home routine as much as possible and use clear, concrete language
C. Use figurative language to make explanations more interesting
D. Limit the parent's presence to prevent the child from becoming dependent
Show rationale ▾
A. Excessive social demand can be overwhelming and counterproductive.
B.CORRECT. Maintaining routine and using concrete language reduces anxiety and helps the child process the experience.
C. Figurative language is often interpreted literally and can frighten or confuse the child.
D. Parental presence is essential — they know the child's communication and coping needs.
NCLEX® Connection: Psychosocial Integrity — Therapeutic Communication
Q3
A parent of a 5-year-old with Down syndrome asks about enrolling the child in karate classes. Which response by the nurse is most appropriate?
A. "Karate is great exercise — go ahead and enroll."
B. "Children with Down syndrome should not exercise at all."
C. "Your child should be evaluated for atlantoaxial instability with a cervical spine X-ray before participating."
D. "Karate isn't appropriate; try swimming instead."
Show rationale ▾
A. Atlantoaxial instability risk must be assessed first.
B. Children with Down syndrome benefit from exercise; this advice is incorrect.
C.CORRECT. Children with Down syndrome should be evaluated for atlantoaxial instability before participating in contact sports or activities involving neck hyperflexion. About 10–20% have radiographic instability.
D. Categorical recommendations are inappropriate without evaluation.
NCLEX® Connection: Health Promotion and Maintenance — Health Promotion/Disease Prevention
Q4
A parent asks why early intervention is recommended for their newborn who failed the universal hearing screen. Which response is most accurate?
A. "Hearing aids cannot be used until age 2."
B. "Early identification and intervention before 6 months optimizes language development."
C. "Most babies who fail the screen have normal hearing on retest."
D. "Hearing testing for newborns is unreliable; we'll repeat it at school age."
Show rationale ▾
A. Hearing aids can be fit in infancy.
B.CORRECT. Early identification of hearing loss before 3 mo and intervention before 6 mo is associated with significantly better language outcomes.
C. While some screen results need confirmation, this answer dismisses the importance of follow-up.
D. Newborn hearing screening is reliable and recommended universally.
NCLEX® Connection: Health Promotion and Maintenance — Health Screening
Q5
A nurse is teaching the parents of a 4-year-old recently diagnosed with amblyopia. Which statement indicates correct understanding?
A. "We will patch the weaker eye to help it heal."
B. "We will patch the stronger eye to force the weaker eye to develop."
C. "Amblyopia usually corrects on its own without treatment."
D. "Treatment is not effective after age 3."
Show rationale ▾
A. Patching is applied to the stronger eye, not the weaker.
B.CORRECT. Patching the stronger eye forces visual development in the weaker eye. Most effective when started in early childhood.
C. Untreated amblyopia leads to permanent vision loss in the affected eye.
D. Treatment can be effective into the school-age years, although earlier is better.
NCLEX® Connection: Reduction of Risk Potential — Therapeutic Procedures
Children in respiratory distress need the right oxygen device for their age and severity, with effective humidification and family-friendly delivery (blow-by, oxygen tents). Aerosol and inhaler therapy require spacer use for MDIs and proper technique to reach the lungs. Tracheostomy care, suctioning, and chest physiotherapy round out the chapter's skills.
TL;DR · One-glance summary
Match the device to the age and FiO₂ need. Nasal cannula 1–6 L/min (24–44%). Simple mask 6–10 L/min (35–60%). Non-rebreather 10–15 L/min (up to ~95%). Oxygen hood for infants; oxygen tent for larger children. Blow-by when child refuses mask. MDI requires a spacer in children (improves deposition). Suction <10–15 sec; preoxygenate. Always have a spare trach tube at the bedside.
Oxygen safety
No smoking · no open flames in oxygen environment
Secure tanks upright; avoid petroleum products on patient
Synthetic fabrics generate static; use cotton
"Oxygen in use" sign on door
Continuous pulse oximetry
Key indicators of distress
Nasal flaring, retractions, tachypnea
Grunting (in infants — keeps airways open)
Use of accessory muscles
Head bobbing (severe distress in infants)
Cyanosis (late finding)
Oxygen delivery devices
Device
Flow rate
FiO₂
Best use
Nasal cannula
1–6 L/min
24–44%
Stable, mild needs; allows talking and eating
Simple face mask
6–10 L/min
35–60%
Short-term moderate O₂; minimum 6 L/min to clear CO₂
Partial rebreather
6–10 L/min
60–90%
Higher need; reservoir stays partially inflated
Non-rebreather
10–15 L/min
up to 95%
Severe distress; reservoir bag stays inflated; one-way valves prevent exhaled air rebreathing
Venturi mask
4–15 L/min
24–60% (precise)
Need precise FiO₂; less common in pediatrics
Oxygen hood
10–15 L/min
up to 80–90%
Infants — clear plastic hood over head and shoulders
From the textbook — uses the ATI Active Learning Template: Nursing Skill. Practice answering before reviewing the key.
Scenario
A nurse is teaching a child how to use a metered-dose inhaler. What information should be included in the teaching?
DESCRIPTION OF SKILL: Outline the steps for using a metered-dose inhaler.
Answer key
Description Of Skill
Remove the cap from the inhaler
Shake the inhaler five to six times.
Attach the spacer. (A spacer should be encouraged for children to facilitate proper inhalation of the medication.)
Hold the inhaler with the mouthpiece at the bottom.
Hold the inhaler with the thumb near the mouthpiece and the index and middle fingers at the top.
Open-mouth technique: Hold the inhaler approximately 3 to 4 cm (1.2 to 1.6 in) away from the front of the mouth.
Closed-mouth method: Place the inhaler between the lips and instruct the child to form a seal around the inhaler.
Take a deep breath and then exhale.
Tilt the head back slightly, and press the inhaler. While pressing the inhaler, begin a slow, deep breath that lasts for 3 to 5 seconds to facilitate delivery to the air passages.
Hold the breath for approximately 5 to 10 seconds to allow the medication to deposit in the airways.
If an additional puff is needed, wait 1 min between puffs.
Take the inhaler out of the mouth and slowly exhale through the nose.
Resume normal breathing.
Application Exercises
Q1
A nurse is caring for a 6-month-old infant who requires oxygen therapy but will not tolerate a mask. Which oxygen delivery method is most appropriate?
A. Non-rebreather mask
B. Oxygen hood
C. Dry powder inhaler
D. Nasal cannula at 8 L/min
Show rationale ▾
A. Infants don't tolerate masks well; mask is the problem here.
B.CORRECT. Oxygen hood provides a controlled, humidified environment without disturbing the infant — ideal when the child cannot tolerate a face device.
C. DPI requires active patient cooperation; not appropriate for an infant.
D. Nasal cannula flow rates >4–6 L/min cause excessive drying and discomfort; not appropriate at this rate.
NCLEX® Connection: Reduction of Risk Potential — Therapeutic Procedures
Q2
A nurse is teaching a parent how to administer an MDI with corticosteroid to a 5-year-old. Which instructions should the nurse include? (Select all that apply.)
A. Use a spacer (valved holding chamber)
B. Have the child take a slow, deep breath
C. Rinse the mouth with water after the dose
D. Repeat the dose every 5 minutes if symptoms persist
E. Shake the MDI before each puff
Show rationale ▾
A.CORRECT. Spacer is essential in pediatric MDI use — improves lung deposition.
B.CORRECT. Slow, deep inhalation maximizes deposition.
C.CORRECT. Mouth rinse after ICS prevents oral candidiasis.
D. Dosing intervals are prescribed and don't change based on symptoms (especially for ICS — these are scheduled controllers, not rescue medication).
E.CORRECT. Shaking suspends the medication for accurate dosing.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Q3
A nurse is preparing to suction a tracheostomy in a 4-year-old. Which action is essential before initiating the procedure?
A. Withhold supplemental oxygen for 30 seconds
B. Preoxygenate the child with 100% oxygen
C. Instill 5 mL of normal saline into the trach
D. Apply continuous suction during catheter insertion
Show rationale ▾
A. Withholding O₂ before suctioning increases hypoxia risk.
B.CORRECT. Preoxygenation with 100% O₂ prevents desaturation during the suction pass.
C. Routine saline instillation is no longer recommended — can increase infection risk and cause distress.
D. Apply suction only during withdrawal, not insertion (suction during insertion damages mucosa).
NCLEX® Connection: Reduction of Risk Potential — Therapeutic Procedures
Q4
A nurse is providing tracheostomy care for a child at home. Which equipment should the nurse instruct the parents to keep at the bedside? (Select all that apply.)
A. Extra tracheostomy tube of the same size
B. Extra tracheostomy tube one size smaller
C. Suction equipment
D. Resuscitation bag (ambu)
E. Nebulizer with antibiotics
Show rationale ▾
A.CORRECT. Same-size tube for replacement.
B.CORRECT. Smaller tube in case the stoma narrows or same size won't pass.
C.CORRECT. Suction equipment for emergencies and routine care.
D.CORRECT. Resuscitation bag for emergency ventilation.
E. Antibiotics aren't routine for all trach patients; would be provider-prescribed if indicated.
NCLEX® Connection: Health Promotion and Maintenance — Self-Care
Q5
A nurse is performing chest physiotherapy on a child with cystic fibrosis. When is the best time to perform CPT?
A. Immediately after meals
B. Before meals or 1–2 hours after
C. During sleep to avoid disrupting daily activities
D. Only when the child is symptomatic
Show rationale ▾
A. Performing CPT immediately after meals risks vomiting and aspiration.
B.CORRECT. Schedule CPT before meals or 1–2 hr after to avoid vomiting and aspiration.
C. CPT during sleep is impractical and disrupts rest.
D. In CF, CPT is performed routinely (not only with symptoms) to prevent secretion accumulation.
NCLEX® Connection: Reduction of Risk Potential — Therapeutic Procedures
This chapter spans common infections (URI, pharyngitis, tonsillitis), the croup syndromes (LTB vs. epiglottitis — a critical distinction), bronchiolitis/RSV, pneumonia, and pertussis. Epiglottitis is the can't-miss diagnosis: respiratory emergency, drooling, tripod position, and the rule of never put anything in the mouth or throat.
TL;DR · One-glance summary
Epiglottitis = emergency (do NOT use tongue blade or visualize throat): drooling, dysphagia, distressed, tripod, dysphonia ("4 Ds"); Hib vaccine prevents. LTB (viral croup): barking cough, inspiratory stridor; cool/humid mist + racemic epinephrine + dexamethasone. Bronchiolitis/RSV: <2 yr, wheezing/retractions; supportive care; contact + droplet precautions; palivizumab prophylaxis for high-risk. Strep throat: rapid antigen + culture; full antibiotic course to prevent rheumatic fever and glomerulonephritis.
Do NOT examine the throat or use a tongue blade — can trigger complete airway obstruction
Keep the child upright and calm; allow parent to hold the child
Do not place in supine position
Have emergency airway equipment immediately available
Anticipate transfer to OR for intubation under controlled conditions
IV antibiotics (ceftriaxone) and corticosteroids after airway secured
Bronchiolitis (RSV)
Overview
Lower respiratory infection of small airways
Most common cause: respiratory syncytial virus (RSV)
Affects children < 2 yr; most severe < 6 mo
Highly contagious; peaks in winter and early spring
Expected findings
URI prodrome → rhinorrhea, low-grade fever
Progresses to cough, wheeze, tachypnea, retractions
Difficulty feeding (work of breathing)
Crackles, wheezes, prolonged expiration
Apnea episodes possible in young infants
Nursing care
Contact + droplet precautions — RSV is highly contagious
Supportive: O₂ if hypoxic, hydration, suctioning of nasal secretions (especially before feeds), elevate HOB
Cluster care to allow rest
Monitor for apnea, especially in young infants
Bronchodilators inconsistently effective; trial may be warranted
Routine antibiotics, corticosteroids not indicated for viral bronchiolitis
Prevention
Hand hygiene; isolation of infected children
Palivizumab (Synagis): monoclonal antibody given monthly during RSV season to high-risk infants (preterm, chronic lung disease, congenital heart disease)
Limit exposure of high-risk infants during RSV season
Breastfeeding offers some protection
Other respiratory infections
Acute pharyngitis / tonsillitis
Most pharyngitis is viral; ~15–30% bacterial (group A streptococcus — GAS)
GAS findings: sudden sore throat, fever, beefy red tonsils with white/yellow exudate, tender anterior cervical lymphadenopathy, palatal petechiae, strawberry tongue (scarlet fever); typically no cough or rhinorrhea
Rapid antigen detection test; if negative and clinical suspicion high, follow with throat culture
Treatment: penicillin V or amoxicillin × 10 days; complete the full course to prevent rheumatic fever and acute glomerulonephritis
Tonsillectomy considered for recurrent infections (≥ 7 in 1 yr or 5/yr × 2 yr) or airway obstruction
Pneumonia
Viral (most common in young children — RSV, influenza), bacterial (S. pneumoniae, mycoplasma in older children)
Chest X-ray confirms; consolidation in bacterial pneumonia
Treatment: antibiotics for bacterial pneumonia (amoxicillin first-line for typical community-acquired); azithromycin for atypical
Supportive care: O₂, hydration, antipyretics, position upright
Encourage cough/deep breathing, chest physiotherapy as ordered
Tuberculosis (TB)
Caused by Mycobacterium tuberculosis; airborne transmission; can be latent or active
Screening: Mantoux tuberculin skin test (TST/PPD) — 0.1 mL intradermal on forearm; read induration (not erythema) at 48–72 hr; positive: ≥ 5 mm (high-risk), ≥ 10 mm (moderate-risk), ≥ 15 mm (low-risk)
IGRA (interferon-gamma release assay) blood test is alternative
Most bleeding risk: first 24 hr and 5–10 days postop (eschar separation)
Pain management with acetaminophen; avoid NSAIDs (bleeding risk per some surgeon preferences)
QUICK CHECK: A 4-year-old presents with sudden onset high fever, drooling, tripod posture, and muffled voice. What should the nurse NOT do? Answer: Do not examine the throat, use a tongue blade, or place the child supine — these can trigger complete airway obstruction in epiglottitis. Keep the child upright and calm; prepare for emergency airway management.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Basic Concept. Practice answering before reviewing the key.
Scenario
A nurse is teaching a guardian of a child who has an infectious respiratory illness. What should the nurse include in the teaching?
RELATED CONTENT: Identify at least three strategies to decrease the spread of infection. RN NURSING CARE OF CHILDREN
Answer key
Related Content
Perform appropriate hand hygiene.
Cover the nose and mouth with tissues when sneezing and coughing.
Dispose of tissues properly.
Do not share cups, eating utensils, or towels.
Keep infected children from contact with children who are well.
Application Exercises
Q1
A 4-year-old presents to the ED with sudden onset of high fever, drooling, dysphagia, and a tripod position. Which action should the nurse take first?
A. Examine the throat with a tongue blade to assess the airway
B. Place the child supine and start an IV
C. Keep the child calm and upright; do not examine the throat
D. Encourage the child to drink fluids to soothe the throat
Show rationale ▾
A. Examining the throat can trigger complete airway obstruction.
B. Supine position worsens airway obstruction.
C.CORRECT. Findings suggest epiglottitis. Keep the child upright and calm with parent present. Do not examine throat. Prepare for emergency airway management.
D. The child has dysphagia and is at risk for aspiration; avoid oral intake.
NCLEX® Connection: Physiological Adaptation — Medical Emergencies
Q2
A nurse is caring for a 6-month-old with bronchiolitis caused by RSV. Which interventions are appropriate? (Select all that apply.)
B.CORRECT. Clear nasal passages before feeds improve intake.
C. RSV is viral; antibiotics not indicated unless secondary bacterial infection.
D.CORRECT. HOB elevation improves work of breathing.
E.CORRECT. Clustering care reduces fatigue and oxygen demand.
NCLEX® Connection: Safety and Infection Control — Standard/Transmission-Based Precautions
Q3
A child has been diagnosed with viral croup (LTB). Which interventions are appropriate? (Select all that apply.)
A. Keep the child calm
B. Provide cool humidified air
C. Administer prescribed oral dexamethasone
D. Examine the throat with a tongue blade for redness
E. Anticipate nebulized racemic epinephrine for stridor
Show rationale ▾
A.CORRECT. Agitation worsens airway obstruction.
B.CORRECT. Cool humidified air helps reduce airway swelling.
C.CORRECT. Dexamethasone reduces airway inflammation; standard treatment.
D. While LTB is less restrictive than epiglottitis, throat examination is unnecessary and may cause distress.
E.CORRECT. Racemic epinephrine reduces stridor in moderate-to-severe croup.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Q4
A nurse is providing postoperative care for a 6-year-old after a tonsillectomy. Which finding requires immediate intervention?
A. Sore throat rated 5/10
B. Refusal to drink fluids
C. Frequent swallowing
D. Low-grade fever of 38°C (100.4°F)
Show rationale ▾
A. Pain is expected; treat with prescribed analgesics.
B. Common but expected; encourage cool clear fluids.
C.CORRECT. Frequent swallowing is a key sign of postoperative bleeding — child swallows blood trickling down the throat. Inspect the oropharynx and notify the provider.
D. Low-grade fever is common postop.
NCLEX® Connection: Reduction of Risk Potential — Potential for Complications
Q5
A parent calls about a 5-year-old with sore throat, fever, and red tonsils with white exudate. The rapid strep test is positive. Which teaching point is most important?
A. "Stop antibiotics when your child feels better."
B. "Complete the full antibiotic course to prevent rheumatic fever."
C. "Skip school for at least 1 month."
D. "Antibiotics will not help; rest and fluids only."
Show rationale ▾
A. Premature discontinuation increases risk of complications and resistance.
B.CORRECT. Completing the full antibiotic course is critical to prevent acute rheumatic fever and post-streptococcal glomerulonephritis.
C. Return to school is typically permitted after 24 hr of effective antibiotic therapy.
D. GAS pharyngitis requires antibiotics.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Asthma is the most common chronic respiratory disease of childhood — a triad of airway inflammation, bronchoconstriction, and mucus hypersecretion that produces reversible obstruction. Care centers on long-term control with inhaled corticosteroids, quick relief with short-acting beta-agonists, trigger avoidance, peak-flow monitoring, and recognizing status asthmaticus.
TL;DR · One-glance summary
Triad: inflammation + bronchospasm + mucus. Quick relief = SABA (albuterol) — rescue inhaler. Long-term control = ICS (fluticasone, budesonide); LABA always combined with ICS, never alone. Peak flow zones: Green ≥80% personal best, Yellow 50–79%, Red <50% (emergency). Status asthmaticus = unresponsive to standard therapy → emergency. Always use a spacer with MDI in children. Rinse mouth after ICS.
Oxygen to maintain SpO₂ ≥ 90% (≥ 94% in some protocols)
Continuous or back-to-back nebulized SABA (albuterol + ipratropium)
Systemic corticosteroids (IV methylprednisolone or oral prednisone) early
IV access; consider IV magnesium sulfate for severe
Subcutaneous or IM epinephrine for life-threatening exacerbation
Heliox (helium-oxygen mixture) may help in severe cases
Prepare for possible intubation if respiratory failure progresses
Position upright (high-Fowler's) leaning forward; family at bedside if helpful
QUICK CHECK: A child with asthma exacerbation suddenly stops wheezing. Is this a sign of improvement? Answer: Not necessarily. A "silent chest" can indicate severe airflow obstruction — too little air movement to generate wheeze. Combined with worsening respiratory distress and decreased LOC, this is an ominous sign requiring immediate intervention.
Client and family education
Asthma action plan — written, individualized, reviewed at every visit; copies for school, child care, sports
Distinguish rescue vs. controller medications
Inhaler technique with spacer; demonstrate at every visit
Rinse mouth after ICS (oral candidiasis prevention)
Avoid known triggers; allergy testing if appropriate
Tobacco smoke exposure — eliminate
Annual influenza vaccine; pneumococcal vaccine
Exercise: pretreat with SABA 15 min before activity if exercise-induced
Recognize early warning signs and act on them
Peak flow technique and zone interpretation
When to seek emergency care: red-zone PEF, severe distress, no relief from rescue inhaler
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.
Scenario
A nurse is teaching a child about asthma triggers. What information should the nurse include in the teaching?
CLIENT EDUCATION: List at least eight possible asthma triggers. CONTENT MASTERY SERIES
Answer key
Client Education
Allergens
Indoor: mold, cockroach antigen, dust mites
Outdoor: grasses, pollen, trees, shrubs, molds, spores, air pollution
Exercise/activity
Cold air or changes in weather or temperature
Tobacco smoke
Infections/colds
Animal hair or dander
Medications
Strong odors
Emotions
Food allergies or additives
Application Exercises
Q1
A nurse is reviewing the medications of an 8-year-old with persistent asthma. The child takes daily fluticasone and uses albuterol as needed. Which teaching point is most important?
A. "Use fluticasone for sudden symptoms of wheezing."
B. "Rinse your mouth with water after each fluticasone dose."
C. "Skip fluticasone when feeling well."
D. "Albuterol should be taken every day on a schedule."
Show rationale ▾
A. Fluticasone is a controller, not a rescue medication.
B.CORRECT. Rinsing the mouth after inhaled corticosteroids prevents oral candidiasis and dysphonia.
C. ICS must be taken daily even when symptom-free to maintain control.
D. Albuterol is for as-needed rescue; daily scheduled use suggests poor control.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Q2
A nurse is assessing a 10-year-old with an asthma exacerbation. Which finding is most concerning?
A. Audible expiratory wheeze
B. Respiratory rate 28/min
C. Markedly diminished breath sounds bilaterally
D. Use of accessory muscles
Show rationale ▾
A. Wheezing indicates airflow obstruction but means air is moving.
B. Tachypnea is expected; needs treatment but isn't the most concerning finding.
C.CORRECT. "Silent chest" — markedly diminished breath sounds — indicates severe airflow obstruction with little air movement; an ominous sign of impending respiratory failure.
D. Accessory muscle use is a sign of moderate-to-severe distress but not the most ominous in this list.
NCLEX® Connection: Physiological Adaptation — Medical Emergencies
Q3
A child uses a peak flow meter daily. Today's reading is 60% of personal best. What action should the nurse instruct the parent to take?
A. Continue current routine; this is the green zone
B. Administer rescue inhaler and follow the yellow-zone action plan
C. Go immediately to the emergency department
D. Stop all asthma medications
Show rationale ▾
A. Green zone is ≥ 80% of personal best.
B.CORRECT. Yellow zone (50–79%) signals caution — give rescue medication and follow the written action plan; may need controller adjustment.
C. ED is recommended for red-zone (<50%) or unresponsive symptoms.
D. Continuing controller medications is critical during exacerbations.
NCLEX® Connection: Health Promotion and Maintenance — Health Promotion/Disease Prevention
Q4
A nurse is administering albuterol via nebulizer to a child with an asthma exacerbation. Which finding is an expected side effect?
A. Bradycardia
B. Constipation
C. Tachycardia and tremor
D. Hypoglycemia
Show rationale ▾
A. Albuterol causes tachycardia, not bradycardia.
B. Not a typical SABA side effect.
C.CORRECT. Tachycardia, tremor, and jitteriness are expected SABA side effects from beta-2 stimulation (with some beta-1 cross-reactivity at higher doses).
D. SABAs can cause hyperglycemia and hypokalemia, not hypoglycemia.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Expected Actions/Outcomes
Q5
A parent of a 12-year-old with exercise-induced asthma asks how to prevent symptoms during soccer practice. What is the most appropriate response?
A. "Your child should stop playing soccer."
B. "Use the albuterol inhaler 15 minutes before exercise."
C. "Take fluticasone immediately before exercise for fast relief."
D. "There is nothing that can be done to prevent symptoms."
Show rationale ▾
A. Children with asthma should remain physically active; treatment is the answer.
B.CORRECT. Pretreating with SABA 15 minutes before exercise prevents exercise-induced bronchospasm.
C. Fluticasone is a daily controller, not a fast-acting medication.
D. Exercise-induced asthma is highly preventable.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Cystic fibrosis is an autosomal recessive disorder of the CFTR protein that causes thick, sticky secretions across multiple organs — leading to chronic lung disease, pancreatic insufficiency, malabsorption, and reproductive issues. Nursing care centers on airway clearance, nutrition with pancreatic enzymes and fat-soluble vitamins, infection prevention, and family support across the lifespan.
TL;DR · One-glance summary
Autosomal recessive CFTR mutation. Sweat chloride >60 mEq/L = diagnostic. Pancreatic enzyme replacement (pancrelipase / Creon) with all meals/snacks (open capsules into non-protein food — applesauce — for young children). Fat-soluble vitamins (ADEK) daily. High-calorie, high-protein, high-fat diet. Multiple airway clearance daily (CPT, vest, PEP). Watch for Pseudomonas aeruginosa infections. Skin tastes salty. Newborn often has meconium ileus.
Treatment: IV antibiotics (often dual coverage for Pseudomonas — e.g., tobramycin + piperacillin-tazobactam or ceftazidime), intensified airway clearance, nutritional support
Often requires hospitalization or home IV therapy
Nutritional management
Pancreatic enzyme replacement (PERT)
Take with every meal and every snack
Dose based on lipase units/kg/meal
Swallow capsules whole if able; for young children, open capsule and sprinkle beads into a small amount of acidic, non-protein food (applesauce) — do not mix into protein-rich foods (formula, milk, meat) as protein inactivates the enzyme coating
Do not crush or chew beads (enteric coating preserves enzymes until small intestine)
Take immediately before or with the meal — not after
Watch for fibrosing colonopathy with very high doses
Diet
High-calorie (110–200% of standard for age)
High-protein, high-fat diet (do not restrict fat — energy density needed)
QUICK CHECK: A parent reports that pancreatic enzymes seem to "stop working" when mixed into a bottle of formula. Why? Answer: Pancreatic enzyme capsules contain enteric-coated beads that protect the enzyme until it reaches the small intestine. Mixing the beads into protein-rich food like formula or milk allows protein to begin digesting the enzyme coating, inactivating it. The beads should be sprinkled into a small amount of acidic, non-protein food like applesauce, given immediately before the meal.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.
Scenario
A nurse is caring for a child who has cystic fibrosis. What nursing interventions should the nurse expect to provide?
NURSING CARE: ● Describe at least three general nursing actions. ● Describe three nursing actions related to the management of pulmonary function. ● Describe two nursing actions related to gastrointestinal system management. ● Describe two nursing actions related to endocrine system management.
Answer key
Nursing Care
General Nursing Actions
Assess lung sounds and respiratory status.
Assess vital signs with oxygen saturation.
Obtain IV access (peripherally inserted central catheter).
Obtain sputum for culture and sensitivity.
Provide support to the child and family. Pulmonary management
Perform ACT as prescribed. Avoid immediately before and after meals.
Administer aerosol therapy (bronchodilator, human deoxyribonuclease).
Administer IV antibiotics (tobramycin, ticarcillin, or gentamicin).
Encourage physical aerobic exercise.
Provide oxygen as prescribed. (Assess for carbon dioxide retention.) Gastrointestinal management
Consume a well balanced diet high in protein and calories.
Eat three meals a day with snacks.
Encourage oral fluid intake.
Administer pancreatic enzymes within 30 min of eating.
Take vitamin supplements: multivitamin, vitamins A, D, E, and K.
Administer laxatives or stool softeners for constipation.
Administer histamine-receptor antagonist and motility Medications for GERD.
Administer possible formula supplements in addition to breastfeeding or via a gastric tube.
Consult a dietitian. Endocrine management
Monitor blood glucose levels.
Administer insulin as prescribed.
Application Exercises
Q1
A nurse is teaching a parent of a 6-month-old with newly diagnosed cystic fibrosis about pancreatic enzyme replacement. Which instruction should the nurse include?
A. Crush the enzyme beads and mix them with formula
B. Sprinkle the enzyme beads into a small amount of applesauce immediately before each feeding
C. Give the enzymes 30 minutes after each feeding
D. Withhold enzymes when stools appear normal
Show rationale ▾
A. Beads should not be crushed (destroys enteric coating); never mix with protein-rich food (formula).
B.CORRECT. Beads in a small amount of acidic, non-protein food (applesauce) preserve the enteric coating; give immediately before feeding for proper enzyme action.
C. Enzymes must be given before or with meals/feeds, not after.
D. Enzymes are needed for every meal and snack regardless of stool appearance.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Q2
A nurse is reviewing diagnostic findings for a child with suspected cystic fibrosis. Which result confirms the diagnosis?
A. Sweat chloride 65 mEq/L
B. Sweat chloride 35 mEq/L
C. Sweat chloride 45 mEq/L
D. Stool culture positive for Pseudomonas
Show rationale ▾
A.CORRECT. Sweat chloride > 60 mEq/L (on two occasions) is diagnostic of CF.
B. Less than 40 is considered normal.
C. 40–60 is borderline; requires further evaluation.
D. Pseudomonas in respiratory cultures (not stool) is a sign of CF lung disease, not a diagnostic criterion.
NCLEX® Connection: Reduction of Risk Potential — Laboratory Values
Q3
A nurse is teaching parents of an 8-year-old with cystic fibrosis about diet. Which instruction is appropriate?
A. Restrict fat to less than 20% of calories
B. Provide a high-calorie, high-protein, high-fat diet with fat-soluble vitamin supplements
C. Limit fluid intake
D. Restrict sodium intake
Show rationale ▾
A. Fat restriction in CF causes inadequate calorie intake.
D. Salt supplementation is encouraged due to high losses through sweat.
NCLEX® Connection: Basic Care and Comfort — Nutrition and Oral Hydration
Q4
A nurse is performing chest physiotherapy on a child with cystic fibrosis. Which finding indicates the treatment has been effective?
A. Decreased respiratory rate
B. Increased productive cough during and after treatment
C. Decreased SpO₂
D. Increased work of breathing
Show rationale ▾
A. Respiratory rate may or may not change immediately.
B.CORRECT. Increased productive cough indicates that secretions are mobilized and being cleared — the goal of CPT.
C. Decreased SpO₂ would suggest worsening, not improvement.
D. Increased work of breathing indicates a poor response, not improvement.
NCLEX® Connection: Reduction of Risk Potential — Therapeutic Procedures
Q5
A nurse is providing care for a child with CF in the clinic. Another patient with CF is in the waiting room. Which infection-control action is most appropriate?
A. Place both children in the same exam room
B. Keep the children physically separated at all times
C. Allow them to play together while waiting
D. Have them share the same equipment
Show rationale ▾
A. Co-locating patients with CF risks cross-infection with virulent organisms (Burkholderia cepacia, multi-drug-resistant Pseudomonas).
B.CORRECT. Individuals with CF should never be in the same physical space — distinct exam rooms, no shared waiting areas — due to cross-infection risk with serious CF pathogens.
C. Cross-infection risk; should never play together in clinic.
D. Shared equipment violates infection-control standards in CF.
NCLEX® Connection: Safety and Infection Control — Standard/Transmission-Based Precautions
Pediatric cardiovascular disease is dominated by congenital heart defects (CHDs), classified by their effect on pulmonary blood flow: increased (left-to-right shunts), decreased (right-to-left shunts with cyanosis), obstructive, or mixed. Acquired conditions — rheumatic fever and Kawasaki disease — round out the chapter. Key skills: recognizing heart failure, safely administering digoxin, and supporting families through cardiac catheterization and surgery.
TL;DR · One-glance summary
Four CHD categories: ↑ pulmonary flow (ASD, VSD, PDA — acyanotic, CHF), ↓ pulmonary flow (Tet, tricuspid atresia — cyanotic), obstructive (COA, AS, PS), and mixed (TGA, HLHS, TAPVR, truncus). Tet spells: place child in knee-chest position. Coarctation: ↑ BP and bounding pulses in arms, weak/absent femoral pulses, ↓ BP in legs. Digoxin toxicity: bradycardia, vomiting, anorexia, vision changes. Kawasaki disease: IVIG + high-dose aspirin to prevent coronary aneurysms. Rheumatic fever: Jones criteria; treat strep promptly to prevent.
Older children: intolerance to exercise, dizziness, chest pain, possible ejection murmur
Systolic ejection murmur at right upper sternal border; thrill in suprasternal notch
Activity restriction if severe
Treatment:
Nonsurgical: balloon dilation with cardiac catheterization; beta blockers or calcium channel blockers
Surgical: Norwood procedure, aortic valvotomy, or valve replacement
Pulmonic stenosis (PS)
Narrowing of the pulmonary valve or pulmonary artery → RV outflow obstruction
Findings: systolic ejection murmur at left upper sternal border; possibly asymptomatic; cyanosis varies (worse with severe narrowing); cardiomegaly; heart failure
Treatment:
Nonsurgical: balloon angioplasty with cardiac catheterization (first-line)
Administer antibiotics parenterally for an extended length of time (2–8 weeks), usually via a peripherally inserted central catheter (PICC)
Maintain a high level of oral care
Advise the family's regular dentist of existing cardiac problems to ensure preventive treatment
Observe for manifestations of endocarditis: low-grade fever, malaise, decreased appetite with weight loss
AHA prophylaxis guidelines — high-risk groups
Prophylactic antibiotics are given before dental procedures, surgical procedures involving the respiratory tract, and procedures on infected skin or musculoskeletal tissue for clients with:
Artificial (prosthetic) heart valves
Previous diagnosis of infective endocarditis
Unrepaired cyanotic congenital heart disease
Repaired congenital heart disease using prosthetic material/device during the first 6 months after the procedure
Residual defects after congenital heart disease repair
Complications
Heart failure, myocardial infarction, embolism
Cardiomyopathy
Abnormalities of the myocardium that interfere with effective contraction; can lead to heart failure
Anaphylactic: IM epinephrine (anterolateral thigh) — priority intervention; then IM epinephrine (1:1000 = 1 mg/mL) 0.01 mg/kg (max 0.3 mg) into anterolateral thigh — first-line, repeat q5–15 min PRN; then antihistamines (diphenhydramine 1–2 mg/kg IV/IM), corticosteroids (methylprednisolone), IV fluids, bronchodilators (albuterol)
Continuous cardiac and respiratory monitoring
Acquired heart disease
Acute rheumatic fever (ARF)
Inflammatory disease that occurs as a reaction to Group A beta-hemolytic streptococcal (GABHS) infection of the throat — typically 2–6 weeks after untreated or partially treated strep throat.
Fever; tachycardia; cardiomegaly; new or changed murmur; muffled heart sounds; pericardial friction rub; chest pain (carditis)
Nontender subcutaneous nodules over bony prominences
Polyarthritis — painful swelling of large joints (knees, elbows, ankles, wrists, shoulders); migratory pattern (often disappears in one joint and returns in another)
Erythema marginatum — pink, nonpruritic macular rash on trunk and inner extremities that appears and disappears rapidly
Sydenham chorea — involuntary, purposeless muscle movements; muscle weakness; involuntary facial movements; difficulty with fine motor activities; labile emotions; irritability, poor concentration, behavioral changes
Labs:
Throat culture for GABHS (current recommendation is to screen all school-aged children with sore throats)
Blood antistreptolysin O (ASO) titer — elevated or rising titer is the most reliable diagnostic test
CRP and ESR — elevated with inflammation
Modified Jones criteria for diagnosis: 2 major criteria OR 1 major + 2 minor following acute GABHS infection
Nursing care: bed rest during acute illness; antibiotics as prescribed; nutritionally balanced meals; assess for chorea progression
Antibiotic prophylaxis regimens (one of the following):
Two daily oral doses of penicillin V
Monthly IM injection of penicillin G
Daily oral dose of sulfadiazine
Length of treatment varies with residual heart disease — 5 years to indefinitely
Client education: promote rest during acute phase; reassurance about self-limiting nature of chorea; may need valve repair or replacement surgery; regular cardiologist follow-up
Acute systemic vasculitis of unknown cause. Most commonly affects children < 5 yr.
Acute phase findings:
Fever ≥ 5 days (typically high, unresponsive to antipyretics)
Bilateral nonpurulent conjunctivitis
Bright red, chapped lips
Strawberry tongue with white coating or red bumps on the posterior aspect
Red oral mucous membranes with inflammation including the pharynx
Swelling of hands and feet with red palms and soles
Nonblistering polymorphous rash
Bilateral joint pain
Cervical lymphadenopathy (often unilateral)
Desquamation of the perineum
Cardiac: myocarditis, decreased left ventricular function, pericardial effusion, mitral regurgitation
Subacute phase: resolution of fever and gradual subsiding of other manifestations; irritability; peeling skin around the nails, on palms and soles; temporary arthritis
Convalescent phase: no symptoms except altered labs; resolution in 6–8 weeks from onset
Monitor LFTs, CBC, CK, fasting lipid profile at 4- and 8-week intervals
Recommend a multivitamin supplement while on this medication
Lifestyle interventions
Heart-healthy diet (Mediterranean-style; limit saturated fats, trans fats, simple sugars)
Regular physical activity (60 min/day moderate-to-vigorous for children/adolescents)
Weight management; smoking avoidance/cessation
Dietary counseling via interprofessional team (registered dietitian)
Cardiac catheterization
An invasive test used for diagnosing congenital defects, repairing some defects, and evaluating dysrhythmias. A radiopaque catheter is peripherally inserted (usually femoral) and threaded into the heart with fluoroscopy. A contrast medium (often iodine-based) is injected to visualize blood vessels and heart structures.
Preprocedure nursing actions
Perform nursing history and physical exam — evidence of infection (e.g., severe diaper rash) may necessitate canceling if femoral access is required
Check for allergies to iodine and shellfish (contrast media reactions)
NPO per protocol (commonly 4–6 hr)
Baseline vital signs, oxygen saturation, weight
Assess and mark distal pulses on both extremities for postprocedure comparison
Verify informed consent; document baseline neurovascular status
Provide age-appropriate teaching: describe how long the procedure will take, who will be present, what the child will see and feel, recovery plan
Postprocedure nursing actions
Vital signs every 15 min × 4, then every 30 min × 2, then every hour × 4
Check pulses distal to the catheter site every 15 min initially; compare to baseline — pulse strength, color, temperature, capillary refill
Keep affected extremity straight for 4–8 hr (per facility protocol)
Monitor cath site for bleeding or hematoma
Encourage oral fluids to flush contrast and maintain hydration
Monitor for arrhythmias, hypotension, low-grade fever
Monitor blood glucose — risk of hypoglycemia related to NPO status and contrast osmotic effect
If bleeding at the catheter site
Apply direct continuous pressure 2.5 cm (1 inch) ABOVE the catheter entry site — this localizes pressure over the vessel puncture
Position the child flat to reduce gravitational effect on the rate of bleeding
Notify the provider immediately
Prepare for possible administration of replacement fluids and/or medication to control emesis
Potential complications
Nausea, vomiting
Low-grade fever
Loss of pulse in the catheterized extremity (arterial thrombosis or occlusion — emergency)
Transient dysrhythmias
Acute hemorrhage from entry site
Hypoglycemia — monitor blood glucose
Client/family education
Monitor for possible complications (bleeding, infection, thrombosis)
Limit activity for 24 hours
Encourage fluids
Bathing per facility instructions (typically no submersion for several days)
QUICK CHECK: An infant with tetralogy of Fallot has a sudden episode of deep cyanosis after vigorous crying. What is the priority nursing action? Answer: Place the infant in the knee-chest position. This increases systemic vascular resistance, which decreases the right-to-left shunt and improves pulmonary blood flow. Calm the infant, administer 100% oxygen, and notify the provider.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.
Scenario
A nurse is discussing care of a child who has Kawasaki disease with a newly hired nurse. What should be included in this discussion?
EXPECTED FINDINGS: Identify for the acute, subacute, and convalescent phase.
NURSING CARE: List seven nursing actions for this client. CONTENT MASTERY SERIES
Answer key
Expected Findings
Acute phase: onset of high fever that is unresponsive to
antipyretics, with development of other Manifestations
Fever greater than 38.9° C (102° F) lasting 5 days to 2 weeks and unresponsive to antipyretics
Irritability
Red eyes without drainage
Bright red, chapped lips
Strawberry tongue with white coating or red bumps on the posterior aspect
Red oral mucous membranes
Swelling of hands and feet with red palms and soles
Non-blistering rash
Bilateral joint pain
Enlarged lymph nodes
Subacute phase: resolution of the fever and gradual subsiding of other Manifestations
Irritability
Peeling skin around the nails, on the palms and soles Convalescent phase: no Manifestations seen except altered laboratory findings. Resolution in about 6 to 8 weeks from onset.
Administer IV fluids. Offer clear liquids and soft foods.
Administer IV gamma globulin according to facility policy.
Administer aspirin as prescribed.
Provide care to include oral hygiene, cool cloths to extremities, application of skin lotion; providing for a quiet environment to promote rest; cluster nursing care.
Application Exercises
Q1
A nurse is administering digoxin to a 4-month-old with heart failure. Before administering the dose, the apical pulse is 84/min. Which action should the nurse take?
A. Administer the dose as scheduled
B. Hold the dose and notify the provider
C. Administer a half dose
D. Mix the dose in formula and feed in 30 min
Show rationale ▾
A. HR < 90 in infants is indication to hold; do not administer.
B.CORRECT. Hold digoxin and notify the provider if apical HR < 90/min in infants (< 70/min in older children). Bradycardia may indicate digoxin toxicity or excess effect.
C. Nurse should not adjust the dose independently.
D. Digoxin should never be mixed in formula.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Q2
A nurse is caring for a 6-month-old with tetralogy of Fallot. The infant suddenly becomes deeply cyanotic during a crying episode. Which is the priority action?
A. Lay the infant flat in the crib
B. Place the infant in the knee-chest position
C. Begin chest compressions
D. Stimulate the infant to wake fully
Show rationale ▾
A. Supine position does not help and may worsen hypoxic spell.
B.CORRECT. Knee-chest position increases systemic vascular resistance, redirects blood through the pulmonary circulation, and relieves a hypercyanotic ("tet") spell.
C. Compressions are not yet indicated.
D. Calm the infant, not stimulate further.
NCLEX® Connection: Physiological Adaptation — Medical Emergencies
Q3
A nurse is assessing an infant suspected of having coarctation of the aorta. Which findings would support this diagnosis? (Select all that apply.)
A. Higher blood pressure in the upper extremities than in the lower
B. Bounding pulses in the arms
C. Weak or absent femoral pulses
D. Continuous "machinery" murmur
E. Cool lower extremities
Show rationale ▾
A.CORRECT. Hypertension proximal to the coarctation.
B.CORRECT. Increased flow to upper extremities → bounding pulses.
C.CORRECT. Reduced flow distal to coarctation → weak/absent femoral pulses.
D. Continuous "machinery" murmur is characteristic of PDA, not coarctation.
E.CORRECT. Reduced flow → cool lower extremities.
NCLEX® Connection: Reduction of Risk Potential — System Specific Assessments
Q4
A nurse is caring for a child diagnosed with Kawasaki disease. Which treatments are appropriate? (Select all that apply.)
A. IV immunoglobulin
B. High-dose aspirin during acute phase
C. Live MMR vaccine within 1 month of IVIG
D. Serial echocardiograms
E. Long-term anticoagulation for all patients
Show rationale ▾
A.CORRECT. IVIG 2 g/kg within 10 days of fever onset reduces coronary aneurysm risk.
B.CORRECT. High-dose aspirin for anti-inflammatory effect, then low-dose antiplatelet. Kawasaki is one of the few pediatric indications for aspirin.
C. Live vaccines should be deferred ~11 months after IVIG.
D.CORRECT. Serial echos monitor for coronary aneurysms.
E. Long-term anticoagulation is for patients who develop large coronary aneurysms; not universal.
NCLEX® Connection: Physiological Adaptation — Alterations in Body Systems
Q5
A nurse is monitoring a child 4 hours after cardiac catheterization through the right femoral artery. Which finding requires immediate intervention?
A. Heart rate 92/min
B. Cool, pale right foot with diminished pedal pulse
C. Sleeping comfortably
D. Urinary output of 1 mL/kg/hr
Show rationale ▾
A. Within expected range.
B.CORRECT. Cool, pale extremity with diminished pulse distal to the cath site suggests arterial occlusion or thrombosis — immediate provider notification required.
C. Expected — child should be at rest.
D. Adequate urine output.
NCLEX® Connection: Reduction of Risk Potential — Therapeutic Procedures
Pediatric hematology covers anemias (iron deficiency is by far the most common, with sickle cell and beta thalassemia as the inherited heavyweights), bleeding disorders (hemophilia, ITP), and aplastic anemia. Themes that repeat across the chapter: monitor for bleeding, hydrate aggressively in sickle cell crisis, and educate families about lifelong management of genetic conditions.
TL;DR · One-glance summary
Iron deficiency anemia: most common; cow's milk over-consumption is a key cause in toddlers; iron supplements between meals with vitamin C, stools turn dark/tarry. Sickle cell: autosomal recessive; treat crisis with hydration, oxygen, pain control; hydroxyurea ↑ HbF. Hemophilia: X-linked recessive; factor VIII (A) or IX (B) deficiency; replace factor for bleeds; no IM injections, no aspirin/NSAIDs, no contact sports. ITP: low platelets, usually self-limited post-viral; bleeding precautions. Beta thalassemia: chronic transfusions → iron overload → chelation.
Hematomas; intracranial bleeding (severe injuries — high mortality risk)
Often diagnosed in infancy with circumcision bleeding or significant bruising
Labs
↑ aPTT (intrinsic pathway), normal PT
Decreased factor VIII or IX activity (definitive)
Normal platelet count and bleeding time
Management
Factor replacement — recombinant factor VIII or IX given IV for bleeding episodes or prophylaxis
DDAVP (desmopressin) — releases stored factor VIII; useful for mild hemophilia A
Antifibrinolytics (aminocaproic acid, tranexamic acid) — for mucosal bleeding
Joint care during bleed: RICE — Rest, Ice (yes — cold reduces bleeding here, contrast with sickle), Compression, Elevation; immobilize, factor replacement
Physical therapy after bleed resolves to preserve joint function
Family teaching: home factor administration; recognize bleeding early
Critical safety teaching
Avoid IM injections when possible — use subcutaneous; if IM unavoidable, give factor first and apply pressure
Von Willebrand disease (vWD)
Most common inherited bleeding disorder; autosomal dominant (affects both sexes)
Deficiency or dysfunction of von Willebrand factor (vWF) — needed for platelet adhesion
Findings: prolonged bleeding time, mucosal bleeding (epistaxis, gum bleeding, heavy menstruation in adolescents), prolonged bleeding from cuts, easy bruising
Labs: prolonged bleeding time, normal platelet count, ↓ vWF, may have ↑ aPTT
Treatment: desmopressin (DDAVP) — releases stored vWF from endothelial cells (type 1); vWF-containing factor concentrates for severe types
Avoid aspirin and NSAIDs (impair platelet function)
Dental care: may need DDAVP or aminocaproic acid before procedures
Medical alert identification
Avoid aspirin and NSAIDs — use acetaminophen for pain/fever
Soft toothbrush; electric razors only
No contact sports — encourage swimming, cycling (with helmet), golf
Helmets, knee/elbow pads for biking/skating
Medical alert bracelet
Carry factor concentrate while traveling
Other hematologic disorders
Beta thalassemia (Cooley anemia)
Autosomal recessive defect in beta-globin synthesis
Severity: minor (carrier, mild anemia) → intermedia → major (transfusion-dependent)
Most common in Mediterranean, Middle Eastern, South Asian heritage
Findings: severe anemia, frontal bossing/skull deformity (extramedullary hematopoiesis), hepatosplenomegaly, growth retardation, bronze skin from iron deposition
Treatment:
Chronic transfusions (every 3–4 wk)
Iron chelation with deferoxamine (IV/SC) or oral deferasirox to prevent iron overload (cardiac, hepatic, endocrine damage)
Splenectomy if needed
Stem cell transplant — curative
Idiopathic thrombocytopenic purpura (ITP)
Autoimmune destruction of platelets
Often follows a viral illness in children
Usually self-limited in pediatric cases (75% resolve within 6 mo)
Findings: sudden onset of petechiae, purpura, easy bruising; mucosal bleeding (epistaxis, gums); platelets < 100,000 (often < 20,000); WBC and Hgb normal
Treatment: observation if asymptomatic; IVIG, anti-D, corticosteroids if symptomatic or platelets very low; splenectomy if chronic refractory
Bleeding precautions: avoid contact sports, no IM injections, soft toothbrush, no aspirin/NSAIDs
Aplastic anemia
Pancytopenia from bone marrow failure (RBCs, WBCs, platelets all low)
Causes: idiopathic (most), drug toxicity (chloramphenicol, sulfonamides), radiation, viral, autoimmune
Treatment: immunosuppression (anti-thymocyte globulin, cyclosporine) or stem cell transplant; supportive care with transfusions and antibiotics
QUICK CHECK: A child with sickle cell disease is in vaso-occlusive crisis with severe knee pain. The parent applies a cold pack. What should the nurse teach? Answer: Avoid cold packs in sickle cell crisis — cold causes vasoconstriction that worsens sickling and pain. Use warm compresses instead. Contrast this with hemophilia, where cold packs (RICE) reduce bleeding into joints.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.
Scenario
A nurse is caring for a child who has a new diagnosis of hemophilia A.
EXPECTED FINDINGS: List two physical assessment findings associated with hemophilia.
CLIENT EDUCATION: List three concepts to include in the teaching with the family and child.
Answer key
Expected Findings
Active bleeding (possibly from the gums, epistaxis, hematuria, and/or GI tract)
Hematomas and bruising occur easily even with minor injuries
Joint pain and stiffness, warmth, swelling, redness, loss of range of motion of the joints
Cerebral bleeding can cause headaches, slurred speech, and decreased level of consciousness
Client Education
Prevent bleeding at home.
Provide a safe home and a play environment that is free of clutter.
Place padding on corners of furniture.
Set activity restrictions to avoid injury. Stress importance of wearing protective equipment during activities.
Caution with contact sports.
Recommend the use of soft-bristled toothbrushes or oral water irrigations.
Encourage regular exercise and physical therapy when not actively bleeding.
Teach the importance of wearing a Medical identification.
Teach Manifestations of internal bleeding and hemarthrosis
Inform of the RICE (rest, ice, compression, elevation) method to control active bleeding.
Application Exercises
Q1
A nurse is teaching the parents of a 1-year-old with iron deficiency anemia who has been prescribed oral ferrous sulfate. Which statement indicates correct understanding?
A. "I'll give the iron with milk to prevent stomach upset."
B. "I'll give the iron with orange juice between meals."
C. "I'll mix the iron with formula in the bottle."
D. "If the stools turn dark, I'll stop the medication."
Show rationale ▾
A. Milk and dairy decrease iron absorption.
B.CORRECT. Give iron between meals (better absorption) with vitamin C source like orange juice.
C. Iron should not be mixed in formula; reduced absorption and the full dose may not be received.
D. Dark/tarry stools are expected with iron therapy and not a reason to stop.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Q2
A nurse is caring for a 6-year-old in vaso-occlusive sickle cell crisis. Which interventions should the nurse implement? (Select all that apply.)
A. Increase IV fluids to 1.5× maintenance
B. Apply cold packs to painful joints
C. Administer prescribed opioid analgesics around-the-clock
D. Provide supplemental oxygen if hypoxic
E. Monitor for signs of acute chest syndrome
Show rationale ▾
A.CORRECT. Hydration is a cornerstone of crisis treatment.
B. Cold causes vasoconstriction and worsens sickling — use warm compresses.
C.CORRECT. Round-the-clock opioid analgesia, often via PCA in older children.
E.CORRECT. Acute chest syndrome is a major cause of mortality and can develop during admissions.
NCLEX® Connection: Physiological Adaptation — Alterations in Body Systems
Q3
A nurse is providing teaching to the parents of a 4-year-old with severe hemophilia A. Which instructions should the nurse include? (Select all that apply.)
B. Aspirin and NSAIDs increase bleeding risk — use acetaminophen only.
C.CORRECT. Avoid contact sports; encourage swimming, golf, cycling with helmet.
D. Avoid IM injections when possible; subcutaneous preferred. If IM is necessary (e.g., vaccines), give factor first and apply prolonged pressure.
E.CORRECT. Home factor allows immediate treatment of bleeds.
NCLEX® Connection: Safety and Infection Control — Accident/Injury Prevention
Q4
A nurse is reviewing lab values for a child newly diagnosed with ITP. Which finding is most consistent with the diagnosis?
A. Hemoglobin 8 g/dL, MCV 65 fL, platelets 250,000
B. WBC 12,000, Hgb 13 g/dL, platelets 18,000
C. WBC 2,500, Hgb 7 g/dL, platelets 30,000 (pancytopenia)
D. ↑ aPTT, normal PT, normal platelets
Show rationale ▾
A. Microcytic anemia with normal platelets suggests iron deficiency.
B.CORRECT. ITP characteristically shows isolated thrombocytopenia (often < 20,000) with normal WBC and Hgb.
C. Pancytopenia suggests aplastic anemia or marrow failure.
D. Isolated aPTT prolongation suggests hemophilia.
NCLEX® Connection: Reduction of Risk Potential — Laboratory Values
Q5
A child with beta thalassemia major requires chronic transfusions. The provider prescribes deferoxamine. The parent asks the nurse why this medication is needed. What is the best response?
A. "It is used to prevent transfusion reactions."
B. "It helps the body absorb iron from food."
C. "It binds excess iron from transfusions to prevent organ damage."
D. "It stimulates the bone marrow to produce new red blood cells."
Show rationale ▾
A. Deferoxamine is not for preventing transfusion reactions.
B. It does not aid iron absorption — it removes iron.
C.CORRECT. Deferoxamine is an iron-chelating agent that binds excess iron from chronic transfusions, preventing iron overload damage to the heart, liver, and endocrine glands.
D. Deferoxamine does not stimulate erythropoiesis.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Expected Actions/Outcomes
Acute gastroenteritis is one of the most common pediatric problems and a leading cause of dehydration in young children worldwide. Nursing care centers on recognizing the severity of dehydration, restoring fluid and electrolyte balance (oral rehydration first when tolerated), implementing the right precautions, and preventing transmission with hand hygiene.
TL;DR · One-glance summary
Most acute gastroenteritis is viral (rotavirus, norovirus) — supportive care only. Oral rehydration solution (Pedialyte) is first-line for mild/moderate dehydration: small frequent sips. Return to age-appropriate diet ASAP (BRAT diet no longer recommended). C. difficile: contact precautions + soap and water handwashing (alcohol-based hand rub does NOT kill spores). Pinworm: "scotch tape test" early morning; mebendazole/albendazole; treat the whole household.
Enterobius vermicularis (pinworm): very common in young children
Findings: intense perianal itching, especially at night (when worms emerge to lay eggs)
Diagnosis: "scotch tape test" — apply clear tape to perianal area in early morning before bathing/wiping; examine for eggs/worms under microscope
Treatment: mebendazole or albendazole as a single dose with a repeat in 2 weeks
Treat all household members; wash bedding, clothing, toys in hot water; trim child's fingernails; emphasize handwashing after toileting and before eating
Contact precautions in hospital for diarrheal illness
For C. difficile: contact precautions + soap and water for handwashing (alcohol-based products do not kill spores)
Disinfect contaminated surfaces with bleach-based products (especially for C. diff and norovirus)
Exclude affected children from daycare/school until 24 hr without symptoms (or per local policy)
Rotavirus and hepatitis A immunizations prevent specific causes
QUICK CHECK: A child is hospitalized with C. difficile colitis. Which infection-prevention measures are essential? Answer: Contact precautions and handwashing with soap and water (alcohol-based hand rub does not kill C. difficile spores). Use bleach-based disinfectants on surfaces. Dedicated equipment in the room when possible.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.
Scenario
A nurse is teaching a guardian of a child who has an acute gastrointestinal infection. What information should the nurse include in the teaching?
CLIENT EDUCATION: Describe at least 10 points to review regarding care after discharge.
Answer key
Client Education
Have the parents inform the child’s school or day care center of the infection/infestation. The child should stay home during the incubation period.
Use commercially prepared oral rehydration therapy when the child experiences diarrhea. Foods and fluids to avoid include the following:
Fruit juices, carbonated sodas, and gelatin, which have high carbohydrate content, low electrolyte content, and high osmolality
Caffeine, due to its mild diuretic effect
Chicken or beef broth, which have high sodium content and inadequate carbohydrates
Follow prevention measures, including immunization for rotavirus and methods to prevent further spread of the disease.
Provide frequent skin care to prevent skin breakdown.
Teach the family how to avoid the spread of infectious diseases.
Change bed linens and underwear daily for several days. Avoid shaking linens to prevent the spread of disease.
Cleanse toys and child care areas thoroughly to prevent further spread or reinfestation.
Shower frequently.
Avoid undercooked or under-refrigerated food.
Perform proper hand hygiene after toileting and after changing diapers.
Do not share dishes and utensils. Wash them in hot, soapy water or in the dishwasher.
Clip nails, and discourage nail-biting and thumb-sucking.
Clean toilet areas.
Application Exercises
Q1
A nurse is assessing an 18-month-old with vomiting and diarrhea. Which finding indicates moderate dehydration?
A. Moist mucous membranes, brisk capillary refill, normal urine output
B. Tacky mucous membranes, slightly sunken fontanel, decreased tears, tachycardia
C. Deeply sunken fontanel and eyes, lethargy, capillary refill 4 seconds, no urine output
C. These findings indicate severe dehydration (≥ 10%).
D. Findings contradict the question stem.
NCLEX® Connection: Physiological Adaptation — Fluid and Electrolyte Imbalances
Q2
A parent calls about their 2-year-old with vomiting and watery stools. The child is alert with moist mucous membranes. Which recommendation is most appropriate?
A. Withhold all fluids for 24 hours to rest the stomach
B. Offer small frequent amounts of an oral rehydration solution
C. Provide undiluted apple juice frequently
D. Limit the child to the BRAT diet for 1 week
Show rationale ▾
A. Withholding fluids worsens dehydration.
B.CORRECT. Mild dehydration: oral rehydration solution in small frequent amounts is the first-line approach.
C. High-sugar juices worsen osmotic diarrhea.
D. BRAT diet is no longer recommended — return to age-appropriate diet as tolerated.
NCLEX® Connection: Basic Care and Comfort — Nutrition and Oral Hydration
Q3
A nurse is caring for a child with C. difficile colitis. Which infection-prevention measures are appropriate? (Select all that apply.)
A. Place the child on contact precautions
B. Use alcohol-based hand sanitizer between care activities
C. Use soap and water for handwashing
D. Use bleach-based disinfectant for surfaces
E. Wear gown and gloves when entering the room
Show rationale ▾
A.CORRECT. Contact precautions are required for C. diff.
B. Alcohol-based hand rub does not kill C. diff spores.
C.CORRECT. Mechanical removal with soap and water is essential against spores.
D.CORRECT. Bleach-based products kill C. diff spores on surfaces.
E.CORRECT. Gown and gloves are required.
NCLEX® Connection: Safety and Infection Control — Standard/Transmission-Based Precautions
Q4
A parent of a 6-year-old reports the child has been scratching the anal area at night and they have noticed small white "thread-like" items near the rectum. Which diagnostic test should the nurse anticipate?
A. Stool culture
B. Perianal "scotch tape test" applied in early morning
C. Sweat chloride test
D. Upper GI series
Show rationale ▾
A. Stool culture is not the diagnostic test for pinworm.
B.CORRECT. Findings are consistent with pinworm (Enterobius vermicularis). The "scotch tape test" applied to the perianal area in the early morning (before bathing or wiping) captures eggs/worms for microscopic examination.
C. Sweat chloride evaluates for cystic fibrosis.
D. Upper GI evaluates structural disorders, not pinworm.
NCLEX® Connection: Reduction of Risk Potential — Diagnostic Tests
Q5
A nurse is caring for a 3-year-old with bloody diarrhea caused by E. coli O157:H7. The parent asks why antibiotics are not being given. What is the best response?
A. "Antibiotics will be ordered as soon as test results return."
B. "Antibiotics are not effective against this organism."
C. "Antibiotics can increase the risk of hemolytic uremic syndrome with this infection."
D. "Antibiotics are unnecessary because the child is no longer bleeding."
Show rationale ▾
A. Antibiotics are contraindicated for EHEC.
B. Antibiotics have some activity, but the issue is harm, not effectiveness.
C.CORRECT. Antibiotic use in EHEC infection increases the risk of hemolytic uremic syndrome (HUS) — characterized by hemolytic anemia, thrombocytopenia, and acute kidney injury.
D. Decision is not based on whether bleeding has resolved.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Adverse Effects/Contraindications
This chapter covers a wide range of structural defects (cleft lip/palate, TEF, pyloric stenosis, intussusception, Hirschsprung disease, hernias), inflammatory conditions (GERD, appendicitis, IBD, hepatitis), and the diet-controlled disease celiac. Each requires recognizing distinct early signs and applying targeted preop/postop or long-term care.
TL;DR · One-glance summary
Pyloric stenosis: projectile non-bilious vomiting after feeds + palpable olive-shaped mass; pyloromyotomy. Intussusception: sudden severe colicky abdominal pain, drawing knees up, sausage-shaped mass, currant-jelly stools; air or hydrostatic enema. Hirschsprung: failure to pass meconium >24 hr; ribbon-like stools; pull-through surgery. TEF/EA: 3 Cs — coughing, choking, cyanosis with first feeding; can't pass NG. Appendicitis: McBurney's point pain + rebound tenderness; sudden pain relief = perforation. Celiac: strict lifelong gluten-free diet.
Classic emergency signs
Drawing knees up + currant-jelly stools → intussusception
Bile-stained vomiting in newborn → obstruction (malrotation, atresia)
Coughing/cyanosis with first feed → TEF
Sudden pain relief in appendicitis → perforation
Failure to pass meconium >24 hr → Hirschsprung or obstruction
NPO / dietary essentials
Cleft palate post-op: no straws, hard utensils, pacifiers
Pyloric stenosis: NPO preop, NG decompression
Celiac: lifelong gluten-free (no wheat/rye/barley)
GERD infants: thicken feeds, upright after feeds
Appendicitis: NPO until OR
Cleft lip and palate
Overview
Congenital failure of facial structures to fuse; may occur separately or together
Often diagnosed prenatally on ultrasound
Common, multifactorial; associated with some syndromes
Repair timing:
Cleft lip repair: ~ 2–3 months ("rule of 10s" — 10 lb, 10 g Hgb, 10 wk)
Umbilical hernia: protrusion at umbilicus; usually closes spontaneously by 4–5 yr; surgical repair if persistent or incarcerated
Inguinal hernia: protrusion into inguinal canal (often into scrotum in boys); requires surgical repair; risk of incarceration (irreducible) and strangulation (compromised blood supply)
Telescoping of one bowel segment into another (most often ileocecal)
Children 3 mo – 3 yr (most common 6–12 mo)
Classic findings:
Sudden, severe, intermittent abdominal pain (drawing knees to chest)
Inconsolable crying alternating with calm periods
Bilious vomiting
Currant-jelly stools (blood + mucus) — late sign
Sausage-shaped abdominal mass (RUQ)
Lethargy between episodes
Diagnosis and treatment:
Abdominal ultrasound
Air enema (or contrast/hydrostatic enema) — both diagnostic and therapeutic; reduces intussusception in most cases
Surgery if enema fails or perforation suspected
Watch for passage of normal brown stool — indicates successful reduction
Monitor for recurrence within 24–48 hr
Meckel diverticulum
Most common congenital anomaly of the GI tract; remnant of the omphalomesenteric (vitelline) duct
"Rule of 2s": affects ~2% of population, located within 2 feet of ileocecal valve, ~2 inches long, commonly presents before age 2
Findings: painless bright red or currant-jelly rectal bleeding (most common presentation); may also cause bowel obstruction, intussusception, or diverticulitis with pain
Diagnosis: Meckel (technetium-99m pertechnetate) scan — identifies ectopic gastric mucosa within the diverticulum
Treatment: surgical resection of the diverticulum
Appendicitis
Inflammation of the appendix; most common pediatric surgical emergency
Findings:
Periumbilical pain that migrates to right lower quadrant (McBurney's point)
Anorexia, nausea, vomiting (vomiting after pain onset)
Rebound tenderness; guarding; rigid abdomen
Low-grade fever; tachycardia
Rovsing's sign (RLQ pain on LLQ palpation); psoas sign
Child prefers to lie still with knees flexed
Red flag: sudden relief of pain may signal perforation followed by peritonitis (high fever, severe diffuse pain, rigid abdomen, shock)
Care:
NPO; IV fluids; pain control (small doses of opioids)
Antibiotics
Do NOT apply heat to the abdomen — may hasten perforation
Appendectomy
Position semi-Fowler's or right side-lying after surgery; postop care includes monitoring for peritonitis, encouraging deep breathing
GERD (gastroesophageal reflux disease)
Reflux of stomach contents into the esophagus
Infants: spitting up, irritability, arching back, poor weight gain, recurrent pneumonia from aspiration
Standard precautions; HAV may require contact precautions in diapered/incontinent children
Rest, hydration, nutrition; avoid hepatotoxins (acetaminophen with caution)
QUICK CHECK: A 9-month-old has episodes of inconsolable crying with the parent reporting the infant draws knees up to chest, then becomes calm, then repeats. The diaper now contains stool that looks like red jelly. What is the likely diagnosis? Answer: Intussusception. Sudden colicky abdominal pain with calm periods, drawing knees up, and currant-jelly stools (mucus + blood) are classic. Initial treatment is an air or hydrostatic enema, which is both diagnostic and therapeutic.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.
Scenario
A nurse is caring for a child who is postoperative following an open appendectomy for a perforated appendix.
NURSING CARE: List postoperative nursing interventions.
Answer key
Nursing Care
assess respiratory status and Maintain airway.
Provide supplemental oxygen as prescribed.
obtain vital signs.
administer analgesics for pain as prescribed.
assess surgical site for bleeding or any other abnormalities.
assess bowel sounds and bowel function.
iV fluids and antibiotics as prescribed.
Maintain nPo status.
Maintain nG tube to low continuous suction.
Provide wound care for open surgical sites with antibacterial solution or saline as prescribed.
Provide drain care.
assess for peritonitis.
Application Exercises
Q1
A nurse is assessing a 4-week-old who has been vomiting forcefully after feedings for the past 3 days. The infant feeds eagerly between episodes. On examination, the nurse palpates an olive-shaped mass in the right upper quadrant. Which condition is most likely?
A. Intussusception
B. Pyloric stenosis
C. Hirschsprung disease
D. Tracheoesophageal fistula
Show rationale ▾
A. Intussusception classically causes intermittent severe pain with currant-jelly stools, not the described picture.
B.CORRECT. Projectile non-bilious vomiting in a young infant with palpable olive-shaped mass = pyloric stenosis.
C. Hirschsprung presents with constipation/failure to pass meconium, not projectile vomiting.
D. TEF presents in the newborn period with feeding-related coughing, choking, and cyanosis.
NCLEX® Connection: Reduction of Risk Potential — System Specific Assessments
Q2
A nurse is providing postoperative care for an infant after cleft palate repair. Which interventions are appropriate? (Select all that apply.)
A. Use elbow immobilizers
B. Offer fluids through a straw
C. Use a soft wide-mouth cup or syringe to feed
D. Position on side or abdomen for drainage
E. Provide pacifier for comfort
Show rationale ▾
A.CORRECT. Elbow immobilizers prevent the infant from rubbing the surgical site.
B. No straws — they can disrupt the palate repair.
C.CORRECT. Soft wide-mouth cup or syringe feeding protects the suture line.
D.CORRECT. Side or abdomen position facilitates drainage and keeps secretions away from suture line.
E. Pacifiers and other hard objects in the mouth are contraindicated.
NCLEX® Connection: Reduction of Risk Potential — Therapeutic Procedures
Q3
A child is being evaluated for appendicitis. The child reports that the severe abdominal pain has suddenly resolved. Which interpretation is most likely?
A. The appendicitis is resolving spontaneously
B. The appendix has perforated, potentially leading to peritonitis
C. The pain medication has finally taken effect
D. The child was misdiagnosed
Show rationale ▾
A. Appendicitis does not spontaneously resolve in this acute manner.
B.CORRECT. Sudden relief of pain in suspected appendicitis often signals perforation. Diffuse peritonitis follows; expect fever, rigid abdomen, and shock. Notify the provider immediately.
C. Even if it had, this would be a coincidence given the timing of perforation pain pattern.
D. The clinical picture is consistent with appendicitis.
NCLEX® Connection: Physiological Adaptation — Alterations in Body Systems
Q4
A nurse is teaching the parents of a 2-year-old newly diagnosed with celiac disease about diet. Which foods should be excluded? (Select all that apply.)
A. Wheat bread
B. Rye crackers
C. Rice cereal
D. Barley soup
E. Fresh fruit
Show rationale ▾
A.CORRECT. Wheat contains gluten.
B.CORRECT. Rye contains gluten.
C. Rice is naturally gluten-free.
D.CORRECT. Barley contains gluten.
E. Fresh fruit is naturally gluten-free.
NCLEX® Connection: Basic Care and Comfort — Nutrition and Oral Hydration
Q5
A nurse is providing teaching to parents of a 2-month-old with GERD. Which instructions are appropriate? (Select all that apply.)
A. Place the infant flat on the back immediately after feeding
B. Keep the infant upright for 30 minutes after feeds
C. Thicken feeds with rice cereal as prescribed
D. Give small, frequent feedings
E. Burp the infant frequently during and after feedings
Show rationale ▾
A. Lying flat after feeds worsens reflux. Note: infants still sleep supine for SIDS prevention; upright positioning is during/after waking feedings only.
B.CORRECT. Upright after feeds (held by caregiver) reduces reflux.
UTIs are common in children, more so in females after infancy, and present differently by age — fever and irritability in infants, classic dysuria in older children. Enuresis (involuntary urination) is developmentally normal up to age 5 and rarely indicates an underlying disorder. Family teaching and reassurance dominate management of both.
TL;DR · One-glance summary
UTI in infants: often only fever, poor feeding, vomiting, irritability, foul-smelling urine. UTI in older children: dysuria, frequency, urgency, suprapubic pain, secondary enuresis, possibly hematuria. E. coli is the most common organism. Diagnose: clean-catch (toilet trained) or catheterized specimen (infants). Treat with antibiotics + push fluids. Prevent: wipe front to back, void regularly, adequate fluids, cotton underwear, avoid bubble baths. Enuresis: usually developmental; reassurance + positive reinforcement; enuresis alarms most effective; DDAVP for short-term use.
UTI by age presentation
Infants: fever (may be only sign), poor feeding, vomiting, lethargy, irritability, FTT, foul-smelling urine
Toddlers: abdominal/back pain, dysuria, fever, change in toileting
Urine culture (gold standard) — must be obtained correctly
Toilet-trained: clean-catch midstream
Not toilet-trained: sterile catheterization or suprapubic aspiration (bag specimens have high false-positive rates and are generally not used for diagnosis)
Voiding cystourethrogram (VCUG) and renal ultrasound to rule out structural causes after first febrile UTI
Management
Oral antibiotics (amoxicillin-clavulanate, cephalexin, TMP-SMX) per culture and sensitivity
IV antibiotics for infants < 3 mo, severe pyelonephritis, vomiting, or inability to tolerate oral
Antipyretics (acetaminophen, ibuprofen)
Push fluids to flush organisms
Frequent voiding (every 2–3 hr)
Reculture after treatment to confirm clearance in young children with first UTI
Prophylactic antibiotics may be prescribed for recurrent UTIs or VUR
Prevention teaching
Wipe front to back (girls)
Adequate fluid intake
Void regularly (every 2–3 hr; before bed)
Empty bladder completely
Cotton underwear; avoid tight pants
Avoid bubble baths, bath bombs, perfumed soaps
Treat constipation
For sexually active adolescents: void after intercourse
Enuresis
Causes / contributing factors
Maturational delay of bladder control (most common)
Genetic — strong familial pattern
Small functional bladder capacity
Deep sleep with delayed arousal to bladder fullness
Constipation
UTI
Diabetes (polyuria)
Emotional stress (secondary enuresis)
Structural anomalies (rare)
Assessment
Voiding history (frequency, timing, daytime symptoms)
Fluid intake patterns; constipation history
Family history
Recent stressors
Urinalysis (rule out UTI, glycosuria)
Management strategies
Reassure the family and child — enuresis is involuntary and not the child's fault; avoid punishment, shaming, or scolding
Treat any underlying constipation
Limit fluids 1–2 hr before bedtime; encourage voiding before bed
Positive reinforcement (sticker chart for dry nights)
Enuresis alarms — most effective long-term treatment; moisture sensor wakes the child as wetting begins; weeks-to-months of consistent use
Bladder training (timed voiding) for diurnal enuresis
Medications:
DDAVP (desmopressin) — reduces nighttime urine production; useful for special events or short-term; relapse common when stopped; risk of hyponatremia → limit fluids in evening
Imipramine — tricyclic; rarely used due to side effects and overdose risk
Oxybutynin — anticholinergic; for daytime enuresis with overactive bladder; side effects include dry mouth, constipation, blurred vision
QUICK CHECK: A parent asks the nurse why a urine specimen for an 8-month-old can't just be collected from a urine bag. What is the appropriate response? Answer: Bag specimens have a very high rate of contamination from skin flora, leading to false-positive cultures. For an infant who cannot provide a clean-catch sample, the recommended methods are sterile catheterization or suprapubic aspiration.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.
Scenario
A nurse educator is reviewing care of a child who has enuresis with a group of newly hired pediatric nurses. What should the educator include in the review? Use the ATI Active Learning Template: System Disorder to complete this item ALTERATION IN HEALTH (DIAGNOSIS) CLIENT EDUCATION: List at least 10
CLIENT EDUCATION: List at least 10 points to review. RN NURSING CARE OF CHILDREN
Answer key
Client Education
Have the child empty the bladder prior to bedtime.
Encourage fluids during the day, and restrict fluids 2 hr before bedtime.
Avoid fruit and fruit drinks.
Avoid caffeinated or carbonated drinks.
Use positive reinforcement. Avoid punishing, scolding, or teasing the child following an incident.
Assist the child in keeping a calendar of wet and dry days.
Have the child change bed linens and clothing following an incident.
Wake the child at scheduled intervals during the night to void.
Ensure the child takes all Medications as prescribed.
Use conditioning therapy, retention control measures, and teach Kegel/pelvic floor exercises.
Application Exercises
Q1
A nurse is assessing a 9-month-old with fever, poor feeding, irritability, and foul-smelling urine. Which diagnostic test should the nurse anticipate first?
A. Bag-collected urine specimen
B. Catheterized urine specimen for culture
C. 24-hour urine collection
D. Throat culture
Show rationale ▾
A. Bag specimens have high contamination rates; not recommended for diagnostic culture.
B.CORRECT. Sterile catheterized specimen is appropriate for an infant who cannot provide a clean-catch sample, especially with possible UTI.
C. 24-hour collection is not used to diagnose UTI.
D. Throat culture is unrelated to urinary infection.
NCLEX® Connection: Reduction of Risk Potential — Diagnostic Tests
Q2
A nurse is teaching the parents of a 4-year-old girl about UTI prevention. Which instructions should the nurse include? (Select all that apply.)
A. Wipe from front to back after toileting
B. Encourage daily bubble baths to keep clean
C. Encourage adequate fluid intake
D. Use cotton underwear
E. Have the child empty the bladder regularly
Show rationale ▾
A.CORRECT. Prevents fecal flora from entering the urethra.
B. Bubble baths and perfumed soaps irritate the urethra.
C.CORRECT. Adequate hydration flushes the urinary tract.
D.CORRECT. Breathable fabric reduces moisture and bacterial growth.
NCLEX® Connection: Health Promotion and Maintenance — Health Promotion/Disease Prevention
Q3
A nurse is counseling parents of a 6-year-old with primary nocturnal enuresis. Which approach is most appropriate?
A. Restrict the child to clear fluids the day before checking for "control"
B. Use a sticker chart, limit fluids before bed, and consider an enuresis alarm
C. Punish the child for each wetting episode
D. Begin DDAVP daily as the only treatment
Show rationale ▾
A. Severe fluid restriction is not appropriate; the strategy is timing.
B.CORRECT. Positive reinforcement, limiting fluids in the evening, voiding before bed, and the enuresis alarm are first-line behavioral approaches. Alarms are the most effective long-term treatment.
C. Punishment is harmful and ineffective.
D. DDAVP is useful for short-term needs (sleepovers) but is not first-line monotherapy.
NCLEX® Connection: Health Promotion and Maintenance — Developmental Stages and Transitions
Q4
A 10-year-old with a UTI is prescribed an oral antibiotic. Which teaching point should the nurse emphasize most?
A. "Stop the antibiotic once you feel better."
B. "Take the entire prescribed course of antibiotic, even after symptoms resolve."
C. "Take with milk for better absorption."
D. "Avoid all fluids during therapy."
Show rationale ▾
A. Stopping early leads to treatment failure and resistance.
B.CORRECT. Complete the full course to fully eradicate the infection and reduce resistance.
C. Milk impairs absorption of some antibiotics (tetracyclines, fluoroquinolones).
D. Fluids should be encouraged to help flush the urinary system.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Q5
A parent of a 7-year-old reports that the child, who was previously dry at night for over a year, has started wetting the bed again over the past two months. Which type of enuresis is this?
A. Primary nocturnal enuresis
B. Secondary nocturnal enuresis
C. Diurnal enuresis
D. Functional urinary retention
Show rationale ▾
A. Primary means the child has never been reliably dry.
B.CORRECT. Secondary enuresis: ≥ 6 months of continence followed by wetting recurrence. Often associated with stress, illness, or new psychosocial factors; evaluate for underlying causes (UTI, diabetes, emotional stress, constipation).
C. Diurnal refers to daytime wetting.
D. Functional retention is a separate condition involving incomplete bladder emptying.
NCLEX® Connection: Health Promotion and Maintenance — Developmental Stages and Transitions
Structural Disorders of the GU and Reproductive System
This chapter covers anatomic anomalies of the urinary tract and external genitalia (hypospadias, epispadias, bladder exstrophy), undescended testes, vesicoureteral reflux, hydrocele, phimosis, and the testicular emergency that you can never miss — testicular torsion. Most require surgical correction with carefully timed care and clear family teaching.
TL;DR · One-glance summary
Hypospadias / epispadias: abnormal urethral opening; do NOT circumcise — foreskin used in surgical repair around 6–12 months. Cryptorchidism: usually descends by 6 mo; if not by 12 mo, orchiopexy. Vesicoureteral reflux (VUR): retrograde urine flow → recurrent UTIs; antibiotic prophylaxis ± surgical reimplantation. Testicular torsion = emergency: severe sudden scrotal pain, swelling, nausea; viability window ~ 6 hr; immediate surgery (orchiopexy or orchiectomy).
Critical "no circumcision" rule
Defer circumcision in:
Hypospadias (urethra on ventral surface)
Epispadias (urethra on dorsal surface)
Bladder exstrophy
Foreskin tissue is needed for surgical reconstruction
Emergency: testicular torsion
Sudden severe scrotal pain, swelling
Nausea, vomiting
Affected testis higher and horizontal ("bell-clapper" deformity)
Hypospadias: urethral meatus on ventral (under) surface of the penis or perineum
Epispadias: urethral meatus on dorsal (upper) surface; less common; often associated with bladder exstrophy
Often associated with chordee (downward penile curvature)
Defer circumcision — foreskin used for surgical reconstruction
Surgical repair typically between 6–12 months of age
Postoperative care:
Maintain urinary stenting (catheter or stent left in place)
Double diaper (inner for stool, outer for urine via stent) to protect site
Encourage fluids; monitor for urinary output and patency
Pain management, analgesics, antispasmodics for bladder spasms
Antibiotic prophylaxis as prescribed
Restrict activity that could injure the site (no straddling toys, swimming, rough play)
Vesicoureteral reflux (VUR)
Retrograde flow of urine from bladder back up the ureters toward the kidneys
Predisposes to recurrent UTIs and renal scarring
Graded I (mild) to V (severe with renal pelvis dilation)
Diagnosis: voiding cystourethrogram (VCUG)
Treatment:
Low-grade reflux: observation and prophylactic antibiotics (often resolves spontaneously)
Higher-grade reflux: ureteral reimplantation surgery
Endoscopic injection of bulking agents in selected cases
Aggressive UTI prevention strategies are essential
Bladder exstrophy
Severe congenital anomaly — bladder is exposed on the lower abdominal wall
Associated with epispadias and pelvic/abdominal wall defects
Care of the exposed bladder before surgery: keep moist with sterile saline-soaked gauze; cover with plastic to prevent dehydration of mucosa; avoid pressure
Postoperative teaching: no straddling toys, no rough play for 2 weeks; tub baths usually deferred
Hydrocele
Fluid collection within the tunica vaginalis surrounding the testis
Common in newborns; communicating hydroceles connect with the peritoneal cavity
Painless scrotal swelling; transilluminates with light (helps differentiate from a hernia or mass)
Most resolve spontaneously by 1 year
Persistent or communicating hydrocele requires surgical correction
Varicocele
Abnormal dilation of veins in the pampiniform plexus of the spermatic cord; appears as a "bag of worms" on palpation
Usually left-sided (due to left testicular vein draining into the left renal vein at a 90° angle)
Most common during adolescence; may cause scrotal aching, especially with prolonged standing
Concern: potential cause of male infertility (elevated testicular temperature impairs spermatogenesis)
Treatment: surgical varicocelectomy or embolization if symptomatic or affecting fertility
Teach adolescent testicular self-examination
Phimosis
Tightness of the foreskin preventing retraction over the glans
Physiologic in infants and young children (often resolves by age 3–5)
Pathologic if persistent or causing infection, urinary symptoms
Treatment: topical steroids; circumcision in severe/persistent cases
Do not forcibly retract the foreskin in young children — causes trauma and scarring
Testicular torsion (urologic emergency)
Spermatic cord twists, compromising blood flow to the testis
Peak incidence in adolescents
Findings:
Sudden, severe scrotal pain (often awakening child from sleep)
Nausea, vomiting
Affected testis: high-riding, swollen, tender, possibly with horizontal orientation
Absent cremasteric reflex on affected side
Pain not relieved by elevation of scrotum (negative Prehn's sign)
Time-critical: testicular viability declines rapidly after 6 hours of ischemia
Management:
NPO; immediate urology consultation
Doppler ultrasound or scrotal exploration
Manual detorsion may be attempted
Surgical detorsion with orchiopexy of both testes (the unaffected side is also fixed to prevent future torsion); orchiectomy if testis is non-viable
Teen male education: any sudden scrotal pain requires immediate medical evaluation; testicular self-exam beginning in adolescence
QUICK CHECK: A 15-year-old reports waking up with sudden severe right-sided scrotal pain, nausea, and vomiting. On exam, the right testis appears swollen and high-riding. What is the priority action? Answer: Suspect testicular torsion. Make the patient NPO and notify the provider immediately — emergent urology consultation and surgical detorsion are needed within 6 hours to preserve testicular viability.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Basic Concept. Practice answering before reviewing the key.
Scenario
A nurse is teaching a newly licensed nurse about structural disorders of the genitourinary tract and reproductive system. What should the nurse include in the teaching?
RELATED CONTENT: Describe six structural disorders of the genitourinary tract and reproductive system. STRUCTURAL DISORDERS OF THE GENITOURINARy TRACT AND REPRODUCTIVE SySTEm 157
Answer key
Related Content
Obstructive uropathy: Structural or functional obstruction in the urinary system.
Chordee: Ventral curvature of the penis.
Bladder exstrophy: Eversion of the posterior bladder through the anterior bladder wall and lower abdominal wall.
Hypospadias: Urethral opening located just below the glans penis, behind the glans penis, or on the ventral surface of the penile shaft.
Epispadias: meatal opening located on the dorsal surface of the penis.
Phimosis: Narrowing of the preputial opening of the foreskin.
Cryptorchidism: Undescended testes.
Hydrocele: Fluid in the scrotum.
Varicocele: Elongated, dilated, and tortuosity of the veins superior to the testicle.
Testicular torsion: Testicle hangs free from the vascular structures.
Ambiguous genitalia: Erroneous or abnormal sexual differentiation.
Application Exercises
Q1
A nurse is admitting a newborn diagnosed with hypospadias. Which is the most important early teaching point for the parents?
A. The baby should be circumcised before discharge
B. Circumcision is delayed because the foreskin is needed for the surgical repair
C. The condition will resolve without any treatment
D. Surgery is typically performed in adolescence
Show rationale ▾
A. Circumcision is contraindicated before hypospadias repair.
B.CORRECT. The foreskin tissue is needed for surgical reconstruction. Circumcision is deferred until repair is complete.
C. Hypospadias does not resolve without surgery.
D. Repair is typically performed at 6–12 months of age, not adolescence.
NCLEX® Connection: Reduction of Risk Potential — Therapeutic Procedures
Q2
A 16-year-old presents with sudden severe scrotal pain, swelling, and nausea. The right testis appears high-riding and horizontal. The cremasteric reflex is absent on the right. Which action takes priority?
A. Apply ice to the scrotum and reassess in 1 hour
B. Encourage the patient to ambulate to improve circulation
C. Keep the patient NPO and prepare for emergent urology consultation
D. Provide oral pain medication and discharge home with follow-up
Show rationale ▾
A. Delay leads to testicular loss.
B. Activity does not help and delays diagnosis.
C.CORRECT. Findings indicate testicular torsion — surgical emergency. Make patient NPO, obtain emergent urology consult, and prepare for surgical detorsion within the 6-hour viability window.
D. Discharge is inappropriate; this is an emergency.
NCLEX® Connection: Physiological Adaptation — Medical Emergencies
Q3
A nurse is providing postoperative care for a 10-month-old after hypospadias repair. Which interventions are appropriate? (Select all that apply.)
A. Maintain the urinary stent/catheter as prescribed
B. Use a double-diaper technique to protect the surgical site
C. Encourage tub baths within 24 hr
D. Administer antispasmodic medication for bladder spasms
E. Encourage adequate fluids
Show rationale ▾
A.CORRECT. Maintain urinary drainage to keep the repair site dry.
B.CORRECT. Inner diaper for stool, outer for urine drainage protects the site.
C. Tub baths are typically restricted in early postop period to prevent infection.
D.CORRECT. Antispasmodics (oxybutynin) relieve bladder spasms common after surgery.
E.CORRECT. Adequate hydration supports urine output and stent patency.
NCLEX® Connection: Reduction of Risk Potential — Therapeutic Procedures
Q4
The parent of a 14-month-old asks the nurse why surgery is being recommended for an undescended testis when the baby seems fine. Which response is most accurate?
A. "The testis will rupture if not surgically corrected."
B. "Delayed correction increases risk of infertility, testicular cancer, and torsion."
C. "It's purely a cosmetic issue."
D. "Surgery is the only treatment that prevents UTIs."
Show rationale ▾
A. The testis does not "rupture" without surgery.
B.CORRECT. Untreated cryptorchidism increases the risk of infertility, testicular cancer, and torsion — orchiopexy by 12 months reduces these risks.
C. Cosmetic appearance is not the medical reason for surgery.
D. UTIs are not the indication.
NCLEX® Connection: Reduction of Risk Potential — Therapeutic Procedures
Q5
A nurse is teaching the parent of an infant with phimosis. Which statement indicates correct understanding?
A. "I'll forcibly retract the foreskin at each diaper change."
B. "Phimosis is normal in young children and often resolves by age 3–5."
C. "My child needs an emergency circumcision."
D. "I'll apply hot compresses to loosen the foreskin."
Show rationale ▾
A. Forcible retraction causes trauma, bleeding, and scarring.
B.CORRECT. Physiologic phimosis is normal in infants and young children and usually resolves spontaneously.
C. Emergency circumcision is not indicated for routine phimosis.
D. Hot compresses are not a recommended intervention.
NCLEX® Connection: Health Promotion and Maintenance — Developmental Stages and Transitions
This chapter focuses on the three classic pediatric renal diagnoses tested on the NCLEX: acute glomerulonephritis (post-streptococcal), nephrotic syndrome, and hemolytic uremic syndrome — plus the broader picture of acute and chronic kidney disease and dialysis. The distinguishing features of each are tested often: AGN brings hematuria, periorbital edema, and hypertension; nephrotic brings massive proteinuria and anasarca; HUS brings hemolysis + thrombocytopenia + AKI after EHEC.
TL;DR · One-glance summary
Acute glomerulonephritis (post-strep): 1–2 weeks after strep; hematuria (cola-colored), periorbital edema, hypertension, oliguria; treat strep + manage HTN + restrict Na/fluids. Nephrotic syndrome: massive proteinuria (≥3.5 g/day or 50 mg/kg/day in children), hypoalbuminemia, generalized edema (anasarca), hyperlipidemia; corticosteroids are first-line. HUS: hemolytic anemia + thrombocytopenia + AKI after EHEC infection; supportive care + dialysis as needed. Avoid antibiotics in EHEC — increases HUS risk.
QUICK CHECK: A 5-year-old presents with periorbital edema, cola-colored urine, hypertension, and decreased urine output. Two weeks ago, the child had strep pharyngitis. What is the likely diagnosis? Answer: Acute post-streptococcal glomerulonephritis. The combination of hematuria, periorbital edema, hypertension, and oliguria following recent strep infection is classic. Expected lab findings include elevated ASO titer and decreased complement (C3).
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.
Scenario
A nurse is teaching a parent of a child who has a new prescription for prednisone for nephrotic syndrome. Use the Active Learning Template: medication to complete this item. NURSING INTERVENTIONS: List three. CLIENT EDUCATION: List four teaching points.
NURSING INTERVENTIONS: List three.
CLIENT EDUCATION: List four teaching points.
Answer key
Nursing Interventions
Administer 2 mg/kg/day for 6 weeks followed by 1.5 mg/kg every other day for 6 weeks.
Monitor for adverse effects (hirsutism, slowed linear growth, hypertension, GI bleeding, infection, and hyperglycemia).
Administer with meals.
Client Education
Avoid large crowds (to decrease the risk of infection).
Using corticosteroids can increase appetite, cause weight gain (especially in the face), and cause mood swings.
Adhere to the medication regimen.
Monitor for adverse effects and notify the provider.
Application Exercises
Q1
A nurse is assessing a 6-year-old admitted with suspected nephrotic syndrome. Which findings would the nurse expect? (Select all that apply.)
A. Generalized edema (anasarca)
B. Frothy urine
C. Gross hematuria
D. Hypoalbuminemia
E. Hypertension
Show rationale ▾
A.CORRECT. Anasarca results from hypoalbuminemia and fluid shift.
B.CORRECT. Heavy proteinuria gives urine a foamy/frothy appearance.
C. Hematuria is the hallmark of AGN, not nephrotic syndrome. Microscopic hematuria can occur but gross hematuria is not classic.
D.CORRECT. Hypoalbuminemia results from urinary protein loss.
E. BP is typically normal or low in nephrotic syndrome (HTN is a feature of AGN).
NCLEX® Connection: Reduction of Risk Potential — System Specific Assessments
Q2
A nurse is caring for a child with acute post-streptococcal glomerulonephritis. Which dietary modifications should the nurse anticipate? (Select all that apply.)
A. Sodium restriction
B. Fluid restriction
C. High-protein, high-calorie diet
D. Potassium restriction if hyperkalemic
E. Unlimited high-sodium snacks
Show rationale ▾
A.CORRECT. Sodium restriction reduces fluid retention and hypertension.
B.CORRECT. Fluid restriction is typically based on previous day's output.
C. Protein may be restricted in severe AGN, not loaded.
D.CORRECT. Potassium restriction if labs show hyperkalemia.
E. High-sodium intake worsens edema and hypertension.
NCLEX® Connection: Basic Care and Comfort — Nutrition and Oral Hydration
Q3
A nurse is caring for a 3-year-old with HUS following an E. coli O157:H7 infection. Which finding is consistent with HUS?
A. Hypertension, hematuria, and elevated ASO titer
B. Massive proteinuria and hypoalbuminemia
C. Hemolytic anemia, thrombocytopenia, and acute kidney injury
D. Leukocytosis and elevated complement
Show rationale ▾
A. Describes post-streptococcal glomerulonephritis.
B. Describes nephrotic syndrome.
C.CORRECT. The HUS triad is hemolytic anemia, thrombocytopenia, and AKI — classically after EHEC infection.
D. Not characteristic of HUS.
NCLEX® Connection: Reduction of Risk Potential — Laboratory Values
Q4
A nurse is providing teaching to a parent of a child receiving home peritoneal dialysis. Which finding should the parent report immediately?
A. Clear, straw-colored effluent
B. Cloudy effluent with abdominal pain and fever
C. Slight increase in thirst
D. Decreased appetite once daily
Show rationale ▾
A. Clear effluent is the expected finding.
B.CORRECT. Cloudy effluent, abdominal pain, and fever indicate peritonitis — the most serious complication of peritoneal dialysis. Notify the provider immediately.
C. Increased thirst is not an emergency.
D. Decreased appetite can happen with CKD and is not urgent unless persistent.
NCLEX® Connection: Reduction of Risk Potential — Therapeutic Procedures
Q5
A nurse is teaching the parent of a child with nephrotic syndrome receiving corticosteroids. Which statement indicates a need for further teaching?
A. "I'll watch for signs of infection because my child is more susceptible."
B. "I'll give the steroid early in the morning with food."
C. "I'll stop the steroid suddenly if my child feels better."
D. "I'll check the first-morning urine for protein as instructed."
Show rationale ▾
A. Correct — immunosuppression from steroids and immunoglobulin loss increases infection risk.
B. Correct — morning dosing with food matches diurnal cortisol pattern and reduces GI upset.
C.INCORRECT STATEMENT (needs teaching). Corticosteroids must be tapered gradually — abrupt discontinuation can cause adrenal insufficiency.
D. Correct — home dipstick monitoring helps detect relapse early.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Children's bones differ from adults — they're more flexible (greenstick fractures), have growth plates (Salter-Harris injuries), and heal faster. The nurse focuses on neurovascular monitoring (the "5 Ps"), proper cast and traction care, recognizing compartment syndrome early, and identifying patterns that suggest non-accidental trauma.
TL;DR · One-glance summary
5 Ps of neurovascular assessment: Pain (especially with passive movement, out of proportion), Pallor, Pulselessness, Paresthesia, Paralysis. Compartment syndrome = surgical emergency. Cast care: elevate above heart 24–48 hr, ice, "petal" rough edges, NEVER stick objects inside (use cool air for itching). Traction: weights hang free, ropes in pulley grooves, never lift weights, maintain alignment. Spiral fractures in non-ambulatory infants raise concern for abuse.
Higher types carry increasing risk of growth disturbance.
Clinical findings
Pain at site (especially with movement); refusing to use limb
Swelling, bruising
Deformity, abnormal angulation
Decreased ROM; protective guarding
Crepitus on palpation (do not actively elicit)
Distal neurovascular changes if severe
Cast care
Initial care (first 24–48 hours)
Elevate the casted extremity above the heart
Ice packs over the cast (covered, intermittently — 20 min on, 20 min off)
Plaster casts: handle with palms (not fingertips) until dry to prevent indentations
Allow to air dry (24–48 hr for plaster, much faster for fiberglass)
"Petal" rough edges with adhesive tape to protect skin
Neurovascular assessment every 1 hr × 24 hr, then every 2 hr × 24 hr, then every 4 hr
Ongoing care and family teaching
Keep cast clean and dry — bag for bathing
Never insert objects into the cast (pencils, hangers) — use cool air from a hair dryer for itching
Inspect skin at cast edges for redness, breakdown, drainage
Smell cast for foul odor (possible infection)
Monitor capillary refill, pulses, sensation, movement at fingers/toes
Report immediately: severe pain unrelieved by analgesics, numbness/tingling, cool or blue digits, fever, foul odor, drainage
Hip spica cast
Covers torso and one or both legs (for hip surgery, dysplasia, femur fractures)
Toileting:
Tuck a disposable diaper or plastic-backed pad under the perineal opening; for older children, may use a fracture bedpan
Change diaper frequently to prevent soiling under the cast
Position with HOB lower than feet during toileting to direct flow away from cast
Turn every 2 hr to prevent skin breakdown
Skin care; inspect perineum and cast edges
Feeding: small frequent meals (cast restricts abdominal expansion)
Transport: support with pillows; use child-sized car bed/seat designed for spica casts
Traction
General principles
Used to reduce fractures, immobilize, reduce muscle spasm, correct deformity
Weights must hang freely — never resting on the floor or bed
Ropes in pulley grooves; not frayed or knotted
Never lift or remove weights without an order
Maintain proper alignment and counter-traction
Pin care (skeletal traction): clean per agency protocol; monitor for infection
Neurovascular checks every 1–2 hr initially
Skin checks; reposition as allowed; prevent pressure injuries
Encourage isometric exercises of unaffected extremities
Common traction types
Buck's traction: skin traction; lower extremity; commonly used for hip fractures, knee injuries
Bryant's traction: skin traction; bilateral lower extremities with hips at 90°; for young children < 2 yr with femur fractures; child's buttocks should be slightly off the mattress
Russell traction: skin traction for femur fractures; uses a sling under the knee
90/90 femoral traction: skeletal traction; for older children with femur fracture; hip and knee at 90°
Halo traction: skeletal traction for cervical spine; ring secured to skull with pins; do not lift by halo; pin care; keep wrench/tools at bedside for emergency removal
Compartment syndrome and fat embolism
Pathophysiology
Pressure within a closed muscle compartment exceeds perfusion pressure → tissue ischemia
Causes: tight cast, dressing, burn eschar, crush injury, hemorrhage, surgery
Most often in forearm or leg
Untreated → muscle necrosis, contractures, paralysis, possible amputation, rhabdomyolysis
Findings (the 5 Ps)
Pain — out of proportion to injury, unrelieved by analgesics; pain with passive stretch is most sensitive early sign
QUICK CHECK: A child with a long-arm cast for a forearm fracture reports severe burning pain unrelieved by acetaminophen and "pins and needles" in the fingertips. The fingers appear pale and cool. What is the priority action? Answer: Compartment syndrome is suspected. Notify the provider immediately, prepare to loosen or bivalve the cast, and keep the extremity at heart level (not above). Continuous neurovascular monitoring is essential. Untreated compartment syndrome leads to permanent muscle and nerve damage within hours.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.
Scenario
A nurse is teaching about compartment syndrome to a group of nurses.
EXPECTED FINDINGS: List five.
NURSING CARE: List three nursing actions.
CLIENT EDUCATION: List one teaching point. RN NURSING CARE OF CHILDREN
Answer key
Expected Findings
Pain that is unrelieved with elevation or analgesics; increases with passive Movement
Paresthesia or numbness (early finding)
Pulselessness distal to the fracture (late finding)
Paralysis or an inability to move digits (nerve damage)
Pale, cold skin and cyanosis to nail beds
Nursing Care
Assess the extremity every hour for the first 24 hr.
The space between the skin and the cast should allow for one finger to be placed.
Notify the provider if compartment syndrome is suspected.
Place the affected extremity at heart level.
Loosen the dressing or open and bivalve the cast.
Prepare the client for fasciotomy.
Complete dressing changes or Maintain negative pressure wound therapy.
Client Education
Instruct the client to report pain that is not relieved by analgesics, pain that continues to increase in intensity, numbness or tingling, or a change in color of the extremity.
Application Exercises
Q1
A nurse is assessing a child 4 hours after application of a long-leg cast for a tibial fracture. Which finding requires immediate intervention?
A. Capillary refill of 2 seconds in the toes
B. Mild swelling at the cast edges
C. Severe pain unrelieved by analgesics and pale, cool toes
D. Itching at the cast edge
Show rationale ▾
A. Capillary refill of ≤ 3 seconds is within expected range.
B. Mild edema is expected in the first 48 hr.
C.CORRECT. Severe unrelieved pain combined with pallor and cool extremity suggests compartment syndrome — a surgical emergency.
D. Itching is common and not urgent (advise cool air, not inserted objects).
NCLEX® Connection: Physiological Adaptation — Medical Emergencies
Q2
A nurse is teaching the parent of a 7-year-old with a new cast about home care. Which statements indicate correct understanding? (Select all that apply.)
A. "I'll keep the casted arm elevated above the heart for the first 24–48 hours."
B. "I'll use a hairdryer on cool to relieve itching inside the cast."
C. "I'll use a knitting needle to scratch any itchy areas inside the cast."
D. "I'll cover the cast with a plastic bag when my child showers."
E. "I'll call the provider if there's a foul odor from the cast."
Show rationale ▾
A.CORRECT. Elevation minimizes swelling.
B.CORRECT. Cool air is the safe option for itching.
C. Never insert objects inside the cast — risk of skin trauma and infection.
D.CORRECT. Keep cast dry.
E.CORRECT. Foul odor suggests infection.
NCLEX® Connection: Reduction of Risk Potential — Therapeutic Procedures
Q3
A nurse is providing care for a child in Buck's traction. Which actions are appropriate? (Select all that apply.)
A. Ensure that the weights hang freely
B. Lift the weights briefly to reposition the child
C. Inspect ropes for fraying or knots
D. Perform neurovascular checks regularly
E. Encourage isometric exercises of the unaffected limbs
Show rationale ▾
A.CORRECT. Weights must hang freely for effective traction.
B. Never lift traction weights without an order.
C.CORRECT. Ropes must be intact and in pulley grooves.
D.CORRECT. Frequent neurovascular checks are essential.
E.CORRECT. Isometric exercises preserve strength.
NCLEX® Connection: Reduction of Risk Potential — Therapeutic Procedures
Q4
A nurse is teaching parents how to care for an infant in a hip spica cast at home. Which intervention is most important?
A. Loosen the cast at night to allow movement
B. Position the infant with the head lower than the feet during diaper changes
C. Apply moisturizing cream inside the cast for skin care
D. Provide unrestricted regular-sized meals
Show rationale ▾
A. Cast should not be loosened.
B.CORRECT. Positioning with head lower than feet directs urine and stool away from the cast, preventing soiling under it.
C. Do not apply creams or powders inside the cast.
D. Small frequent meals are better tolerated due to limited abdominal expansion.
NCLEX® Connection: Reduction of Risk Potential — Therapeutic Procedures
Q5
A nurse is admitting a 4-month-old infant brought to the ED with a spiral fracture of the femur. The reported mechanism is "rolling off the couch." Which is the most appropriate nursing action?
A. Stabilize the leg and provide routine care
B. Confront the parents about possible abuse
C. Stabilize the leg, document findings carefully, and notify the provider and social services
D. Discharge the family with cast care instructions
Show rationale ▾
A. The mechanism is inconsistent with a spiral femur fracture in a non-ambulatory infant; further evaluation is needed.
B. Confronting parents directly is not the nurse's role; investigation is the responsibility of designated authorities.
C.CORRECT. Spiral femur fracture in a non-ambulatory infant with an inconsistent mechanism raises strong concern for non-accidental trauma. Stabilize the injury, document objectively, and notify the provider and child protection services per protocol.
D. Discharge would be inappropriate.
NCLEX® Connection: Safety and Infection Control — Accident/Injury Prevention
This chapter covers four classic congenital MS conditions: developmental dysplasia of the hip (DDH), clubfoot (talipes equinovarus), osteogenesis imperfecta (brittle bone disease), and idiopathic scoliosis, plus the avascular hip condition Legg-Calvé-Perthes. Early identification and treatment optimize long-term function.
TL;DR · One-glance summary
DDH: Ortolani (relocation "clunk") and Barlow (dislocation) tests; asymmetric thigh/gluteal folds, positive Galeazzi; Pavlik harness in infants < 6 mo. Clubfoot: Ponseti serial casting starting first weeks of life. Osteogenesis imperfecta: blue sclerae, easy fractures; handle gently. Scoliosis: Adam's forward bend test reveals rib hump; brace 23–25–45°, surgery (spinal fusion with instrumentation (Harrington rod or newer systems); Risser scale (0–5) measures skeletal maturity via iliac crest ossification — guides treatment decisions (higher Risser = more mature, less progression risk)) >45–50°. Legg-Calvé-Perthes: avascular necrosis of femoral head; limp + referred knee/groin pain.
DDH signs
Positive Ortolani (relocation) and Barlow (dislocation) maneuvers
Idiopathic adolescent scoliosis (most common); females > males for progression
Developmental dysplasia of the hip (DDH)
Overview
Spectrum: dysplasia → subluxation → frank dislocation
Risk factors: female sex, breech presentation, family history, firstborn, oligohydramnios, tight swaddling with hips extended
Newborn screening at every well-child visit; ultrasound for high-risk infants
Assessment maneuvers
Ortolani: with infant supine, hips flexed 90°, gentle abduction with upward force on greater trochanter — palpable "clunk" indicates reduction of dislocated hip into the acetabulum
Barlow: with hip adducted, posterior pressure attempts to dislocate an unstable hip — palpable "clunk" indicates dislocation
Galeazzi (Allis) sign: infant supine with knees and hips flexed; affected knee appears lower
Asymmetric thigh skin folds and limited hip abduction in older infants
Management by age
Newborn–6 mo:Pavlik harness
Holds hips flexed and abducted
Worn 23 hr/day initially, may progress to nighttime only
Family teaching: do not adjust the straps without provider guidance; place a thin shirt under the harness to protect skin; check skin daily for redness/breakdown; diaper goes under the straps
Worn for 6–12 wk on average
6–18 mo: closed reduction under anesthesia + spica cast
> 18 mo: open reduction + spica cast; possible osteotomy
Clubfoot (Talipes Equinovarus)
Foot turned inward and downward; may be unilateral or bilateral
Affected foot is smaller and calf is hypotrophic
Ponseti method is the gold standard:
Begins in the first weeks of life
Serial gentle manipulation + long-leg casting; casts changed weekly
Total ~5–6 casts over 6–8 weeks
Most children require percutaneous Achilles tenotomy after casting
Foot-abduction brace (Denis Browne bar) worn ~23 hr/day for 3 mo, then nights for years
Family teaching: cast care (neurovascular checks, keep dry), brace compliance is critical to prevent recurrence
Osteogenesis imperfecta (OI)
Genetic disorder of collagen synthesis (typically COL1A1/COL1A2); autosomal dominant in most types
Multiple types ranging from mild to lethal in infancy
Handle the infant very gently — support the head and trunk fully; lift gently with the entire body supported
Use blood pressure cuff with caution
Avoid placing IV in long bones if possible
Encourage swimming and other low-impact activities; avoid contact sports
Bisphosphonates (pamidronate) may decrease fracture frequency
Adequate calcium and vitamin D intake
Genetic counseling for families
Important: Some pediatric fractures from minor trauma are due to OI rather than abuse — careful evaluation prevents misdiagnosis
Scoliosis
Overview
Lateral curvature of the spine (> 10° Cobb angle)
Most cases are idiopathic adolescent scoliosis
Curve progression more likely in females and during growth spurts
Screening: Adam's forward bend test (looks for asymmetric rib hump or lumbar prominence); often part of school screening
Clinical findings
Uneven shoulders or hips
One scapula more prominent than the other
Rib hump on Adam's forward bend test
Uneven waistline; clothing fits asymmetrically
Usually painless
Management by curve size
Cobb angle
Approach
< 25°
Observation with periodic re-evaluation
25–45°
Bracing (Boston, Milwaukee, others); typically worn 16–23 hr/day during growth
> 45–50°
Surgery — spinal fusion with instrumentation
Brace teaching
Wear over a snug t-shirt
Inspect skin daily for redness, irritation, breakdown
Adherence is critical — bracing only works if worn as prescribed
Psychosocial support — body image concerns are common in adolescents
Postoperative spinal fusion care
Log-roll the patient every 2 hr; maintain spinal alignment
Strict pain management (PCA common)
Monitor neurovascular status (especially lower extremities)
Monitor for ileus, urinary retention
Early ambulation as ordered (often within 24–72 hr)
Incentive spirometry to prevent atelectasis
Activity restrictions: no bending, twisting, or lifting for several months
Legg-Calvé-Perthes disease
Idiopathic avascular necrosis of the femoral head
Typically affects children 4–8 yr; males > females
Findings:
Insidious-onset hip or groin pain — often referred to the thigh or knee
Painless limp (early)
Limited internal rotation and abduction of the hip
Diagnosis: hip X-ray; MRI for early disease
Management:
Goal: keep femoral head contained within acetabulum during healing
Activity restriction; non-weight-bearing as ordered
Bracing or abduction orthotics may be used
Surgery (osteotomy) for severe disease
Prognosis varies; younger age at diagnosis = better outcome
QUICK CHECK: A 6-year-old reports knee pain and is observed limping. Hip examination reveals limited internal rotation. What disorder should be considered? Answer: Legg-Calvé-Perthes disease — pain is often referred to the knee from hip pathology. Other causes to consider: slipped capital femoral epiphysis (older children, especially obese adolescents), transient synovitis, septic arthritis. Imaging guides diagnosis.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Therapeutic Procedure. Practice answering before reviewing the key.
Scenario
A nurse is caring for a child in a hip spica cast. What should the nurse include in the care of this client?
NURSING INTERVENTIONS: List at least five actions the nurse should include in the child’s care.
CLIENT EDUCATION: List at least six teaching points the nurse should include for the client and the client’s parents.
Answer key
Nursing Interventions
Assess and Maintain the hip spica cast.
Perform frequent neurovascular checks.
Perform range of motion with the unaffected extremities.
Perform frequent assessment of skin integrity, especially in the diaper area.
Assess for pain control using an age-appropriate pain tool. Intervene as indicated.
Evaluate hydration status frequently.
Assess elimination status daily.
Client Education
Reinforce teaching regarding positioning, turning, neurovascular assessments, and care of the cast.
Position casts on pillows.
Keep the casts elevated until dry.
Encourage frequent position changes to allow for drying.
Handle the casts with the palm of the hand until dry.
Note color and temperature of toes on casted extremity.
Give sponge baths to avoid wetting the cast.
Use a waterproof barrier around the genital opening of spica cast to prevent soiling with urine or feces.
Educate regarding care after discharge with emphasis on using appropriate equipment (stroller, wagon, car seat) for Maintaining mobility.
Application Exercises
Q1
A nurse is assessing a 2-month-old infant. Which findings would suggest developmental dysplasia of the hip? (Select all that apply.)
A. Asymmetric gluteal and thigh folds
B. Positive Ortolani sign
C. Apparent shortening of one leg with the knees flexed
D. Symmetric leg length with equal hip abduction
E. Limited hip abduction on the affected side
Show rationale ▾
A.CORRECT. Asymmetric thigh/gluteal folds are characteristic.
B.CORRECT. Ortolani sign — palpable reduction of a dislocated hip.
C.CORRECT. Galeazzi (Allis) sign indicates limb-length discrepancy from hip dislocation.
D. Symmetric findings argue against DDH.
E.CORRECT. Limited abduction is a sign of DDH, especially in older infants.
NCLEX® Connection: Reduction of Risk Potential — System Specific Assessments
Q2
A nurse is teaching the parent of a 4-month-old fitted with a Pavlik harness. Which statement indicates correct understanding?
A. "I will remove the harness for several hours each day for bathing."
B. "I'll adjust the straps if my baby seems uncomfortable."
C. "I'll put a thin shirt under the harness and check the skin daily."
D. "The harness keeps the hips fully extended and the legs straight."
Show rationale ▾
A. Initial use is 23 hr/day; only specific adjustments allowed.
B. Strap adjustments require provider direction.
C.CORRECT. A thin shirt protects the skin; daily skin assessment prevents breakdown.
D. The harness keeps hips flexed and abducted, not extended.
NCLEX® Connection: Reduction of Risk Potential — Therapeutic Procedures
Q3
A nurse is caring for a newborn with osteogenesis imperfecta. Which intervention is most important?
A. Encourage active range of motion exercises
B. Handle the infant gently with full support of the head and trunk
C. Apply tight diapers to provide support
D. Stretch the limbs daily to prevent contractures
Show rationale ▾
A. Active or aggressive ROM can cause fractures.
B.CORRECT. Brittle bones require very gentle handling; never pull on limbs; support the whole body when lifting.
C. Tight diapers can cause fractures.
D. Aggressive stretching risks fractures.
NCLEX® Connection: Safety and Infection Control — Accident/Injury Prevention
Q4
A nurse is performing scoliosis screening on a 12-year-old. Which technique helps identify scoliosis?
A. Have the child stand on one leg and assess balance
B. Have the child bend forward at the waist and observe the back for asymmetry
C. Have the child lie supine and measure leg lengths
D. Palpate the spinous processes while the child is sitting
Show rationale ▾
A. Not a scoliosis screening test.
B.CORRECT. Adam's forward bend test — observe for asymmetric rib hump or lumbar prominence.
C. Leg length screening is not the primary scoliosis test.
D. Palpation while seated does not reveal the lateral curvature pattern as well as Adam's test.
NCLEX® Connection: Health Promotion and Maintenance — Health Screening
Q5
A nurse is caring for a 14-year-old after spinal fusion surgery for scoliosis. Which interventions are appropriate? (Select all that apply.)
A. Log-roll every 2 hours
B. Allow the patient to sit up independently within the first 4 hours
C. Perform neurovascular checks of lower extremities
D. Use incentive spirometry to prevent atelectasis
This chapter covers four lifelong conditions affecting movement and function: cerebral palsy (CP), muscular dystrophy (Duchenne most common), spina bifida (neural tube defect), and juvenile idiopathic arthritis (JIA). Care across all four centers on maximizing function, preventing complications, supporting family, and engaging interprofessional rehabilitation.
TL;DR · One-glance summary
CP: non-progressive motor disorder from perinatal brain injury; spastic is most common; PT/OT/speech, antispasmodics (baclofen). Duchenne MD: X-linked recessive; Gowers' sign (climbing up legs to stand); pseudohypertrophy of calves; progressive weakness; wheelchair by ~12 yr. Spina bifida/myelomeningocele: prevent with prenatal folic acid; latex precautions; cover defect with sterile saline-soaked gauze; prone position pre-op. JIA: morning stiffness; NSAIDs/DMARDs/biologics; warm baths/exercise help.
Latex allergy in spina bifida
Risk from repeated exposure during many surgeries and catheterizations
Use latex-free supplies (gloves, catheters, tape, etc.) from birth
Avoid foods that cross-react: banana, avocado, kiwi, chestnut
Carry epinephrine auto-injector if allergic; medical alert ID
Gowers' sign — Duchenne MD
Child rises from floor by "walking" hands up their own legs
Indicates proximal muscle weakness (hips, thighs)
Pseudohypertrophy of calves from fat replacement of muscle
Toe walking, waddling gait, frequent falls
Cerebral palsy (CP)
Overview
Non-progressive motor disorder caused by injury or anomaly of the developing brain (prenatal, perinatal, or early postnatal)
Common causes/risk factors: prematurity, low birth weight, intrauterine infections, perinatal hypoxia, kernicterus, head injury, meningitis in infancy
Severity ranges from mild to profound functional impairment
Ataxic: wide-based gait, poor balance and coordination, intention tremor
Mixed: combination of types
Findings
Persistent primitive reflexes beyond expected age
Delayed motor milestones
Abnormal muscle tone (hyper- or hypotonia)
Scissoring of legs, toe walking, asymmetric movement
Feeding difficulties; poor head control; tongue thrust
Associated conditions: seizures, intellectual disability (in some), visual/hearing impairment, communication impairments, GI dysfunction (GERD, constipation)
Management
Interdisciplinary team: PT, OT, speech therapy, special education
Mobility aids: braces, walkers, wheelchairs
Medications:
Baclofen (oral or intrathecal pump) for spasticity
Diazepam, dantrolene as additional antispasmodics
Botulinum toxin (Botox) injections for localized spasticity
Cover the sac with sterile saline-soaked gauze; cover with plastic to prevent drying
Strict aseptic technique; meticulous diaper area and skin care; avoid contamination from urine/stool
Measure head circumference; assess neuro status frequently
Use latex-free supplies from birth
Surgical closure within 24–72 hr
Long-term care
Bladder management: clean intermittent catheterization (usually every 3–4 hr); anticholinergics for overactive bladder; monitor for UTIs and renal damage
Bowel management: high-fiber diet, fluids, scheduled bowel program, stool softeners, suppositories, or enemas as needed
PT/OT; assistive devices for mobility
Monitor shunt function (signs of malfunction: ↑ ICP — headache, vomiting, lethargy, change in LOC)
Skin care over areas of decreased sensation
Educational support; transition planning
Latex-free environment lifelong
Juvenile idiopathic arthritis (JIA)
Overview
Group of inflammatory arthritides beginning before age 16, lasting ≥ 6 weeks, with no other identifiable cause
Subtypes include oligoarticular, polyarticular, systemic, enthesitis-related, and psoriatic
Risk for uveitis (silent, can cause vision loss) — regular ophthalmology screening
Findings
Joint pain, swelling, warmth, decreased ROM
Morning stiffness ("gel phenomenon") — improves with movement during the day
Limp; refusing to walk
Low-grade fever, irritability, fatigue
Systemic JIA: high spiking fevers, salmon-colored rash, hepatosplenomegaly, lymphadenopathy
Growth delays
Diagnostics
Elevated ESR, CRP
ANA (often positive — increased uveitis risk)
Rheumatoid factor (may be positive in older children with polyarticular)
Joint X-rays, MRI to assess damage
Management
NSAIDs — first-line; ibuprofen, naproxen for pain/inflammation
Corticosteroids (oral, joint injection, or IV) for severe flares
Heat (warm baths, paraffin) for stiffness; encourage activity — swimming is particularly beneficial
PT and OT to maintain function
Ophthalmology slit-lamp exams every 3–6 months
Nutritional support; calcium and vitamin D for bone health
Psychosocial support; school accommodations
Family teaching
Apply heat (warm shower/bath) in the morning for stiffness
Encourage gentle exercise and stretching
Take NSAIDs with food
Schedule activities to balance rest and movement
Watch for signs of uveitis (eye redness, pain) but expect that uveitis is often silent — keep up screening eye exams
Methotrexate: weekly dose only; folic acid supplementation; monitor LFTs and CBC; teratogenic — birth control essential in adolescents
QUICK CHECK: A 5-year-old boy is being evaluated for muscular weakness. The nurse asks him to stand from sitting on the floor. He uses his hands to push on his thighs while rising. What does this finding indicate? Answer: Gowers' sign — classic for Duchenne muscular dystrophy. It indicates proximal lower-extremity muscle weakness; the child compensates by "walking" his hands up his legs to achieve a standing position.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.
Scenario
A nurse is caring for a child who has a new prescription for baclofen.
COMPLICATIONS: List adverse effects of baclofen.
CLIENT EDUCATION: Include two teaching points.
Answer key
Therapeutic Uses
Used as a centrally acting skeletal muscle relaxant that decreases muscle spasm and severe spasticity. Indicated for the treatment of cerebral palsy.
Nursing Administration
Administer orally or intrathecally via a specialized, surgically implanted pump.
Educate the family about expected responses of Medications.
Reinforce with the family the adverse effects of Medications and when to call the provider.
Application Exercises
Q1
A nurse is caring for a newborn with myelomeningocele before surgical closure. Which actions are appropriate? (Select all that apply.)
A. Position the infant prone
B. Cover the sac with dry sterile gauze
C. Use latex-free equipment and supplies
D. Cover the sac with sterile saline-soaked gauze
E. Measure head circumference daily
Show rationale ▾
A.CORRECT. Prone position protects the sac from pressure.
B. Dry gauze causes adherence and damage; use moist sterile dressing.
C.CORRECT. Latex-free environment from birth prevents sensitization.
D.CORRECT. Sterile saline-soaked gauze keeps the sac moist and protected.
E.CORRECT. Hydrocephalus is common; daily head circumference detects increased ICP.
NCLEX® Connection: Reduction of Risk Potential — System Specific Assessments
Q2
A nurse is performing a developmental assessment of a 4-year-old with cerebral palsy. Which intervention is most appropriate?
A. Discourage participation in activities to prevent injury
B. Encourage participation in activities at the child's developmental level
C. Restrict the child to bed rest
D. Avoid working with the family to maintain professional distance
Show rationale ▾
A. Restriction discourages development and worsens outcomes.
B.CORRECT. Adaptive activities at the child's developmental level promote function, self-esteem, and inclusion.
C. Bed rest causes deconditioning, contractures, and complications.
D. Family-centered care is essential; the family knows the child best.
NCLEX® Connection: Psychosocial Integrity — Therapeutic Communication
Q3
A nurse is teaching the parent of a child with JIA. Which statement indicates correct understanding?
A. "I'll keep my child in bed during a flare to rest the joints."
B. "I'll apply ice packs for morning stiffness."
C. "I'll encourage swimming and apply warm packs to stiff joints in the morning."
D. "I'll give NSAIDs on an empty stomach for fast absorption."
Show rationale ▾
A. Movement is encouraged; immobilization worsens stiffness and joint function.
B. Heat relieves morning stiffness; ice is occasionally used after acute injury but not for daily stiffness.
C.CORRECT. Swimming is excellent low-impact exercise; warm packs and warm showers relieve morning stiffness.
D. NSAIDs are taken with food to reduce GI upset.
NCLEX® Connection: Health Promotion and Maintenance — Self-Care
Q4
A 5-year-old boy is being evaluated for muscle weakness. The mother reports the child takes longer than peers to get up from sitting and seems to push on his thighs to stand. The CK level is markedly elevated. Which condition is most likely?
A. Cerebral palsy
B. Spina bifida
C. Duchenne muscular dystrophy
D. Juvenile idiopathic arthritis
Show rationale ▾
A. CP causes motor abnormalities but does not typically present with Gowers' sign + elevated CK.
B. Spina bifida is identified at birth.
C.CORRECT. Gowers' sign in a 5-year-old boy with elevated CK is highly suggestive of Duchenne muscular dystrophy. Confirm with genetic testing.
D. JIA causes joint pain and morning stiffness, not Gowers' sign.
NCLEX® Connection: Reduction of Risk Potential — Laboratory Values
Q5
A nurse is teaching parents of an infant with spina bifida about latex precautions. Which foods should the parents be advised to avoid because of cross-reactivity? (Select all that apply.)
A. Banana
B. Avocado
C. Apple
D. Kiwi
E. Chestnut
Show rationale ▾
A.CORRECT. Banana is a common latex cross-reactive food.
B.CORRECT. Avocado cross-reacts with latex.
C. Apple is not on the typical cross-reactive list.
D.CORRECT. Kiwi cross-reacts with latex.
E.CORRECT. Chestnut cross-reacts with latex.
NCLEX® Connection: Safety and Infection Control — Standard/Transmission-Based Precautions
Pediatric skin infections are common and span bacterial (impetigo, cellulitis, MRSA), fungal (tinea, candidiasis), viral (HSV, warts, molluscum), and parasitic (lice, scabies) causes. Nursing care focuses on recognizing characteristic lesions, applying appropriate topical or oral therapy, preventing spread within families and schools, and addressing the strong psychosocial impact of visible skin conditions.
TL;DR · One-glance summary
Impetigo: honey-colored crusted lesions; topical mupirocin or oral antibiotics; very contagious. Tinea capitis: oral griseofulvin (or terbinafine); topicals alone don't work for scalp. Pediculosis (lice): permethrin 1%; remove nits with fine-toothed comb; treat household close contacts. Scabies: permethrin 5% from neck to soles; itching can persist 2–4 weeks after eradication. Diaper candidiasis: beefy-red with satellite lesions; nystatin topical.
Distinctive lesion clues
Honey-colored crusts → impetigo
Annular ring with central clearing → tinea
Dewdrop on rose petal → varicella
Umbilicated papules → molluscum
Vesicle "clusters" on red base → HSV
Linear burrows + intense itch → scabies
Nits attached to hair shafts → pediculosis
Return-to-school rules
Impetigo: after 24 hr antibiotic treatment
Lice: after 1st treatment (most schools)
Tinea capitis: after starting oral therapy
Scabies: after first treatment
Varicella: until all lesions crusted
Bacterial skin infections
Impetigo
Superficial infection, most often Staphylococcus aureus or Group A Streptococcus
Lesions: red macules → vesicles → pustules → honey-colored crusts
Common on face (mouth, nose) and extremities
Highly contagious by direct contact
Treatment:
Topical mupirocin for limited lesions
Oral antibiotics (cephalexin, dicloxacillin) for extensive or refractory cases
Cover the area; soft cloth soaks to soften crusts; gentle washing
Trim child's fingernails; emphasize hand hygiene
Return to school after 24 hr of effective antibiotic therapy
Cellulitis
Deeper infection of dermis and subcutaneous tissue
Erythema, warmth, edema, tenderness; may have fever and lymphangitic streaks
Treat with oral or IV antibiotics; mark borders of erythema and reassess
Consider MRSA when poor response; clindamycin or TMP-SMX often used
MRSA / staphylococcal scalded skin syndrome
Lyme disease: caused by Borrelia burgdorferi transmitted by deer tick (Ixodes); erythema migrans (expanding bull's-eye rash at bite site) is the hallmark; if untreated → arthritis, carditis, neurologic symptoms (Bell's palsy, meningitis); treatment: doxycycline (≥ 8 yr) or amoxicillin (< 8 yr) × 14–21 days; prevention: DEET insect repellent, long sleeves/pants in wooded areas, tick checks after outdoor activity, remove ticks with fine-tipped tweezers close to skin
MRSA infections in skin/soft tissue increasingly common in children; presents as abscesses ("spider bite" appearance) or recurrent boils; incision and drainage often needed
Staphylococcal scalded skin syndrome (SSSS): toxin-mediated; widespread erythema and superficial peeling; resembles a burn; usually in young children; supportive care + IV antistaphylococcal antibiotics
Sharply demarcated red plaques with raised borders
Topical antifungal; loose dry clothing
Candidiasis (diaper)
Diaper area
Beefy-red, sharply marginated; satellite lesions
Topical nystatin or clotrimazole; air-dry; frequent changes
Viral skin infections
Herpes simplex virus (HSV)
HSV-1 typically orolabial; HSV-2 typically genital (but overlap common)
Grouped vesicles on erythematous base; painful
Primary infection: gingivostomatitis in young children (fever, painful oral vesicles, drooling, refusal to eat/drink)
Treat with oral acyclovir; topical for limited disease
Neonatal HSV is severe — disseminated infection possible
Varicella (chickenpox)
Highly contagious; varicella-zoster virus
Lesions in all stages simultaneously: macule → papule → vesicle ("dewdrop on rose petal") → crust
Intensely pruritic; fever and malaise often precede rash
Spread by respiratory droplets and direct contact with vesicle fluid
Airborne + contact precautions in hospital
Most cases prevented by varicella vaccine
Antivirals (acyclovir) for high-risk children or severe disease
Symptomatic care: acetaminophen (never aspirin — Reye risk), antihistamines for itching, calamine lotion, cool baths, trim nails
Contagious from ~ 1–2 days before rash until all lesions crusted
Molluscum contagiosum and warts
Molluscum: flesh-colored pearly papules with central umbilication; spread by skin contact or fomites; usually self-resolves over months; can be treated with curettage, cantharidin, or cryotherapy if bothersome
Verruca (warts): caused by HPV; common on hands and feet (plantar); often self-resolve over time; treat with cryotherapy, salicylic acid, or duct tape if bothersome
Infestations
Pediculosis capitis (head lice)
Highly contagious; transmitted by direct head-to-head contact (occasionally fomites)
Intense pruritus; visible nits (eggs) cemented to hair shafts near scalp
Live lice may be observed; nape and behind ears common
Treatment:
Permethrin 1% cream rinse (Nix) or pyrethrin shampoos (Rid) — apply to dry hair, leave 10 minutes, rinse; repeat in 7–10 days
For resistant cases: spinosad, ivermectin lotion, malathion
Manual removal of nits with a fine-toothed comb — section hair, comb each section thoroughly
Wash bedding, towels, recently worn clothing in hot water; dry on high heat
Items that can't be washed: seal in a plastic bag for 2 weeks
Soak combs/brushes in hot water (≥ 130°F / 54°C) for 5–10 min
Vacuum upholstered furniture, car seats, floors
Check household members; treat infested contacts
Most schools allow return after one treatment; "no-nit" policies vary
Scabies
Sarcoptes scabiei mite burrows into skin
Intense pruritus, especially at night
Linear burrows; papules; common in finger webs, wrists, axillae, waist, genitals; in infants includes scalp, palms, soles
Transmission: prolonged skin-to-skin contact; can be sexual
Treatment:
Permethrin 5% cream from neck down (entire body in infants and young children) — leave on 8–14 hr, then wash off
Ivermectin orally for severe or refractory
Apply at night, wash off in morning; repeat in 1 week
Treat all household members and close contacts simultaneously
Wash bedding, towels, clothing in hot water
Itching can persist 2–4 weeks after successful treatment — does not indicate failure; antihistamines and topical steroids for symptom relief
QUICK CHECK: A child treated for scabies one week ago still has intense itching. The parent asks if the treatment failed. What should the nurse explain? Answer: Itching can persist 2–4 weeks after successful scabies treatment because of ongoing immune response to dead mites and feces in the skin. This does not indicate treatment failure. Antihistamines and topical steroids relieve symptoms while the body clears the residual antigens. New burrows or persistent live mites would suggest treatment failure.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.
Scenario
A nurse is teaching a group of caregivers about preventing skin infections.
CLIENT EDUCATION: Describe five teaching points.
Answer key
Client Education
Use good hand hygiene.
Avoid sharing clothing, hats, combs, brushes, and towels.
Keep the child from touching the affected area by using distraction.
Do not squeeze vesicles.
Apply topical Medications as prescribed.
Administer oral Medications as prescribed.
Application Exercises
Q1
A nurse is assessing a 5-year-old with honey-colored crusted lesions around the nose and mouth. Which is the most likely diagnosis?
A. Atopic dermatitis
B. Impetigo
C. Tinea corporis
D. Varicella
Show rationale ▾
A. Atopic dermatitis is itchy, often dry/scaly; doesn't have honey crusts.
B.CORRECT. Honey-colored crusts are the classic presentation of impetigo.
C. Tinea corporis presents as annular plaques with central clearing.
D. Varicella vesicles appear as "dewdrops on rose petals" with lesions in all stages.
NCLEX® Connection: Reduction of Risk Potential — System Specific Assessments
Q2
A parent calls about a 6-year-old with intense scalp itching and visible "specks" cemented to hairs near the scalp. Which is the most appropriate initial recommendation?
A. Cut all of the child's hair completely off
B. Apply a permethrin 1% rinse and use a fine-toothed comb to remove nits
C. Soak the child's head in vinegar overnight
D. Wait two weeks to see if the condition resolves on its own
Show rationale ▾
A. Cutting hair is not required.
B.CORRECT. Permethrin 1% is first-line for pediculosis; combing removes nits.
C. Vinegar is not a standard treatment.
D. Lice do not resolve untreated.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Q3
A nurse is teaching the parents of a child diagnosed with tinea capitis. Which statement indicates correct understanding?
A. "Topical antifungal cream alone is sufficient treatment."
B. "My child will take oral griseofulvin with a fatty food like milk."
C. "I can stop the medication as soon as the patches start to clear."
D. "Tinea capitis is not contagious."
Show rationale ▾
A. Topicals alone do not reach hair follicle; oral therapy is required.
B.CORRECT. Griseofulvin is taken with high-fat food (whole milk, ice cream) to enhance absorption.
C. Complete the full course to prevent recurrence.
D. Tinea capitis is contagious by direct contact and fomites.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Q4
A nurse is caring for a hospitalized child with varicella. Which precautions are appropriate? (Select all that apply.)
A. Airborne precautions
B. Contact precautions
C. Negative-pressure room
D. Standard precautions only
E. Continue precautions until all lesions are crusted
Show rationale ▾
A.CORRECT. Varicella is transmitted by airborne route.
B.CORRECT. Contact precautions for vesicle fluid.
C.CORRECT. Negative-pressure room is required for airborne isolation.
D. Standard precautions alone are insufficient.
E.CORRECT. Maintain isolation until all lesions are crusted.
NCLEX® Connection: Safety and Infection Control — Standard/Transmission-Based Precautions
Q5
A nurse is teaching the parents of a 4-year-old with scabies. Which instruction is most important?
A. Apply permethrin 5% cream to the child only
B. Apply treatment to all household members simultaneously and wash bedding/clothing in hot water
C. Restrict bathing for two weeks
D. Stop treatment if itching does not resolve in 3 days
Show rationale ▾
A. Untreated contacts reinfest the child.
B.CORRECT. Treat all household members simultaneously and decontaminate clothing and bedding in hot water to prevent reinfestation.
C. Bathing is fine.
D. Itching can persist 2–4 weeks after successful treatment.
NCLEX® Connection: Safety and Infection Control — Standard/Transmission-Based Precautions
This chapter covers atopic dermatitis (eczema, lifelong, often the first manifestation of the atopic triad), contact dermatitis (poison ivy and other irritants/allergens), the two diaper dermatitis patterns (irritant vs candidal), seborrheic dermatitis (cradle cap), psoriasis (chronic autoimmune scaly plaques, less common in children), and acne vulgaris. Themes that repeat: skin hydration, gentle cleansing, trigger avoidance, judicious topical steroids, and protecting the child's self-image during visible flares.
TL;DR · One-glance summary
Atopic dermatitis (eczema): chronic, intensely itchy; emollients are the foundation — apply liberally and frequently; topical steroids for flares; identify and avoid triggers; "soak and seal" (short lukewarm bath → moisturize within 3 min). Irritant diaper rash: spares creases; uses barrier cream. Candidal diaper rash: beefy red with satellite lesions in creases; nystatin or clotrimazole. Acne treatment ladder: topical retinoid + benzoyl peroxide → add topical antibiotic → oral antibiotic → isotretinoin (severe). Isotretinoin is severely teratogenic — iPLEDGE program; two effective contraceptive methods required.
Eczema vs irritant contact
Atopic dermatitis: chronic, relapsing; bilateral; family/personal history of atopy; infants on cheeks/scalp/extensor surfaces; older children on flexural areas (antecubital, popliteal fossae)
Contact dermatitis: distribution matches contact (linear streaks of poison ivy; chemical irritation pattern); often more acute and localized
Diaper rash differential
Irritant (most common): erythema on convex skin (buttocks, perineum); spares the creases
Candidal: beefy red plaques in the creases, with satellite papules/pustules
Seborrheic: greasy yellow scales
Atopic dermatitis: consistent with other body areas of eczema
Atopic dermatitis (eczema)
Overview
Chronic, relapsing inflammatory skin disorder
Part of the atopic triad: atopic dermatitis + allergic rhinitis + asthma
Strong familial pattern
Onset usually in infancy; 60% within first year
Many improve by adolescence; some persist into adulthood
Findings by age
Infants (<2 yr): erythematous, weeping, crusted patches on cheeks, scalp, and extensor surfaces; intense itching → scratching → secondary infection
Children (2 yr–puberty): drier, scaly, lichenified plaques in flexural areas (antecubital, popliteal, neck, wrists)
Adolescents/adults: similar to children, with possible hand/face involvement
Common triggers
Dry skin (cold weather, low humidity, frequent bathing without moisturizing)
Topical retinoids: apply at night; expect initial irritation/dryness; takes 6–12 weeks to see results
Benzoyl peroxide can bleach fabric; apply carefully
Isotretinoin:
Highly teratogenic — pregnancy must be avoided
iPLEDGE program: two negative pregnancy tests before starting; monthly pregnancy tests; two forms of effective contraception (or sworn abstinence) for females of childbearing potential
Adverse effects: dry skin/lips/eyes, photosensitivity, elevated triglycerides and liver enzymes, possible mood changes
Monitor LFTs, lipids; baseline and periodic labs
Avoid donating blood during and 1 month after therapy
Diet/lifestyle has limited evidence; some patients note dairy/high-glycemic foods aggravate
Address psychosocial impact — acne affects self-esteem in adolescents
QUICK CHECK: A 17-year-old female is starting isotretinoin for severe nodulocystic acne. What is the most important teaching point? Answer: Isotretinoin is severely teratogenic. The patient must enroll in the iPLEDGE program, have two negative pregnancy tests before starting, monthly pregnancy tests during therapy, and use two effective forms of contraception (or document sworn abstinence). Pregnancy must be avoided during treatment and for at least 1 month after stopping the medication.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.
Scenario
A nurse is teaching a guardian of a child who has eczema.
CLIENT EDUCATION: Include at least five teaching points. RN NURSING CARE OF CHILDREN
Answer key
Client Education
Clinical Manifestations of infection
Change diapers when wet or soiled.
Keep nails short and trimmed.
Place gloves or cotton socks over hands for sleeping.
Dress young children in soft, cotton, one-piece, long-sleeve, long-pant outfits.
Remove items that can promote itching (woolen blankets, scratchy fabrics). Use cotton items whenever possible.
Use mild detergent to wash clothing and linens. The wash cycle can be repeated without soap.
Avoid latex products, second-hand smoke, furry pets, dust, and molds.
Encourage tepid baths without the use of soap. Avoid oils and powders.
Follow specific directions regarding topical Medications, soaks, and baths.
Emphasize the importance of understanding the sequence of treatments to maximize the benefit of therapy and prevent complications.
Avoid overheating the bedroom during winter months. Use a room humidifier.
Maintain treatment to prevent flare-ups.
Follow up with the provider as directed.
Participate in support groups.
Application Exercises
Q1
A nurse is teaching the parents of a 9-month-old with atopic dermatitis. Which instructions should the nurse include? (Select all that apply.)
A. Bathe the infant in lukewarm water for no more than 10 minutes
B. Apply emollient liberally within 3 minutes of bathing
C. Use heavily perfumed soap to keep the skin smelling fresh
D. Dress the infant in wool clothing for warmth
E. Keep the infant's fingernails short
Show rationale ▾
A.CORRECT. Short lukewarm baths prevent excessive drying.
B.CORRECT. "Soak and seal" — emollient within 3 minutes locks in moisture.
C. Fragrance-free, mild cleansers are recommended; perfumed soaps irritate skin.
D. Wool irritates eczema; cotton is preferred.
E.CORRECT. Short nails reduce skin damage from scratching.
NCLEX® Connection: Basic Care and Comfort — Personal Hygiene
Q2
A nurse is assessing an infant with a diaper rash. The skin shows beefy-red plaques with satellite papules and pustules involving the inguinal creases. Which type of diaper dermatitis is most likely?
A. Irritant diaper dermatitis
B. Candidal diaper dermatitis
C. Seborrheic dermatitis
D. Atopic dermatitis
Show rationale ▾
A. Irritant typically spares creases.
B.CORRECT. Beefy-red, satellite lesions, and involvement of skin creases are characteristic of candidal diaper dermatitis.
C. Seborrheic has greasy yellow scales.
D. Atopic dermatitis would have a different distribution and chronic pattern.
NCLEX® Connection: Reduction of Risk Potential — System Specific Assessments
Q3
A nurse is teaching a 16-year-old about a newly prescribed topical retinoid for acne. Which statement indicates correct understanding?
A. "I should apply it in the morning to maximize sunlight exposure."
B. "I'll scrub my face vigorously to remove the bacteria."
C. "I'll apply it at night and use sunscreen during the day."
D. "I should see improvement within a few days."
Show rationale ▾
A. Retinoids degrade with UV light and increase photosensitivity — apply at night.
B. Vigorous scrubbing worsens acne.
C.CORRECT. Apply at night; use daily sunscreen due to photosensitivity. Improvement typically takes 6–12 weeks.
D. Results take weeks to months.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Q4
A 15-year-old female is being started on isotretinoin. Which teaching points are essential? (Select all that apply.)
A. Enroll in the iPLEDGE program
B. Use two forms of effective contraception or document sworn abstinence
C. Donate blood every month during treatment
D. Have monthly pregnancy tests
E. Report any mood changes or depression
Show rationale ▾
A.CORRECT. iPLEDGE enrollment is required.
B.CORRECT. Two effective contraceptive methods (or sworn abstinence) required for females of childbearing potential.
C. Blood donation is contraindicated during and 1 month after therapy.
D.CORRECT. Monthly pregnancy tests are required during therapy.
E.CORRECT. Possible mood changes warrant monitoring; report any concerns.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Adverse Effects/Contraindications
Q5
A child returns from a hike with linear streaks of erythematous, vesicular lesions on both arms with intense itching. The parent asks if the rash is contagious. Which response is most accurate?
A. "Yes, the fluid from the blisters spreads the rash."
B. "The reaction is from urushiol oil — wash skin and clothing thoroughly. The vesicle fluid is not contagious."
C. "Your child needs to be isolated from school for two weeks."
D. "Apply hot compresses to dry out the lesions quickly."
Show rationale ▾
A. The vesicle fluid itself does not contain urushiol and does not spread the rash.
B.CORRECT. Poison ivy is caused by urushiol oil contacting the skin. Wash skin and any clothing/equipment with soap and water to remove residual oil. The vesicle fluid is not contagious to others.
C. School exclusion is not required.
D. Cool compresses, not hot, are recommended.
NCLEX® Connection: Health Promotion and Maintenance — Health Promotion/Disease Prevention
Pediatric burns differ from adult burns: children have proportionally larger heads, thinner skin (deeper injury for the same heat exposure), greater fluid requirements per kg, higher hypothermia risk, and more vulnerable airways. The chapter emphasizes accurate depth and extent assessment with the Lund-Browder chart, fluid resuscitation using the Parkland formula, infection prevention, nutrition for hypermetabolism, and family-centered rehabilitation.
TL;DR · One-glance summary
Depth: superficial (epidermis, no blister, red, painful), partial-thickness (blisters, weepy, painful), full-thickness (white/leathery/dry, painless because nerves destroyed). Extent: use Lund-Browder chart in pediatrics — accounts for changing body proportions; pediatric rule of 9s assigns 18% to head, 14% to each leg. Parkland formula: 4 mL × kg × %TBSA of LR in first 24 hr; half in the first 8 hours from time of injury, remaining over 16 hours. Major emergencies: airway (inhalation injury), shock, hypothermia, infection. Tetanus prophylaxis as indicated.
Inhalation injury red flags
Burns in enclosed space
Singed nasal or facial hairs; soot in mouth/nose
Carbonaceous sputum
Hoarseness, stridor, drooling
Facial/neck burns, especially circumferential
Carboxyhemoglobin elevation (cherry-red skin is late)
Warm room (above 80°F / 27°C); warming blankets; warmed IV fluids; warm wound care solutions
Pediatric burn patients lose body heat rapidly through damaged skin
Pain management
IV opioids (morphine, fentanyl) — IV route preferred over IM (poor absorption in shock)
Anxiolytics may be added
Tetanus prophylaxis as indicated
NG tube for ileus prevention in major burns; consider early enteral feeding
Foley catheter for accurate output monitoring
Strict aseptic technique to prevent infection
Acute phase
Wound care
Daily wound cleansing in tub/whirlpool or at bedside
Debridement of necrotic tissue (mechanical, enzymatic, surgical)
Topical antimicrobials:
Silver sulfadiazine (Silvadene): broad-spectrum; avoid in sulfa allergy; not recommended on face or in infants < 2 mo (kernicterus risk); leukopenia possible
Mafenide acetate (Sulfamylon): penetrates eschar; painful on application; can cause metabolic acidosis
Bacitracin for facial burns
Silver-impregnated dressings for some wound types
Dressing changes: typically twice daily; pre-medicate with analgesics
Escharotomy for circumferential full-thickness burns with compromised perfusion
Skin grafting for full-thickness burns:
Split-thickness autograft (donor site)
Cultured epidermal autografts for very large burns
Allografts and xenografts as temporary biologic dressings
Infection prevention (leading cause of death)
Strict hand hygiene and protective isolation
Sterile technique for wound care
Monitor for sepsis: fever or hypothermia, leukocytosis, hypotension, altered LOC, ileus, hyperglycemia, decreased platelet count
No prophylactic antibiotics (increase resistant infections); antibiotics only when infection diagnosed
Nutrition (hypermetabolic state)
High-calorie, high-protein diet
Vitamin and mineral supplementation (especially A, C, zinc, iron)
Enteral feeding preferred — early initiation reduces complications
Maintain positioning to prevent contractures (especially neck, axillae, elbows, hands)
Active and passive ROM exercises early in care
Rehabilitation phase
Continues for months to years
Goals: maximize function and appearance, prevent contractures, address psychosocial needs
Interventions:
Pressure garments worn 23 hr/day for 12–24 months to minimize hypertrophic scarring
Splinting to maintain joint position
Physical therapy and occupational therapy for strength, ROM, ADLs
Massage and lubrication of healing skin
Sunscreen and sun protection — burned skin lacks melanin and is at risk for hyperpigmentation and skin cancer
Scar revision surgery as needed (often deferred until scar matures, ~1 yr)
Psychosocial support: child life specialists, support groups, family counseling, treatment of PTSD
School re-entry program with peer education
Burn prevention teaching
Smoke detectors on every level; test monthly, change batteries annually
Family fire escape plan with practice
Water heater thermostat set to < 120°F (49°C) to prevent scald burns
Check bath water with elbow or wrist before placing child in tub
Turn pot handles toward back of stove; use back burners
Keep matches, lighters, hot liquids out of reach
Avoid carrying hot liquids while holding a child
Sun protection: SPF 30+, reapply, hats, sun-protective clothing, avoid midday sun, infants < 6 mo kept out of direct sun
Electrical safety: outlet covers, no chewing on cords
Fireworks: child supervision (or avoidance)
Microwave caution: liquids/foods can superheat
QUICK CHECK: A 4-year-old child weighing 16 kg sustains a 30% TBSA burn. Using the Parkland formula, what is the total fluid requirement in the first 24 hours, and how much should be given in the first 8 hours? Answer: Parkland formula: 4 mL × 16 kg × 30 = 1,920 mL of lactated Ringer's over 24 hours. Half (960 mL) is given in the first 8 hours from time of injury, with the remaining 960 mL over the next 16 hours. Titrate to urine output of 1–2 mL/kg/hr.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Basic Concept. Practice answering before reviewing the key.
Scenario
A nurse is teaching a newly licensed nurse about Manifestations of burns.
UNDERLYING PRINCIPLES: List the depth, appearance, sensation, and healing of first-, second-, third-, and fourth-degree burns.
Answer key
Underlying Principles
Superficial (first-degree)
Damage to the epidermis
Pink to red in color with no blisters
Blanches with pressure
Painful
Heals within 3 to 7 days with no scarring Superficial partial thickness (second-degree)
Damage to the entire epidermis with intact dermal elements
moist
Red in color with blisters
Blanches with pressure
mild to moderate edema
No eschar
Painful
Sensitive to temperature changes and light touch
Heals in less than 21 days with variable scarring Deep partial thickness (second-degree)
Damage to the entire epidermis and some parts of the dermis
Sweat glands and hair follicles remain intact
mottled
Red to white in color with blisters
Blanches with pressure
moderate edema
Painful
Sensitive to temperature changes and light touch
Healing can go beyond 21 days with scarring Full thickness (third degree)
Damage to the entire epidermis and dermis with possible damage to the subcutaneous tissue
Nerve endings, hair follicles, and sweat glands are destroyed
Red to tan, black, brown, or waxy white in color
Dry, leathery appearance
No blanching
As burn heals, painful sensations return and severity of pain increases
Heals within weeks to months
Scarring is present
Grafting is required Deep full thickness (fourth-degree)
Damage to all layers of the skin that extends to the muscle, tendons, and bones.
Color variable, dull, and dry with charring
Possible visible ligaments, bone, or tendons
No pain is present
Heals within weeks to months
Scarring is present and grafting is required
Amputation possible
Application Exercises
Q1
A nurse is caring for a 5-year-old (20 kg) admitted with a 40% TBSA partial-thickness burn. Using the Parkland formula, how much fluid will the child require in the first 8 hours?
A. 800 mL
B. 1,600 mL
C. 3,200 mL
D. 6,400 mL
Show rationale ▾
A. Below the calculated requirement.
B.CORRECT. 4 mL × 20 kg × 40 = 3,200 mL total over 24 hr. Half (1,600 mL) is given in the first 8 hours from the time of injury.
C. That is the total 24-hour requirement, not the 8-hour amount.
D. Double the total requirement; would cause volume overload.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Parenteral/Intravenous Therapies
Q2
A nurse is assessing a child who sustained burns in a house fire. Which findings suggest inhalation injury? (Select all that apply.)
A. Singed nasal hairs
B. Hoarseness
C. Carbonaceous sputum
D. Heart rate of 110/min
E. Stridor
Show rationale ▾
A.CORRECT. Singed nasal hairs indicate heat exposure to upper airway.
B.CORRECT. Hoarseness suggests laryngeal edema.
C.CORRECT. Carbonaceous sputum indicates inhalation of smoke and particulates.
D. Tachycardia is nonspecific in burn injury.
E.CORRECT. Stridor indicates upper airway obstruction — often heralds need for intubation.
NCLEX® Connection: Physiological Adaptation — Medical Emergencies
Q3
A nurse is caring for a 3-year-old with a 25% TBSA burn during the resuscitation phase. Which finding best indicates adequate fluid resuscitation?
A. Heart rate of 145/min
B. Urine output of 1.5 mL/kg/hr
C. Blood pressure 70/40 mm Hg
D. Capillary refill of 5 seconds
Show rationale ▾
A. Tachycardia suggests inadequate volume.
B.CORRECT. Pediatric target urine output is 1–2 mL/kg/hr. Adequate urine output is the best indicator of adequate fluid resuscitation.
C. Hypotension indicates inadequate resuscitation.
D. Delayed capillary refill suggests poor perfusion.
NCLEX® Connection: Physiological Adaptation — Fluid and Electrolyte Imbalances
Q4
A nurse is providing wound care to a child with major burns. Which interventions help prevent infection? (Select all that apply.)
A. Strict aseptic technique during dressing changes
B. Routine prophylactic IV antibiotics
C. Daily wound cleansing and debridement of necrotic tissue
D. Application of topical antimicrobial agents as prescribed
E.CORRECT. Hand hygiene is the single most important infection-prevention measure.
NCLEX® Connection: Safety and Infection Control — Standard/Transmission-Based Precautions
Q5
A nurse is teaching family caregivers of a child recovering from major burns. Which long-term care strategies should be emphasized? (Select all that apply.)
A. Apply sunscreen with high SPF and protective clothing on healed burn areas
B. Wear pressure garments as prescribed for 12–24 months
C. Stop all range-of-motion exercises once wounds are healed
D. Apply moisturizers to keep healing skin supple
E. Provide a high-protein, high-calorie diet
Show rationale ▾
A.CORRECT. Burned skin lacks melanin and pigment — sun protection prevents hyperpigmentation and skin cancer.
Pediatric diabetes is mostly Type 1 (autoimmune destruction of pancreatic β-cells → insulin deficiency), but Type 2 is increasing alongside childhood obesity. Care centers on insulin administration, glucose monitoring, carbohydrate counting, recognition of DKA and hypoglycemia, and helping families adapt to lifelong management. Children with diabetes require an interprofessional team, school accommodations, and developmental adjustment of self-care responsibility.
TL;DR · One-glance summary
T1DM polyuria, polydipsia, polyphagia, weight loss — classic presentation. Pediatric HbA1c targets: 7.5–8.5% for < 6 yr, < 8% for 6–12 yr, < 7.5% for 12 yr through young adulthood. DKA: glucose > 330 mg/dL, ketones, pH < 7.30, HCO₃⁻ < 15 mmol/L; Kussmaul respirations, fruity breath; treat with IV regular insulin at 0.1 unit/kg/hr + fluids + electrolyte replacement (especially potassium). Hypoglycemia (< 70 mg/dL): 10–15 g simple carb (3–6 oz juice, 8 oz milk, 6 oz regular soda), recheck in 15 min; glucagon IM/SC if unconscious. Sick days: continue insulin, monitor glucose and ketones every 3 hr, push sugar-free non-caffeinated fluids.
Site rotation rule: rotate within the same anatomic area for 4–6 injections before switching to a different area — keeps absorption rates consistent and prevents lipohypertrophy
Inject at a 90° angle; use the pinch technique if the child has thin skin
Aspiration for blood is NOT necessary for SC insulin
Mixing NPH and regular: draw the shorter-acting (clear, regular) insulin into the syringe first, then the longer-acting (cloudy, NPH) — reduces risk of contaminating the rapid/short-acting vial with longer-acting insulin
Long-acting insulins (glargine, detemir, degludec) — do not mix with any other insulin due to incompatibility
Roll cloudy insulin (NPH) between palms to mix; never shake
Insulin pumps deliver continuous basal + meal boluses (popular in pediatrics); observe child/parent setup and operation, offer additional instruction
Most pediatric T1DM uses basal-bolus regimen: long-acting once daily + rapid-acting before meals (carb counting)
Always observe the child or parent drawing up and administering insulin; offer additional teaching as needed
Self-monitored blood glucose (SMBG)
Essential to diabetes management — measure at minimum before meals and at bedtime
Follow the manufacturer's procedure for sample collection and meter use
Check strip accuracy with the control solution provided with the meter
Keep a record: time, date, blood glucose, insulin dose, food intake, activity, illness, or other events that can alter glucose
Continuous glucose monitors (CGM) are increasingly used in pediatrics
Oral glucose tolerance test (OGTT) instructions
Consume a balanced diet for the 3 days prior to the test
Fast 8 hr before the test
Fasting blood glucose drawn at the start
Consume a specified amount of glucose; blood glucose drawn every 30 minutes for 2 hours
Assess for hypoglycemia throughout the procedure
Self-monitored blood glucose (SMBG)
Check before meals, at bedtime, before and after exercise, when symptomatic, and during illness
Technique: wash hands with warm water; use side of fingertip (less painful); alternate fingers
Record results in log; bring to all clinic visits
CGM (continuous glucose monitoring) increasingly used — provides trends, arrows, and alarms for highs/lows; calibrate per manufacturer; does not replace fingerstick for treatment decisions in all cases
Glycosylated hemoglobin (HbA1c)
Reflects average blood glucose over the preceding 2–3 months
Measured every 3 months
Goal: < 7% (some pediatric guidelines allow ≤ 7.5% for young children)
Does not reflect daily fluctuations — both SMBG/CGM and HbA1c are needed
Carbohydrate counting
15 g carbohydrate = 1 carbohydrate exchange/unit
Insulin-to-carb ratio individualized (e.g., 1 unit per 10 g carbs)
Correction factor for high pre-meal glucose
Pre-meal rapid-acting insulin given 15–20 min before meal
Diabetic ketoacidosis (DKA)
Overview
Result of severe insulin deficiency + counter-regulatory hormone elevation
Common as the initial presentation of T1DM, with missed insulin doses, or with infection/stress
Labs: ↑ glucose, + ketones, ↓ pH and HCO₃⁻, anion gap metabolic acidosis, ↑ K⁺ initially (then ↓ with treatment), Na⁺ falsely low
Management
ICU admission — place child on cardiac monitor; obtain venous access for fluids, electrolytes, insulin administration
Assess subjective and objective data: ketones (blood and urine), glucose, electrolytes, BUN, ABG, CBC; fruity breath; mental confusion; dyspnea; nausea/vomiting; dehydration; weight loss
Fluid resuscitation — rapid isotonic fluid (0.9% NS) replacement to maintain perfusion. Large quantities are often required to replace losses. Monitor closely for evidence of fluid volume excess and cerebral edema (the major DKA-related cause of death in children)
Insulin: IV continuous infusion of regular insulin at 0.1 unit/kg/hr
Start at least 1 hour after fluids initiated
Aim for glucose ↓ of ~50–75 mg/dL/hr (avoid rapid drop → cerebral edema)
When blood glucose approaches 250 mg/dL, add glucose (D5) to IV fluids to maintain BG 120–240 mg/dL while continuing insulin to clear ketones
Monitor glucose hourly, or more frequently if required
Potassium:
Potassium levels are initially elevated in DKA (extracellular shift from acidosis)
With insulin therapy, potassium shifts back into cells → monitor closely for hypokalemia
Provide potassium replacement in IV fluids as indicated by labs
Ensure adequate urinary output before administering potassium
Sodium bicarbonate by slow IV infusion for severe acidosis (pH < 7.0); monitor potassium because rapid correction of acidosis can lead to hypokalemia; monitor LOC closely
Administer oxygen to children who are cyanotic and dyspneic
Frequent monitoring: glucose every 1 hr, electrolytes every 2–4 hr, neuro checks (cerebral edema risk)
Treat any underlying cause (infection, missed insulin)
Transition to SC insulin when ketones resolved and patient tolerating PO
Cerebral edema warning signs
Severe headache, vomiting
Decreasing LOC, behavior changes
Bradycardia, hypertension
Cranial nerve palsies
Immediate notification; mannitol or hypertonic saline; slow fluid rate
Hypoglycemia management
Recognition
Glucose < 70 mg/dL with or without symptoms
Causes: too much insulin, missed/delayed meal, increased activity without snack, illness, alcohol (adolescents)
Symptoms: shakiness, sweating, pallor, palpitations, irritability, hunger, headache, confusion; severe → seizures, loss of consciousness
Treatment for conscious patients (10–15 g rule)
10–15 g of fast-acting (simple) carbohydrate:
3–6 oz orange juice or other fruit juice
8 oz milk (good choice for mild reactions)
6 oz regular soft drink (not diet)
3–4 glucose tablets
1 tablespoon sugar, honey, or syrup (caution in infants — no honey under 12 mo)
Wait 15 minutes; recheck blood glucose frequently
If still < 70 mg/dL, repeat the simple carbohydrate
Follow with a complex carbohydrate (e.g., crackers, cheese, peanut butter sandwich) — particularly if next meal is > 1 hr away
Severe hypoglycemia (unconscious, unable to swallow, or seizure)
Glucagon IM or SC — every household with a child with T1DM should have a glucagon kit and trained caregivers
Position on side (vomiting common after glucagon)
Once responsive, give carbohydrate orally
In hospital: D50W (older children) or D25W (younger children) IV bolus
Sick day management
NEVER stop insulin during illness — illness increases insulin needs; continue antidiabetic agents, though dosages may differ per provider plan
Monitor blood glucose and urinary ketone levels every 3 hours
Encourage sugar-free, non-caffeinated liquids to prevent dehydration
Meet carbohydrate needs by eating soft foods if possible. If unable, consume liquids equal to the usual carbohydrate content
Rest
If vomiting, take small frequent sips
Call the provider for any of the following
Blood glucose > 240 mg/dL
Positive ketones in the urine
Disorientation or confusion
Rapid breathing (concern for Kussmaul respirations / DKA)
Vomiting more than once
Liquids cannot be tolerated
Fever lasting > 24 hours
Glucose patterns and special considerations
Dawn phenomenon vs Somogyi effect
Dawn phenomenon: early morning hyperglycemia (typically 5–8 AM) caused by normal nocturnal release of growth hormone and cortisol → increased insulin resistance
Blood glucose is elevated at both 3 AM and fasting
Management: increase evening basal insulin or adjust pump settings
Somogyi effect: rebound hyperglycemia in the morning after nocturnal hypoglycemia → counter-regulatory hormone release (epinephrine, glucagon, cortisol) causes rebound high
Blood glucose is LOW at 3 AM but HIGH at fasting
Child may report nightmares, night sweats, headache
Management: decrease evening insulin dose or provide a bedtime snack (opposite of Dawn!)
Key differentiation: check blood glucose at 3 AM — if low → Somogyi (decrease insulin); if normal/high → Dawn (increase insulin)
Honeymoon phase (T1DM)
Temporary partial remission period occurring shortly after T1DM diagnosis and insulin initiation
Remaining β-cells temporarily resume some insulin production → decreased insulin requirements
Can last weeks to months (occasionally up to a year)
Does NOT mean diabetes is cured — educate families that insulin needs will increase again
Continue monitoring and insulin therapy throughout
Urine and blood ketone monitoring
Check ketones when blood glucose > 240 mg/dL, during illness, or if symptoms of DKA
Blood ketone testing (β-hydroxybutyrate) is preferred over urine — more accurate and timely
Urine ketone testing (nitroprusside reagent strips) — detects acetoacetate; can lag behind actual status
Positive ketones with hyperglycemia → increase fluids, possible supplemental insulin; call provider if moderate/large ketones persist
Lipodystrophy
Lipohypertrophy: thickened, fibrotic fatty tissue at injection sites from repeated use of same spot → impairs insulin absorption
Lipoatrophy: loss of subcutaneous fat at injection sites (less common with modern insulin)
Prevention: systematic site rotation — rotate within an anatomic area, then rotate areas
Do not inject into lipohypertrophic areas — erratic absorption
Education and lifestyle
Diet
Carbohydrate counting; consistent timing of meals
Balanced nutrition: carbs (45–55% of calories), protein (15–20%), fat (25–35% mostly unsaturated)
Limit sugar-sweetened beverages
Adequate fiber, fruits, vegetables, whole grains
Include snacks per regimen
Exercise
Daily physical activity encouraged
Check glucose before, during prolonged activity, and after
Have rapid-acting carb available during exercise
Activity lowers glucose for 12–24 hours afterward (delayed hypoglycemia risk)
Adjust insulin/carb intake as needed for activity
Monitoring
SMBG before meals, at bedtime, before/after exercise, when symptoms occur
Continuous glucose monitors (CGM) increasingly common; provide trends and alerts
Good glycemic control (HbA1c at target) significantly delays or prevents long-term complications
School and developmental considerations
Diabetes management plan for school; train school nurse and key staff
504 plan/IEP for accommodations
Glucose-monitoring supplies, fast-acting carb, and glucagon kit at school
Identify safe place for glucose checks and insulin administration
Age-appropriate self-care: school-age children can usually check glucose and identify hypoglycemia; adolescents progress to full self-management with parent backup
Medical alert bracelet
Psychosocial support — risk of depression, eating disorders, treatment burnout in adolescents
Personal hygiene and skin/foot care
Skin integrity and healing status — assess all wounds; pay close attention to feet and skin folds
Caution against wearing sandals, walking barefoot, or wearing shoes without socks
Cleanse cuts with warm water and mild soap; gently dry and apply a dry dressing; monitor for healing and seek intervention promptly if not improving
Nail care: trim toenails straight across with clippers and file edges (or file only if clippers/scissors contraindicated)
Examine eyes yearly by an ophthalmologist (annual dilated exam)
Emphasize importance of regular dental and health care visits
Wear medical identification (bracelet) at all times
Findings of poor glucose control to watch for
Paresthesias (numbness, tingling)
Visual changes
Recurrent infections (including recurrent vaginal yeast infections — an early finding of type 2)
Slow wound healing
Interprofessional team
Refer family to a certified diabetes educator (CDE) for comprehensive diabetes education
Pediatric endocrinologist
Registered dietitian
Exercise physiologist
School teachers, school nurses, guidance counselors, and coaches all need information
Mental health professional as needed (depression and eating disorders are more common with T1DM)
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.
Scenario
A nurse is teaching parent of a school-age child who has type 1 diabetes mellitus.
MEDICATIONS: List the types of insulin used for children who have type 1 diabetes mellitus.
NURSING CARE: Describe eight interventions.
CLIENT EDUCATION: Describe three client outcomes.
Answer key
Medications
insulin lispro: Rapid‑acting
Regular insulin: short‑acting
NPH insulin: intermediate‑acting
insulin glargine u‑100: long‑acting
Nursing Care
Monitor for Manifestations of hyperglycemia and hypoglycemia.
Provide nail care according to policy.
teach wound care.
Provide nutritional guidelines.
encourage yearly eye exams.
encourage dental and Medical follow‑up.
teach self‑Monitoring of blood glucose.
teach guidelines to follow when sick.
teach about Medications.
Client Education
the child will have blood glucose levels within the prescribed range.
the child will Maintain a glycosylated hemoglobin within the target range.
the child and/or family will be able to administer insulin.
the child and/or family will be able to Monitor for complications and intervene as necessary.
the child and/or family will Maintain adequate dietary intake to support growth and development.
Application Exercises
Q1
A nurse is caring for a 10-year-old admitted with DKA. The blood glucose is 480 mg/dL, pH is 7.18, HCO₃⁻ is 12 mEq/L. Which intervention should the nurse anticipate as initial treatment?
A. Oral hydration with sugar-free fluids
B. SC long-acting insulin and discharge home
C. IV isotonic fluid bolus followed by IV regular insulin infusion
D. IV sodium bicarbonate as the priority intervention
Show rationale ▾
A. Oral intake is unsafe in DKA (vomiting, altered LOC).
B. DKA requires IV regular insulin, not SC long-acting.
C.CORRECT. Initial DKA management starts with IV isotonic fluid resuscitation followed by IV regular insulin infusion (started about 1 hour after fluids), with careful electrolyte (especially potassium) replacement.
D. Bicarbonate is rarely used and not the priority.
NCLEX® Connection: Physiological Adaptation — Medical Emergencies
Q2
A school nurse finds a 7-year-old with type 1 diabetes appearing pale, shaky, and confused. The blood glucose is 50 mg/dL. The child is conscious. Which action should the nurse take first?
A. Administer rapid-acting insulin
B. Give 15 g of fast-acting carbohydrate (4 oz juice or 3–4 glucose tablets)
C. Administer glucagon IM
D. Call 911 immediately
Show rationale ▾
A. Insulin would worsen hypoglycemia.
B.CORRECT. For a conscious child with hypoglycemia, administer 15 g fast-acting carbohydrate (15-15 rule). Recheck glucose in 15 min.
C. Glucagon is for unconscious patients or those unable to swallow.
D. Not yet — treat the hypoglycemia first, escalate if not resolving.
NCLEX® Connection: Physiological Adaptation — Medical Emergencies
Q3
A nurse is teaching parents of a child with type 1 diabetes about sick day management. Which statement indicates correct understanding?
A. "We'll stop insulin when our child is not eating."
B. "We'll continue insulin and check glucose and ketones every 2–4 hours."
C. "We'll wait until illness resolves to call the diabetes team."
D. "We'll restrict fluids if our child has a fever."
Show rationale ▾
A. Never stop insulin during illness — illness increases insulin requirements.
B.CORRECT. Continue insulin, check glucose and ketones frequently, push fluids; contact diabetes team as needed.
C. Early communication with diabetes team prevents DKA.
D. Fluids should be encouraged during illness.
NCLEX® Connection: Health Promotion and Maintenance — Self-Care
Q4
A nurse is teaching an adolescent about administering long-acting insulin glargine. Which statement indicates correct understanding?
A. "I'll mix glargine with my rapid-acting insulin in the same syringe."
B. "I'll shake the vial vigorously before drawing it up."
C. "I'll inject glargine subcutaneously and not mix it with other insulins."
D. "Glargine peaks at 4 hours after injection."
Show rationale ▾
A. Glargine cannot be mixed with any other insulin.
B. Insulin should never be shaken; if cloudy, roll between palms.
C.CORRECT. Glargine is administered subcutaneously and never mixed with other insulins.
D. Glargine has no significant peak; it provides a steady basal effect.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Q5
A nurse is monitoring a child receiving IV insulin therapy for DKA. The blood glucose has decreased from 450 to 250 mg/dL over 4 hours. Which action should the nurse anticipate next?
A. Discontinue the insulin infusion
B. Continue insulin and add dextrose to the IV fluids
C. Decrease the IV fluid rate substantially
D. Give an additional bolus of insulin
Show rationale ▾
A. Stopping insulin before ketosis resolves leads to rebound hyperglycemia.
B.CORRECT. When glucose reaches ~250 mg/dL, change IV fluids to a dextrose-containing solution and continue insulin to clear ketosis without causing hypoglycemia.
C. Substantial fluid changes risk cerebral edema; adjustments should be gradual.
D. Additional bolus could cause hypoglycemia and cerebral edema.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Growth hormone deficiency (GHD) results from pituitary insufficiency or hypothalamic dysfunction. Children present with short stature but typically normal body proportions and delayed bone age. Care includes systematic workup to confirm diagnosis (and rule out other causes), nightly subcutaneous somatropin (recombinant human growth hormone), and family teaching on injection technique, growth monitoring, and emotional adjustment.
TL;DR · One-glance summary
Findings: proportional short stature (height < 3rd percentile or growth velocity < 5 cm/yr after age 2), delayed bone age, delayed dentition, possibly delayed puberty. Diagnosis: GH stimulation tests (clonidine, arginine, insulin); low IGF-1 and IGFBP-3; bone-age X-ray; MRI of pituitary to rule out tumor. Treatment: somatropin SC injection nightly (mimics natural GH release during sleep). Continue until satisfactory adult height is achieved or growth plates fuse. Routine growth monitoring every 3–6 months.
Characteristic findings in GHD
Height < 3rd percentile for age
Growth velocity below normal for age
Proportional short stature (vs. disproportionate in skeletal dysplasias)
Delayed bone age on hand X-ray
Delayed dental eruption
Delayed puberty (in some)
Normal intelligence
"Cherubic" facial features in some cases
Workup to differentiate causes
Growth chart and parental heights
Bone age (X-ray of left hand and wrist)
Thyroid function, IGF-1, IGFBP-3
GH stimulation testing
MRI of pituitary (rule out tumor, e.g., craniopharyngioma)
Karyotype (rule out Turner syndrome in females)
Overview and causes
Causes of growth hormone deficiency
Congenital:
Genetic GH defects
Structural pituitary malformations
Septo-optic dysplasia
Idiopathic GHD
Acquired:
Pituitary or hypothalamic tumors (especially craniopharyngioma)
Increased risk of certain cancers (with prolonged use; contraindicated with active malignancy)
Family teaching
Importance of consistent nightly administration; injection technique demonstration and return demonstration
Storage and handling of the medication
Site rotation to prevent lipohypertrophy
Realistic expectations: growth velocity typically increases in the first year; final adult height depends on age at therapy start, dosing, and underlying cause
Watch for adverse effects — particularly hip/knee pain (SCFE), persistent headaches with vision changes, joint swelling
Annual follow-up with pediatric endocrinology
Emotional support: short stature affects body image; provide age-appropriate counseling
Maintain balanced nutrition, adequate sleep, regular exercise to support growth
QUICK CHECK: Why is somatropin given at bedtime rather than in the morning? Answer: Natural growth hormone is secreted in pulses with the largest peaks during deep sleep. Administering somatropin at bedtime mimics this physiologic pattern, optimizing growth-promoting effects and minimizing daytime side effects such as insulin resistance.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Nursing Skill. Practice answering before reviewing the key.
Scenario
A nurse is planning care for a child who is to undergo a growth hormone (GH) stimulation test. What interventions should the nurse include in the plan of care? Use the ATI Active Learning Template: Nursing Skill to complete this item. NURSING INTERVENTIONS: Include two preprocedure nursing actions a
NURSING INTERVENTIONS: Include two preprocedure nursing actions and three intraprocedure actions.
Answer key
Nursing Interventions
Preprocedure
Ensure child has nothing to eat or drink 10 to 12 hr prior to procedure.
Limit child’s activity 10 to 12 hr prior to procedure. Intraprocedure
Draw baseline blood sample between 0600 and 0800.
Administer medication that triggers the release of GH (arginine or GH-releasing hormone).
Obtain blood sample every 30 min during a 3-hr period following medication administration.
Application Exercises
Q1
A nurse is performing an assessment on an 8-year-old child being evaluated for short stature. Which findings are consistent with growth hormone deficiency? (Select all that apply.)
A. Height below the 3rd percentile
B. Decreased growth velocity
C. Bone age advanced for chronologic age
D. Delayed dental eruption
E. Proportional short stature with normal intelligence
Show rationale ▾
A.CORRECT. Height < 3rd percentile is a defining feature.
B.CORRECT. Decreased growth velocity is required to suggest pathologic short stature.
C. Bone age is typically delayed, not advanced, in GHD.
D.CORRECT. Delayed dentition often accompanies delayed bone maturation.
E.CORRECT. Body proportions and cognitive function are typically normal.
NCLEX® Connection: Reduction of Risk Potential — System Specific Assessments
Q2
A nurse is teaching the parents of a child starting somatropin therapy. Which instruction is most important?
A. "Administer the injection first thing in the morning."
B. "Inject the medication subcutaneously each evening before bed."
C. "Give the medication intramuscularly with each meal."
D. "Take a break from the medication on weekends."
Show rationale ▾
A. Bedtime administration mimics natural GH release during sleep.
B.CORRECT. Somatropin is given subcutaneously at bedtime to mimic the natural diurnal GH secretion pattern.
C. IM route and with-meal timing are not used.
D. Consistent daily administration is required for effect.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Q3
A 9-year-old receiving somatropin therapy reports new-onset hip pain and is limping. What is the most appropriate nursing action?
A. Reassure the parent and continue the medication
B. Apply ice and recommend rest
C. Notify the provider — possible slipped capital femoral epiphysis
D. Increase the somatropin dose
Show rationale ▾
A. Hip pain in a child receiving somatropin is a red flag.
B. Symptomatic measures alone delay diagnosis.
C.CORRECT. SCFE is a known adverse effect of somatropin therapy. Notify the provider for orthopedic evaluation; this is an urgent diagnosis requiring imaging.
D. Never increase dose without provider direction; with a possible adverse effect, dose should not increase.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Adverse Effects
Q4
A nurse is reviewing a child's workup for short stature. Which diagnostic test specifically helps differentiate growth hormone deficiency from familial short stature?
A. Complete blood count
B. Thyroid function tests
C. Growth hormone stimulation testing
D. Lipid panel
Show rationale ▾
A. Not specific for GHD.
B. Thyroid testing rules out hypothyroidism but does not diagnose GHD.
C.CORRECT. GH stimulation testing measures GH response to provocative agents; failure to respond in two tests confirms GHD.
D. Lipid panel is not part of the workup.
NCLEX® Connection: Reduction of Risk Potential — Diagnostic Tests
Q5
A nurse is preparing a child for a head MRI as part of the GHD workup. The parent asks why this test is needed. Which response is most accurate?
A. "The MRI confirms the diagnosis of growth hormone deficiency."
B. "It is used to identify any tumor or structural abnormality of the pituitary gland."
C. "It checks the bone age to estimate final height."
D. "It measures growth hormone levels in the brain."
Show rationale ▾
A. GH stimulation testing confirms diagnosis, not MRI.
B.CORRECT. Brain MRI identifies pituitary or hypothalamic tumors (especially craniopharyngioma) and structural anomalies as potential causes.
C. Bone age is assessed with an X-ray of the hand/wrist.
D. MRI does not measure hormone levels.
NCLEX® Connection: Reduction of Risk Potential — Diagnostic Tests
Immunizations are one of the most effective tools in pediatric care, preventing illnesses that historically caused widespread death and disability. The nurse follows the CDC/ACIP schedule (updated annually), screens for contraindications, administers vaccines safely, manages side effects, and helps families understand the science and the schedule.
TL;DR · One-glance summary
Birth: HepB. 2/4/6 mo: DTaP, Hib, PCV13, IPV, RV, HepB. 12–15 mo: MMR, varicella, HepA, PCV13, Hib. 4–6 yr: DTaP, IPV, MMR, varicella boosters. 11–12 yr: Tdap, MenACWY, HPV. 16 yr: MenACWY booster, MenB. Annual: influenza ≥ 6 mo. Live vaccines: MMR, varicella, rotavirus, intranasal influenza — avoid in severe immunocompromise and pregnancy. True contraindications include severe anaphylaxis to vaccine component; mild illness or low-grade fever is NOT a contraindication.
Live vs. inactivated vaccines
Live (avoid in severe immunocompromise, pregnancy): MMR, varicella, rotavirus, intranasal influenza, BCG, yellow fever
Do not use expired vaccines or those exposed to temperature excursions
Common reactions and management
Local reactions (common, expected)
Mild pain, swelling, redness at injection site
Mild fever (especially after DTaP, MMR)
Fussiness for 24–48 hr
Management: cool compresses to injection site; acetaminophen or ibuprofen (≥ 6 mo) for fever or discomfort; do not give as prophylaxis (may blunt immune response)
Severe reactions (rare)
Anaphylaxis — immediate; respiratory distress, hypotension, swelling, hives; treat with IM epinephrine
Seizures (febrile, after MMR rarely)
Encephalopathy
Persistent inconsolable crying ≥ 3 hr after DTaP
Report to VAERS
QUICK CHECK: A parent of a 4-month-old asks if their baby can receive scheduled vaccines despite a runny nose and low-grade fever (37.9°C). What is the most appropriate response? Answer: Mild illness with low-grade fever is NOT a contraindication to immunization. Proceed with the scheduled vaccines after explaining this to the parent. Vaccines should be delayed only for moderate-to-severe acute illness.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Medication. Practice answering before reviewing the key.
Scenario
A nurse is preparing to administer LAIV, 9v-HPV, and MenACWY to a 12 year-old client. Use the ATI Active Learning Template: medication to complete this item. COMPLICATIONS: Include adverse effects for each vaccine.
COMPLICATIONS: Include adverse effects for each vaccine.
Answer key
Laiv
Allergic reaction
Vomiting and/or diarrhea
Cough
Fever
Headache
myalgia
Nasal congestion/runny nose 9v-HPV
Redness, swelling and tenderness at the injection site
mild to moderate fever
Headache
Fatigue
Fainting (shortly after receiving the vaccine) MenACWY
Allergic reaction
Redness and tenderness at the injection site
Fever
Application Exercises
Q1
A nurse is preparing to administer immunizations to a 6-month-old. Which vaccines are typically given at this age? (Select all that apply.)
A. DTaP
B. Hepatitis B
C. MMR
D. Varicella
E. Pneumococcal conjugate (PCV13)
Show rationale ▾
A.CORRECT. DTaP #3 at 6 months.
B.CORRECT. HepB #3 may be given at 6 months.
C. MMR is given at 12–15 months, not 6 months.
D. Varicella is given at 12–15 months.
E.CORRECT. PCV13 #3 at 6 months.
NCLEX® Connection: Health Promotion and Maintenance — Health Promotion/Disease Prevention
Q2
A nurse is screening a 12-month-old child for immunizations. Which condition would be a contraindication to live virus vaccines?
A. Mild cold with low-grade fever
B. Current antibiotic therapy for otitis media
C. Severe immunocompromise (e.g., from chemotherapy)
D. Family history of seizures
Show rationale ▾
A. Mild illness is not a contraindication.
B. Antibiotic use is not a contraindication.
C.CORRECT. Severe immunocompromise contraindicates live vaccines (MMR, varicella, rotavirus, intranasal flu) due to risk of vaccine-strain infection.
D. Family history of seizures is not a contraindication; recommendations may include extra fever vigilance after MMR.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Adverse Effects/Contraindications
Q3
A nurse is preparing to give a 2-month-old an IM vaccine. Which site is appropriate?
A. Deltoid muscle
B. Dorsogluteal muscle
C. Vastus lateralis (anterolateral thigh)
D. Ventrogluteal muscle
Show rationale ▾
A. Deltoid is not well-developed in infants < 12 mo.
B. Dorsogluteal is not recommended in any age due to sciatic nerve injury risk.
C.CORRECT. Vastus lateralis (anterolateral thigh) is the preferred IM site in infants < 12 mo.
D. Ventrogluteal is appropriate for older children (≥ 3 yr), not infants.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Q4
A parent reports that their 4-month-old had a redness and mild swelling at the DTaP injection site after the last dose. Which is the most appropriate nursing response?
A. "We should not give DTaP again because of the reaction."
B. "These are common, expected local reactions and not contraindications. We can give the next dose as scheduled."
C. "Your child may have a severe vaccine allergy."
D. "Switch to an alternative vaccine schedule."
Show rationale ▾
A. Mild local reactions are not contraindications.
B.CORRECT. Mild local reactions to vaccines are common and expected; they are not contraindications to future doses.
C. A severe allergy would involve anaphylactic features.
D. The standard schedule continues.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Expected Actions/Outcomes
Q5
A nurse is teaching a parent about the HPV vaccine for their 11-year-old. Which statement should the nurse include?
A. "HPV vaccination is only for sexually active adolescents."
B. "Routine HPV vaccination is recommended starting at 11–12 years for all genders."
C. "HPV vaccine is contraindicated in children under 18 years."
D. "Only females need to receive the HPV vaccine."
Show rationale ▾
A. Vaccinating before sexual activity is most effective.
B.CORRECT. ACIP recommends routine HPV vaccination for all genders starting at 11–12 yr (can start at 9 yr). Two-dose series if started before age 15; three doses if started at age 15 or older.
C. HPV vaccine is approved for children 9 yr and older.
D. HPV vaccine is recommended for all genders.
NCLEX® Connection: Health Promotion and Maintenance — Health Promotion/Disease Prevention
Unit 2 · Immune/Infectious · Chapter 36
Communicable Diseases
Many classic childhood communicable diseases have become rare in regions with high vaccination rates, but cases continue to occur and resurge with vaccine hesitancy. Knowing the characteristic rashes, contagious periods, isolation precautions, and complications is essential for nursing care.
Droplet precautions until 5 days after onset of parotid swelling
Prevention: MMR
Roseola (sixth disease, exanthem subitum)
Human herpesvirus 6 (HHV-6)
Age 6 mo–3 yr typically
Distinct pattern: high fever for 3–5 days (often 39–40°C) → fever breaks abruptly → rose-pink macular/maculopapular rash on trunk that spreads to extremities
Febrile seizures are common during high fever phase
Standard precautions; supportive care (antipyretics, fluids)
Fifth disease (erythema infectiosum)
Parvovirus B19
Prodromal mild URI symptoms
"Slapped cheek" rash on the face, then lacy reticular rash on extremities; can recur with sun/heat for weeks
Standard precautions (no longer contagious once rash appears)
Major concerns:
Pregnancy: fetal hydrops, anemia, miscarriage
Sickle cell disease: can trigger aplastic crisis
Immunocompromised: persistent severe anemia
Pregnant people exposed should consult their provider
Hand-foot-and-mouth disease (HFMD)
Coxsackievirus A16 (most common) and enterovirus 71
Fever, malaise, sore throat → painful vesicles on tongue, oral mucosa; vesicles/maculopapules on palms, soles, and sometimes buttocks
Highly contagious through fecal-oral and respiratory droplets
Standard precautions; supportive care (hydration, analgesics, soft cold foods)
Watch for dehydration from refusing to drink (painful mouth)
Infectious mononucleosis
Epstein-Barr virus (EBV); transmitted via saliva ("kissing disease")
Adolescents commonly affected
Fever, severe pharyngitis with white exudate, posterior cervical lymphadenopathy, marked fatigue, splenomegaly
Diagnostic: Monospot (heterophile antibodies); EBV titers; atypical lymphocytes on smear
Avoid contact sports for at least 4 weeks due to splenic rupture risk
Avoid amoxicillin/ampicillin if mono suspected — causes characteristic rash
Rest, hydration, supportive care
Bacterial communicable diseases
Scarlet fever
Group A streptococcus producing erythrogenic toxin
Strep pharyngitis findings + sandpaper-like erythematous rash starting on neck/trunk, spreading to extremities; circumoral pallor
Strawberry tongue — bright red with prominent papillae
Pastia lines — dark red transverse lines in skin folds (axillae, antecubital)
Desquamation as rash resolves
Treatment: penicillin (or alternative if allergy) — full course
Prevention: complete antibiotic treatment of strep pharyngitis to prevent rheumatic fever
Diphtheria
Corynebacterium diphtheriae; toxin-mediated
Rare in vaccinated populations
Pseudomembrane on tonsils/pharynx — gray-white; can obstruct airway
Apply appropriate isolation precautions based on transmission mode
Antipyretics: acetaminophen, ibuprofen — never aspirin in children
Adequate hydration
Cool baths and antihistamines for pruritic rashes
Trim fingernails to reduce scratching damage
Skin care
Comfort measures (rest, cool environment)
Educate family on contagious period and exclusion from school
Report cases to public health as required by local regulations
Identify exposed contacts for prophylaxis where appropriate (e.g., pertussis, meningococcus)
QUICK CHECK: A school nurse is informed that a 7-year-old has been diagnosed with rubella. A 25-year-old pregnant teacher works at the school. What is the appropriate response? Answer: Notify the pregnant teacher and recommend she consult her obstetric provider. Rubella infection during pregnancy (especially the first trimester) can cause congenital rubella syndrome with serious birth defects. Confirm immunity (rubella IgG) and provide guidance per public health protocols.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Basic Concept. Practice answering before reviewing the key.
Scenario
A nurse is planning care for a group of clients who have communicable diseases.
RELATED CONTENT: List the communicable diseases that require more than standard isolation precautions during hospitalization.
NURSING INTERVENTIONS: Identify the type of isolation precaution to be implemented with the communicable disease identified above.
Answer key
Related Content
Varicella
Rubella
Fifth disease
Pertussis
mumps
Nursing Interventions
Airborne/contact: Varicella
Droplet: Rubella, fifth disease, pertussis, mumps
Application Exercises
Q1
A nurse is assessing a 5-year-old with fever, cough, runny nose, conjunctivitis, and tiny bluish-white spots on the buccal mucosa. Which condition is most likely?
A. Roseola
B. Rubella
C. Measles (rubeola)
D. Fifth disease
Show rationale ▾
A. Roseola has high fever then rash; no Koplik spots or cough/coryza/conjunctivitis prodrome.
B. Rubella is mild without Koplik spots.
C.CORRECT. The 3 Cs (cough, coryza, conjunctivitis) plus Koplik spots are pathognomonic for measles (rubeola). Airborne precautions required.
D. Fifth disease has a "slapped cheek" rash without these features.
NCLEX® Connection: Reduction of Risk Potential — System Specific Assessments
Q2
A 15-year-old is diagnosed with infectious mononucleosis. Which teaching point is most important?
A. Begin amoxicillin to prevent secondary infection
B. Resume contact sports as soon as fever resolves
C. Avoid contact sports for at least 4 weeks due to splenic rupture risk
D. Return to school as soon as the sore throat improves
Show rationale ▾
A. Amoxicillin/ampicillin should be avoided if mono is suspected — causes characteristic rash.
B. Splenomegaly persists beyond fever; rupture risk continues.
C.CORRECT. Splenomegaly is common in mono; contact sports are avoided for at least 4 weeks (or until cleared) due to splenic rupture risk.
D. Return to school is fine when feeling better, but sports restriction is the key teaching.
NCLEX® Connection: Health Promotion and Maintenance — Health Promotion/Disease Prevention
Q3
A 2-year-old has had a high fever for 4 days. As the fever resolves, a rose-pink macular rash appears on the trunk and spreads to extremities. The child appears well. Which diagnosis is most likely?
A. Measles
B. Roseola
C. Pertussis
D. Scarlet fever
Show rationale ▾
A. Measles rash starts during the febrile period, with classic prodrome.
B.CORRECT. Roseola classically presents with 3–5 days of high fever followed by rapid defervescence and emergence of a rose-pink rash on the trunk → extremities. The child often appears surprisingly well.
C. Pertussis is characterized by paroxysmal cough.
D. Scarlet fever has a sandpaper rash with strep pharyngitis.
NCLEX® Connection: Reduction of Risk Potential — System Specific Assessments
Q4
A pregnant nurse is assigned to care for a hospitalized child. Which diagnosis would require a different staff assignment?
A. Bronchiolitis from RSV
B. Acute otitis media
C. Rubella
D. Fractured tibia
Show rationale ▾
A. RSV is a concern for contagion in pediatric units but not specifically teratogenic.
B. AOM is not contagious in this way.
C.CORRECT. Rubella infection during pregnancy can cause congenital rubella syndrome (deafness, cataracts, cardiac defects); the pregnant nurse should not be assigned. Other teratogenic concerns include fifth disease and CMV.
D. Fracture care is not a teratogenic concern.
NCLEX® Connection: Safety and Infection Control — Standard/Transmission-Based Precautions
Q5
A nurse is caring for a hospitalized child with measles. Which isolation precautions are required?
A. Standard precautions only
B. Contact precautions
C. Droplet precautions
D. Airborne precautions with negative-pressure room
Show rationale ▾
A. Standard precautions are insufficient.
B. Contact precautions are insufficient.
C. Droplet precautions are insufficient.
D.CORRECT. Measles is transmitted by airborne route. Negative-pressure isolation room with N95 respirator is required. Other airborne diseases: varicella, TB.
NCLEX® Connection: Safety and Infection Control — Standard/Transmission-Based Precautions
Acute otitis media (AOM) is the most common bacterial infection of childhood, peaking between 6 months and 3 years of age. The pediatric Eustachian tube is short, horizontal, and floppy — a setup for fluid and infection trapping. Nursing care addresses prompt recognition, antibiotic decisions, pain control, and prevention.
TL;DR · One-glance summary
Most common pathogens: Streptococcus pneumoniae, Haemophilus influenzae (non-typeable), Moraxella catarrhalis. Findings: ear pain, tugging at ear, fever, irritability, decreased hearing; bulging red TM with loss of landmarks. First-line antibiotic: high-dose amoxicillin (80–90 mg/kg/day). Observation 48–72 hr is option for selected mild cases. Pain control is essential — acetaminophen/ibuprofen. Recurrent AOM may require tympanostomy tubes. Prevention: breastfeeding, smoke-free environment, no bottle propping, PCV13 and influenza vaccines.
Why pediatric anatomy matters
Eustachian tube is shorter, wider, and more horizontal in children → drains poorly
As child grows, tube lengthens and angulates → AOM frequency decreases
Adenoid hypertrophy can block tube
Risk factors
Daycare attendance
Secondhand smoke exposure
Bottle feeding while supine
Pacifier use beyond 6 mo
Allergies; URI
Cleft palate; Down syndrome
Family history of recurrent AOM
Clinical findings and diagnosis
Symptoms
Ear pain (older children)
Tugging or pulling at the ear (infants/toddlers)
Irritability; difficulty sleeping
Fever (variable)
Decreased hearing
Loss of appetite; vomiting; diarrhea
Otorrhea if TM perforation occurs (often with pain relief)
Otoscopic findings (key diagnostic features)
Bulging tympanic membrane with loss of landmarks
Red or yellow opaque TM
Decreased mobility on pneumatic otoscopy (most sensitive sign)
Pus visible behind TM
If perforated: purulent drainage in canal
Tympanometry
Adjunct test showing middle ear function
Flat tracing = middle ear effusion or perforation
Otoscopic technique
Infant or child < 3 yr: pull pinna down and back
Older child/adult: pull pinna up and back
Brace hand against child's head to prevent injury if child moves
Use largest speculum that fits comfortably
Management
Antibiotic therapy
First-line: high-dose amoxicillin (80–90 mg/kg/day) × 10 days for < 2 yr or severe disease; 5–7 days for older mild cases
Hearing loss — may affect language development if recurrent
Chronic effusion
Mastoiditis (rare but serious — redness, swelling, tenderness behind ear; possible protrusion of pinna; emergent ENT evaluation)
Cholesteatoma
Meningitis, intracranial abscess (rare)
QUICK CHECK: A parent reports that their 8-month-old "doesn't seem to hear well" since recent ear infections. What is the appropriate response? Answer: Hearing loss from persistent middle ear effusion is common and can affect language development. Recommend audiology evaluation and pediatric follow-up. If effusion persists with hearing loss, tympanostomy tubes may be indicated.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.
Scenario
A nurse is caring for an infant who has acute otitis media for the first time.
NURSING CARE: Describe two interventions.
MEDICATIONS: List two.
CLIENT EDUCATION: Describe two teaching points.
COMPLICATIONS: Identify one.
Answer key
Nursing Care
Comfort care with pain Medications and distraction.
management of fevers
Place child in an upright position
Medications
Amoxicillin, amoxicillin-clavulanate or azithromycin PO or ceftriaxone Im
Acetaminophen or ibuprofen for pain and fever
Benzocaine
Client Education
Inform the parents about comfort measures.
Encourage the parents to feed the child in an upright position when bottle or breastfeeding.
If drainage is present, clean the external ear with sterile cotton swabs. Apply antibiotic ointment.
Teach parents to avoid risk factors (secondhand smoke, exposure to individuals with viral/bacterial respiratory infections).
Stress the importance of seeking Medical care at the onset of findings of infections (change in child’s behavior, tugging on ear).
Encourage the parents to keep the child’s immunizations up to date.
Potential Complication
Hearing loss and/or speech delays
Application Exercises
Q1
A nurse is preparing to perform an otoscopic examination on a 14-month-old. Which technique is correct?
A. Pull the pinna up and back
B. Pull the pinna down and back
C. Insert the otoscope without manipulating the pinna
D. Use the largest speculum available
Show rationale ▾
A. Up and back is used for children > 3 yr and adults.
B.CORRECT. Children < 3 yr have a more horizontal ear canal; pulling the pinna down and back straightens it for visualization.
C. Pinna manipulation is needed for proper visualization.
D. Use the largest speculum that fits comfortably, not the largest available.
NCLEX® Connection: Reduction of Risk Potential — System Specific Assessments
Q2
A nurse is teaching parents about prevention of acute otitis media. Which strategies should the nurse recommend? (Select all that apply.)
A. Breastfeed for at least 6 months
B. Put the infant to bed with a bottle for sleep
C. Maintain a smoke-free environment
D. Keep up with PCV13 and annual influenza vaccinations
E. Avoid propping the bottle during feedings
Show rationale ▾
A.CORRECT. Breastfeeding provides protection.
B. Bottle in bed allows pooling of formula into Eustachian tube area, increasing AOM risk and dental caries.
C.CORRECT. Secondhand smoke is a major modifiable risk factor.
D.CORRECT. Vaccines reduce AOM incidence.
E.CORRECT. Bottle propping allows formula to pool near the Eustachian tube and risks aspiration.
NCLEX® Connection: Health Promotion and Maintenance — Health Promotion/Disease Prevention
Q3
A nurse is teaching parents about caring for a 3-year-old who recently had tympanostomy tube placement. Which instruction is most important?
A. Keep the ears dry during bathing and swimming
B. Avoid all loud noises for 6 months
C. Stop antibiotics if the child develops drainage
D. Restrict food intake for 24 hours
Show rationale ▾
A.CORRECT. Keep ears dry to prevent water from entering the middle ear through the tubes — earplugs or fitted cap for bathing/swimming.
B. Routine noise exposure is not a concern.
C. Drainage requires evaluation; do not adjust antibiotics independently.
D. Food restriction is unnecessary.
NCLEX® Connection: Reduction of Risk Potential — Therapeutic Procedures
Q4
A 2-year-old is diagnosed with acute otitis media. Which medication should the nurse anticipate as first-line therapy?
A. High-dose amoxicillin
B. Cephalexin
C. Doxycycline
D. Ciprofloxacin
Show rationale ▾
A.CORRECT. High-dose amoxicillin (80–90 mg/kg/day) is the first-line treatment for uncomplicated AOM.
B. Cephalexin is not preferred for AOM.
C. Doxycycline is avoided in children under 8 yr due to tooth staining.
D. Ciprofloxacin is not first-line in pediatric AOM.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Q5
A nurse is caring for a child being treated for AOM. The parent reports that the child has redness and tenderness behind the affected ear, with the pinna appearing to protrude. What is the most appropriate nursing action?
A. Continue current antibiotic therapy and recheck in 1 week
B. Apply warm compresses to the area and observe
C. Notify the provider — possible mastoiditis
D. Discontinue antibiotic and switch to acetaminophen
Show rationale ▾
A. Waiting allows progression of a potentially serious infection.
B. Inadequate response to a serious complication.
C.CORRECT. Redness, tenderness, and protrusion of the pinna behind the ear suggest mastoiditis — a serious complication that requires emergent ENT evaluation and IV antibiotics.
D. Inappropriate response.
NCLEX® Connection: Physiological Adaptation — Medical Emergencies
Unit 2 · Immune/Infectious · Chapter 38
HIV/AIDS
Most pediatric HIV results from perinatal (mother-to-child) transmission, though adolescent acquisition through sexual activity and IV drug use is increasing. Antiretroviral therapy (ART), prophylactic prevention of opportunistic infections, immunization modifications, and family-centered psychosocial support are central to care. Confidentiality is essential.
TL;DR · One-glance summary
Perinatal transmission is the dominant pediatric route — prevented by maternal ART, scheduled cesarean, neonatal ART prophylaxis, and avoiding breastfeeding (in resource-rich settings). Diagnosis in infants: HIV DNA/RNA PCR (not antibody — maternal antibodies persist up to 18 mo). Treatment: combination ART for all confirmed HIV+ children regardless of CD4 count. PCP prophylaxis: TMP-SMX in infants 4–6 wk through 12 mo, then per CD4 count. Vaccinations: avoid live vaccines if severely immunocompromised; otherwise follow standard schedule.
AIDS = advanced HIV with specific clinical conditions or CD4 below age-specific thresholds
Perinatal transmission prevention
HIV testing for all pregnant women (and rapid test in labor if status unknown)
Maternal antiretroviral therapy throughout pregnancy
Scheduled cesarean at 38 weeks if viral load is high
IV zidovudine to mother during labor
Neonatal antiretroviral prophylaxis (zidovudine ± others) for 4–6 weeks
Avoid breastfeeding in resource-rich settings (breastfeeding is recommended in resource-limited settings if HIV-positive mother is on ART, due to mortality risk from formula feeding)
Combined approach reduces transmission to < 1–2%
Diagnosis
Infants < 18 months
HIV antibody testing is NOT reliable — maternal antibodies cross the placenta and may persist up to 18 months
HIV DNA or RNA PCR testing is used; positive on two separate samples confirms infection
CD4 count and percentage — monitors immune function
HIV viral load — measures circulating virus; goal is undetectable on ART
Complete blood count, liver and kidney function
Screening for opportunistic infections (PPD/IGRA for TB; toxoplasmosis IgG, hepatitis serologies, syphilis, etc.)
Growth and development monitoring
Treatment and prevention of complications
Antiretroviral therapy (ART)
Combination therapy (typically 3+ drugs from 2+ drug classes)
Recommended for all HIV+ children regardless of CD4 count or symptoms
Drug classes: NRTIs (zidovudine, lamivudine, abacavir, tenofovir, emtricitabine), NNRTIs (efavirenz, nevirapine), PIs (lopinavir/ritonavir, atazanavir), INSTIs (raltegravir, dolutegravir)
Adherence is critical — missed doses lead to resistance and treatment failure
Side effects: GI upset, hepatotoxicity, metabolic changes, hypersensitivity (especially abacavir — HLA-B*5701 testing), lipodystrophy (with older PI regimens)
Opportunistic infection prophylaxis
PCP (Pneumocystis jirovecii pneumonia): trimethoprim-sulfamethoxazole (TMP-SMX) for all HIV-exposed infants from 4–6 weeks of age through 12 months, then per CD4 count
MAC (Mycobacterium avium complex): azithromycin or clarithromycin when CD4 markedly low
Anti-fungal, anti-viral prophylaxis as indicated
Immunizations in HIV+ children
Follow standard schedule with modifications:
Inactivated vaccines (DTaP, Hib, PCV, IPV, HepA, HepB, influenza inactivated, HPV) — give as scheduled
Live vaccines: defer or contraindicate if severely immunocompromised
MMR and varicella — can be given to non-severely immunocompromised; avoid if severely immunocompromised
Rotavirus — given to HIV-exposed infants; HIV+ infants without severe immunosuppression can usually receive it
Live attenuated intranasal influenza — avoid
BCG — generally contraindicated in HIV+ patients
Annual influenza vaccine (inactivated)
Pneumococcal vaccines (PCV13 + PPSV23)
Nutrition
High-calorie, high-protein diet
Monitor growth; address failure to thrive
Vitamin/mineral supplementation as needed
Address poor oral intake from oral thrush, esophagitis
Universal precautions
Use standard precautions with all patients (universal, not based on HIV status)
HIV is not transmitted by casual contact
Confidentiality is paramount; disclosure decisions involve the family and provider
Family-centered care
Education about the diagnosis, treatment, transmission, and prognosis
Mental health support — high rates of depression, anxiety, stigma
Adherence support (pillboxes, alarms, simplified regimens, directly observed therapy)
School/daycare disclosure decisions per family preference and law
Connect with HIV support organizations and case management
Address parental HIV-related issues if applicable
QUICK CHECK: A 2-month-old born to an HIV-positive mother is being seen for routine care. Which laboratory test is appropriate to determine the infant's HIV status? Answer: HIV DNA or RNA PCR. HIV antibody testing is unreliable in infants < 18 months because maternal antibodies cross the placenta and remain detectable until then. Two positive PCRs on separate samples confirm infection.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.
Scenario
A nurse is teaching a guardian of a child who has AIDS.
COMPLICATIONS: List two complications of AIDS and include four nursing actions for each.
Answer key
Complications
Failure to thrive
Obtain a baseline height and weight, and continue to Monitor.
Promote optimal nutrition. This can require the administration of total parenteral nutrition.
Assess growth and development. Monitor for delays.
Provide opportunities for normal development (age-appropriate toys, playing with children of the same age).
Educate the child and parents about appropriate nutrition and how to meet nutritional needs. Pneumocystis carinii pneumonia (PCP)
Assess and Monitor respiratory status, which includes respiratory rate and effort, oxygen saturation, and breath sounds.
Administer appropriate antibiotics.
Administer an antipyretic and/or analgesics.
Provide adequate hydration, and Maintain fluid and electrolyte balance.
Use postural drainage and chest physiotherapy to mobilize and remove fluid from the lungs.
Promote adequate rest.
Educate the child and parents about the infectious process and how to prevent infection.
Educate the child and parents about the importance of medication and the need to Maintain the medication regimen.
Application Exercises
Q1
A nurse is caring for an infant whose mother is HIV-positive. Which diagnostic test should the nurse anticipate for the infant?
A. HIV antibody test
B. HIV DNA or RNA PCR
C. CD4 count alone
D. Western blot test
Show rationale ▾
A. Antibody testing reflects maternal antibodies in infants < 18 mo.
B.CORRECT. HIV DNA/RNA PCR is used to diagnose infection in infants < 18 mo because maternal antibodies persist that long.
C. CD4 monitors immune function but doesn't diagnose HIV.
D. Western blot is an antibody-based confirmatory test, unreliable in young infants.
NCLEX® Connection: Reduction of Risk Potential — Diagnostic Tests
Q2
A nurse is reviewing immunizations for a 1-year-old with HIV who is NOT severely immunocompromised. Which vaccine considerations are appropriate? (Select all that apply.)
A. Give inactivated vaccines on the routine schedule
B. MMR may be given if not severely immunocompromised
C. Live attenuated intranasal influenza vaccine is preferred
D. Annual inactivated influenza vaccine
E. PCV13 vaccination
Show rationale ▾
A.CORRECT. Inactivated vaccines are safe and recommended.
B.CORRECT. MMR can be given to HIV+ children who are not severely immunocompromised.
C. Intranasal live influenza vaccine is avoided in HIV+ patients.
D.CORRECT. Annual inactivated influenza is recommended.
E.CORRECT. PCV13 protects against pneumococcal disease.
NCLEX® Connection: Health Promotion and Maintenance — Health Promotion/Disease Prevention
Q3
A nurse is teaching the parents of a 6-year-old recently diagnosed with HIV about antiretroviral therapy. Which teaching point is most important?
A. ART is started only when CD4 counts drop below 200
B. Strict adherence to ART is essential to prevent drug resistance
C. ART can be stopped when the viral load becomes undetectable
D. Side effects of ART are minimal and never require monitoring
Show rationale ▾
A. ART is recommended for all HIV+ children regardless of CD4 count.
B.CORRECT. Missed doses lead to resistance and treatment failure. Adherence support is a major nursing focus.
C. ART is continued indefinitely; stopping leads to viral rebound and resistance.
D. ART has potential side effects requiring routine monitoring.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Q4
A nurse is teaching an adolescent newly diagnosed with HIV about transmission. Which statement indicates correct understanding?
A. "HIV can be transmitted through casual contact like hugging."
B. "HIV is transmitted through blood, sexual contact, and from mother to baby."
C. "HIV is spread through insect bites."
D. "Sharing dishes with others puts them at risk."
Show rationale ▾
A. HIV is not transmitted by casual contact.
B.CORRECT. HIV is transmitted through blood, sexual contact, perinatal transmission, and (rarely) contaminated blood products.
C. HIV is not transmitted by insects.
D. Sharing dishes does not transmit HIV.
NCLEX® Connection: Health Promotion and Maintenance — Health Promotion/Disease Prevention
Q5
A nurse is providing care to an infant born to an HIV-positive mother. The infant is 6 weeks old. Which prophylactic medication should the nurse anticipate for prevention of Pneumocystis jirovecii pneumonia?
A. Penicillin G
B. Acyclovir
C. Trimethoprim-sulfamethoxazole (TMP-SMX)
D. Azithromycin
Show rationale ▾
A. Penicillin is not used for PCP prophylaxis.
B. Acyclovir is for herpes, not PCP.
C.CORRECT. TMP-SMX is the standard PCP prophylaxis, started at 4–6 weeks of age in HIV-exposed infants and continued until HIV is excluded or per CD4 count.
D. Azithromycin is used for MAC prophylaxis at advanced immunosuppression, not PCP.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Pediatric solid organ tumors include Wilms tumor (most common renal tumor of childhood), neuroblastoma (the most common extracranial solid tumor in children), retinoblastoma (the white pupillary reflex), and brain tumors (the most common solid tumor in pediatrics, often presenting with morning headaches and vomiting). Nursing care centers on early recognition of "red flag" findings, multimodal cancer therapy, and managing the toxicities that come with it.
TL;DR · One-glance summary
Wilms tumor: palpable firm abdominal mass in a toddler — DO NOT PALPATE THE ABDOMEN; sign on the bed and chart "DO NOT PALPATE." Neuroblastoma: firm, nontender, irregular abdominal mass crossing the midline; "raccoon eyes" with orbital metastasis; opsoclonus-myoclonus syndrome. Retinoblastoma: leukocoria (white pupillary reflex / "cat's eye reflex") in a flash photo. Brain tumors: morning headache + vomiting; balance and coordination changes (posterior fossa); papilledema; sunset eyes in infants.
Critical "don't" rules
Wilms tumor: NEVER palpate the abdomen — risk of tumor rupture and dissemination of cancer cells
Bathe carefully; minimize abdominal pressure
Sign at head of bed: "DO NOT PALPATE ABDOMEN"
Inform all staff and visitors
Pediatric brain tumor red flags
Morning headache + vomiting
Behavior changes, irritability, fatigue
Vision changes; diplopia
Balance/coordination changes; ataxic gait
Seizures
Increasing head circumference in infants; bulging fontanel; sunset eyes
Wilms tumor (nephroblastoma)
Overview
Embryonal tumor of the kidney
Most common renal tumor of childhood; peak age 2–5 yr
Often unilateral, encapsulated
Associated genetic syndromes: WAGR (Wilms, Aniridia, GU anomalies, Range of intellectual disability), Beckwith-Wiedemann, Denys-Drash
Findings
Firm, nontender, well-defined abdominal mass — often discovered incidentally during bathing or routine exam
Posterior fossa syndrome: mutism, ataxia, emotional lability after cerebellar surgery
Endocrine evaluation if pituitary involvement
Long-term neurocognitive monitoring
QUICK CHECK: A 3-year-old is admitted with a newly diagnosed abdominal mass. The nurse documents "DO NOT PALPATE ABDOMEN" on the chart. Why is this priority? Answer: This is the standard precaution for suspected Wilms tumor. Palpation could rupture the encapsulated tumor and disseminate cancer cells throughout the abdomen, worsening prognosis. Sign at head of bed, inform all team members, and handle the child gently.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.
Scenario
A nurse is caring for a child who has an organ neoplasm.
NURSING CARE: Describe seven actions.
INTERPROFESSIONAL CARE: Identify two potential referrals. CONTENT MASTERY SERIES
Answer key
Nursing Care
If Wilms’ tumor is suspected, do not palpate the abdomen.
Use caution when handling or bathing the client to prevent trauma to the tumor site.
Assess the child’s and family’s coping and support.
Assess for developmental delays related to illness.
Assess physical growth (height and weight).
Provide education and support to the child and family regarding diagnostic testing, treatment plan, ongoing therapy, and prognosis.
Monitor for findings of infection.
Administer antibiotics as prescribed for infection.
Keep the child’s skin clean and dry.
Provide oral hygiene.
Provide age-appropriate diversional activities.
Provide support to the child and family.
Interprofessional Care
Social services
Dietitian
Application Exercises
Q1
A nurse is admitting a 3-year-old with a suspected diagnosis of Wilms tumor. Which is the priority nursing intervention?
A. Encourage frequent abdominal palpation to monitor mass size
B. Place a "Do Not Palpate Abdomen" sign at the head of the bed
C. Initiate isolation precautions
D. Restrict oral fluids in preparation for surgery
Show rationale ▾
A. Palpation risks tumor rupture.
B.CORRECT. Wilms tumor is encapsulated; palpation can rupture the capsule and disseminate cancer cells. A sign communicates this to all caregivers and visitors.
C. Isolation is not indicated for Wilms tumor.
D. NPO status is determined by surgical schedule, not routinely.
NCLEX® Connection: Safety and Infection Control — Accident/Injury Prevention
Q2
A parent reports that a flash photograph showed a "white spot" in their 18-month-old's pupil. Which condition should the nurse suspect?
A. Cataract
B. Retinoblastoma
C. Strabismus
D. Conjunctivitis
Show rationale ▾
A. Cataracts can cause leukocoria but retinoblastoma is the urgent concern to rule out.
B.CORRECT. Leukocoria (white pupillary reflex) is the most common presenting sign of retinoblastoma — urgent ophthalmology referral required.
C. Strabismus is a less specific sign and not the most worrying interpretation of leukocoria.
D. Conjunctivitis does not cause leukocoria.
NCLEX® Connection: Reduction of Risk Potential — System Specific Assessments
Q3
A nurse is caring for a 4-year-old admitted with a brain tumor. Which findings are consistent with increased intracranial pressure? (Select all that apply.)
A. Morning headache that resolves with vomiting
B. Ataxic gait
C. Persistent vomiting
D. Papilledema on fundoscopy
E. Heart rate of 130/min
Show rationale ▾
A.CORRECT. Morning headache that resolves with vomiting is classic for increased ICP from brain tumor.
Neoplastic Disorders of the Blood (Leukemia and Lymphoma)
Leukemia is the most common pediatric cancer, with acute lymphoblastic leukemia (ALL) accounting for the majority of cases and having an overall cure rate > 85%. Lymphomas — Hodgkin and non-Hodgkin — round out the chapter. Nursing care of children with hematologic malignancies focuses on managing chemotherapy toxicity, preventing and treating infections in immunocompromised hosts, and supporting families through prolonged treatment.
TL;DR · One-glance summary
ALL is the most common pediatric cancer; presents with bone marrow failure (pancytopenia) — pallor, fatigue, infections, bruising, petechiae, bone/joint pain, hepatosplenomegaly, lymphadenopathy. Bone marrow aspiration from posterior iliac crest is definitive. Chemotherapy phases: induction → consolidation → maintenance (2–3 yr total). Hodgkin lymphoma: painless cervical lymphadenopathy; Reed-Sternberg cells; "B symptoms" (fever, night sweats, weight loss). Major nursing focus: neutropenic precautions (ANC < 500–1,000); chemotherapy toxicities (mucositis, nausea, alopecia, fatigue).
Heterogeneous group of lymphoid malignancies (Burkitt lymphoma, lymphoblastic lymphoma, large B-cell lymphoma, anaplastic large cell lymphoma)
More common than Hodgkin in younger children
Often aggressive, rapidly growing
Findings vary by subtype: lymphadenopathy, abdominal mass (Burkitt), mediastinal mass, CNS symptoms
Treatment: intensive multi-agent chemotherapy
High risk of tumor lysis syndrome with treatment initiation
Nursing care across hematologic malignancies
Chemotherapy-related toxicities
Myelosuppression:
Anemia: monitor Hgb, transfuse PRBCs as ordered, manage fatigue
Thrombocytopenia: bleeding precautions (no aspirin/NSAIDs, soft toothbrush, no IM injections, avoid contact sports), platelet transfusion if severe or actively bleeding
Neutropenia: see precautions table above; G-CSF (filgrastim) for prolonged neutropenia
Strict hand hygiene by all caregivers and visitors
Restrict visitors with active infection
No fresh flowers or live plants (mold/fungi)
No raw fruits/vegetables; well-cooked food
No rectal temperatures, no rectal medications, no IM injections
Central line care with strict aseptic technique
Frequent skin assessment for breakdown
Oral care multiple times per day
Fever in a neutropenic patient is an emergency — blood cultures and broad-spectrum antibiotics within 1 hour
Vaccinations: avoid live vaccines for the patient; family should be up to date including annual inactivated influenza
Psychosocial care
Age-appropriate explanations of procedures (child life specialists)
Address fears, body image concerns (alopecia)
School re-entry planning
Support sibling and family
Survivorship: late effects monitoring (cardiac, growth, fertility, secondary cancers, neurocognitive)
QUICK CHECK: A child on chemotherapy for ALL develops a fever of 38.5°C. The most recent ANC is 350. What is the priority nursing action? Answer: This is febrile neutropenia — a medical emergency. Notify the provider immediately, obtain blood cultures (peripheral and central line), and prepare to administer broad-spectrum IV antibiotics within 1 hour. Strict aseptic technique; avoid rectal temperatures and rectal medications.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Diagnostic Procedure. Practice answering before reviewing the key.
Scenario
A nurse is preparing to assist with a lumbar puncture.
NURSING INTERVENTIONS: Describe six.
POTENTIAL COMPLICATIONS: Identify two.
Answer key
Description Of The Procedure
CSF is obtained to determine whether there is CNS involvement.
Nursing Interventions
Have the child empty his bladder.
Apply a topical anesthetic 60 min before the procedure.
Monitor the child if conscious sedation is used.
Position the child in a side-lying position with the head flexed and knees drawn up toward the chest.
Use distraction techniques if needed.
Assist with the procedure.
Apply pressure and an elastic bandage to the site after the needle is withdrawn.
Label the specimens, and deliver them to the laboratory.
Monitor for hematoma, bleeding, and infection.
Keep the bed flat.
Instruct the child to remain in a flat position for at least 30 min after the procedure.
Encourage to drink full glass of fluid after the procedure to prevent spinal headache.
Potential Complications
Spinal headache
Hematoma
Infection
Bleeding
Application Exercises
Q1
A nurse is admitting a 5-year-old with newly diagnosed ALL. Which findings would the nurse most likely observe? (Select all that apply.)
A. Pallor and fatigue
B. Petechiae and bruising
C. Hypertension and bradycardia
D. Recurrent fever
E. Bone pain and limping
Show rationale ▾
A.CORRECT. Anemia → pallor and fatigue.
B.CORRECT. Thrombocytopenia → petechiae and easy bruising.
E.CORRECT. Leukemic infiltration of marrow causes bone/joint pain and refusal to walk.
NCLEX® Connection: Reduction of Risk Potential — System Specific Assessments
Q2
A nurse is caring for a 4-year-old undergoing induction chemotherapy. The ANC is 320. Which interventions are appropriate? (Select all that apply.)
A. Provide a fresh flower arrangement to brighten the room
B. Use a soft toothbrush and gentle oral care
C. Avoid rectal medications and rectal temperatures
D. Place the child in a private room
E. Allow the child to share toys with other patients in the playroom
Show rationale ▾
A. Fresh flowers and plants can harbor mold and bacteria.
B.CORRECT. Soft brush prevents trauma; mucositis common with chemo.
C.CORRECT. Rectal procedures risk mucosal trauma and infection.
D.CORRECT. Private room reduces infection risk.
E. Shared spaces with active infections risk exposure.
NCLEX® Connection: Safety and Infection Control — Standard/Transmission-Based Precautions
Q3
A nurse is caring for a child receiving high-dose chemotherapy. The provider has ordered IV fluids and allopurinol. The nurse understands these are administered to prevent which complication?
A. Cardiotoxicity
B. Hemorrhagic cystitis
C. Tumor lysis syndrome
D. Hepatotoxicity
Show rationale ▾
A. Cardiotoxicity is monitored but prevented by dose limits and dexrazoxane.
B. Hemorrhagic cystitis is prevented with hydration and mesna.
C.CORRECT. Tumor lysis syndrome from rapid cancer cell breakdown is prevented with aggressive hydration and allopurinol or rasburicase.
D. Hepatotoxicity is monitored with LFTs; not prevented by allopurinol.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Adverse Effects/Contraindications
Q4
A 16-year-old is being evaluated for Hodgkin lymphoma. Which findings support this diagnosis? (Select all that apply.)
A. Painless cervical lymph node
B. Fever, night sweats, and weight loss
C. Reed-Sternberg cells on biopsy
D. Hyperglycemia
E. Mediastinal mass on chest imaging
Show rationale ▾
A.CORRECT. Painless lymphadenopathy is the most common initial presentation.
Osteosarcoma and Ewing sarcoma are the two most common pediatric bone cancers, occurring most often in adolescents during their growth spurt. Rhabdomyosarcoma is the most common soft tissue sarcoma in children. Multimodal therapy with surgery, chemotherapy, and (for Ewing) radiation has dramatically improved outcomes — including limb-salvage procedures that preserve function.
TL;DR · One-glance summary
Osteosarcoma: most common bone cancer in children; ages 10–20; distal femur, proximal tibia, proximal humerus (long bone metaphyses); pain especially at night, often after minor trauma; "sunburst" appearance on X-ray; lung metastases common. Ewing sarcoma: diaphysis of long bones (femur, tibia, humerus) and pelvis; "onion-skin" periosteal reaction; small round blue cell tumor; chemotherapy + surgery + radiation. Rhabdomyosarcoma: most common pediatric soft tissue sarcoma; head/neck, GU, extremities; presents as painless mass.
Pediatric bone cancer "red flag" picture
Adolescent in growth spurt
Persistent localized bone pain, especially at night
Pain worsens with activity
Pain "out of proportion" to minor trauma
Local mass or swelling
Pathologic fracture possible
Limp or refusal to bear weight
Limb salvage vs amputation
Limb salvage: resect tumor and replace bone with prosthesis or allograft; preserves limb
Selected based on tumor size, location, neurovascular involvement, age, growth
Amputation: may be necessary for advanced disease or specific anatomic sites
Both treatments are followed by chemotherapy
Psychosocial support critical for adolescents facing body image changes
Osteosarcoma
Overview
Most common malignant bone tumor in children and adolescents
Peak incidence 10–20 yr (during growth spurt)
Arises from osteoblasts (bone-forming cells)
Common sites: distal femur, proximal tibia, proximal humerus (metaphyses of long bones)
Metastasizes most often to the lungs
Findings
Localized bone pain, often worse at night or with activity
Pain that wakes the child from sleep
Visible or palpable mass with localized swelling
Limp; decreased ROM
Pathologic fracture possible
Systemic symptoms uncommon at presentation (except advanced)
Genetic counseling if indicated (e.g., Li-Fraumeni syndrome, hereditary retinoblastoma)
QUICK CHECK: A 14-year-old reports persistent knee pain for several weeks that wakes him from sleep. X-ray shows a "sunburst" pattern at the distal femur. Which diagnosis is most likely? Answer: Osteosarcoma. The combination of an adolescent in growth spurt, persistent nighttime pain at the distal femur (most common site), and a "sunburst" radiographic pattern is classic. Workup includes MRI of the affected area, chest CT for pulmonary metastases, and biopsy for definitive diagnosis.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.
Scenario
A nurse is teaching a guardian of a child who has bone cancer and is receiving chemotherapy about myelosuppression.
NURSING CARE: Describe two actions related to each of the following areas. ● Evaluating laboratory data to assess for complications ● Preventing infection ● Preventing hemorrhage or injury from bleeding ● Preventing anemia or injury from anemia
Answer key
Nursing Care
Evaluating laboratory data to assess for complications
Infection: elevated WBC and fever
Hemorrhage: blood in urine or stool, bruising, and petechiae
Anemia: fatigue and decreased hemoglobin/hematocrit
Preventing infection
Provide a private room when hospitalized.
Restrict staff/visitors who have infections.
Promote frequent hand hygiene by staff/visitors.
Avoid all live-virus vaccines during periods of immunosuppression.
Ensure that household members are up-to-date on immunizations.
Provide a diet adequate in proteins and calories.
Preventing hemorrhage or injury from bleeding
Use a strict aseptic technique for all invasive procedures.
Use gentle technique when providing mouth care.
Clean the perineal area carefully to prevent trauma, and avoid obtaining temperatures rectally.
Infuse platelets as prescribed.
Preventing anemia or injury from anemia
Provide rest periods as needed.
Infuse packed red blood cells as prescribed.
Application Exercises
Q1
A 13-year-old reports persistent left knee pain for several weeks that is worse at night. X-ray shows a "sunburst" appearance at the distal femur. Which condition is most likely?
A. Ewing sarcoma
B. Osteosarcoma
C. Osteomyelitis
D. Legg-Calvé-Perthes disease
Show rationale ▾
A. Ewing sarcoma typically shows "onion-skin" appearance.
B.CORRECT. "Sunburst" pattern at distal femur in an adolescent is classic for osteosarcoma — most common bone cancer in children, occurring during growth spurt.
C. Osteomyelitis presents with fever and infection signs; imaging shows different features.
D. LCP affects the hip, not the knee, and occurs in younger children.
NCLEX® Connection: Reduction of Risk Potential — System Specific Assessments
Q2
A nurse is preparing an adolescent for amputation due to osteosarcoma. Which intervention is most important to address?
A. Restrict the family's visitation to reduce emotional stress
B. Discuss expectations including pain management, prosthetic options, and phantom pain
C. Reassure that they will not experience any sensation in the missing limb
D. Limit conversation about feelings to avoid causing distress
Show rationale ▾
A. Family support is essential for adolescents facing major surgery.
B.CORRECT. Comprehensive preparation about pain, prosthetic options, phantom pain, and rehabilitation prepares the adolescent and family for what to expect.
C. Phantom pain and sensations are common; appropriate teaching prepares the patient.
D. Open communication about feelings is therapeutic.
A nurse is caring for a child receiving cyclophosphamide. Which intervention helps prevent a serious adverse effect?
A. Encourage minimal fluid intake
B. Administer mesna and ensure adequate hydration
C. Limit potassium intake
D. Avoid antiemetics
Show rationale ▾
A. Inadequate hydration increases cystitis risk.
B.CORRECT. Mesna binds the toxic metabolite (acrolein), and aggressive hydration flushes it from the bladder — preventing hemorrhagic cystitis from cyclophosphamide and ifosfamide.
C. Potassium intake is not relevant to this concern.
D. Antiemetics are essential and not contraindicated.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Adverse Effects/Contraindications
Q4
A nurse is reviewing imaging findings for a 12-year-old with bone pain. The X-ray shows an "onion-skin" appearance on the diaphysis of the femur. Which diagnosis is most likely?
A. Osteosarcoma
B. Ewing sarcoma
C. Rhabdomyosarcoma
D. Osteomyelitis
Show rationale ▾
A. Osteosarcoma shows "sunburst" pattern.
B.CORRECT. "Onion-skin" multilayered periosteal reaction is characteristic of Ewing sarcoma, typically in the diaphysis of long bones.
C. Rhabdomyosarcoma is a soft tissue sarcoma, not primarily bone.
D. Osteomyelitis shows different imaging features and presents with infection signs.
NCLEX® Connection: Reduction of Risk Potential — Diagnostic Tests
Q5
A 4-year-old child with rhabdomyosarcoma of the orbit presents with proptosis and ptosis. Which is the most appropriate nursing intervention?
A. Patch the affected eye continuously
B. Coordinate the multidisciplinary care plan including chemotherapy, surgical evaluation, and ophthalmology
C. Discharge the patient with outpatient follow-up only
D. Apply warm compresses to the eye
Show rationale ▾
A. Continuous eye patching is not the standard intervention.
B.CORRECT. Rhabdomyosarcoma requires multimodal therapy (chemotherapy, surgery, radiation) and an interdisciplinary team including pediatric oncology, surgery, and ophthalmology.
C. Outpatient-only management without coordinated multidisciplinary care is inadequate.
D. Warm compresses are not indicated for this condition.
NCLEX® Connection: Management of Care — Collaboration with Interdisciplinary Team
This chapter covers a wide range of complications affecting newborns and young infants: hyperbilirubinemia and jaundice, neonatal sepsis, respiratory distress syndrome and bronchopulmonary dysplasia of prematurity, necrotizing enterocolitis, apnea of prematurity, intraventricular hemorrhage, retinopathy of prematurity, sudden unexpected infant death, inborn errors of metabolism, and failure to thrive. Nursing care focuses on early recognition, supportive interventions, family education, and prevention.
TL;DR · One-glance summary
Pathologic jaundice: first 24 hr of life, rapid rise, or persistent > 14 days → workup; kernicterus from unconjugated bilirubin crossing the BBB. RDS: surfactant deficiency in preemies; treat with surfactant + CPAP/ventilation. NEC: classic triad — feeding intolerance, abdominal distention, bloody stools; pneumatosis intestinalis on X-ray; immediate NPO + NG + antibiotics. SIDS prevention: ABCs — Alone in crib, on Back, in a Clear/Crib environment (firm mattress, no soft objects, breastfeed, no smoking). PKU: strict low-phenylalanine diet for life; no aspartame.
ABO incompatibility: occurs when mother is type O and newborn is type A or B; maternal anti-A or anti-B antibodies cross the placenta and attack fetal RBCs
Rh incompatibility: Rh-negative mother produces antibodies against Rh-positive fetal RBCs (typically after sensitization from prior pregnancy); prevented with RhoGAM
Direct Coombs test: reveals presence of antibody-coated (sensitized) Rh-positive RBCs in the newborn — confirms hemolytic disease of the newborn (HDN) — positive = isoimmunization
Hour-specific bilirubin nomogram (Bhutani) is the gold standard for predicting at-risk newborns ≥ 35 weeks
Findings: tachypnea, retractions, nasal flaring, grunting, cyanosis; usually presents soon after birth
Chest X-ray: "ground glass" appearance, air bronchograms
Treatment:
Antenatal corticosteroids (betamethasone) given to mothers in preterm labor 24–34 wk to accelerate fetal lung maturity
Exogenous surfactant (beractant, poractant alfa, calfactant) administered via endotracheal tube; assess respiratory status and ABGs before/after; suction before administration; avoid suctioning ET tube for 1 hr after administration
CPAP or mechanical ventilation
Supplemental oxygen (titrate to lowest needed)
Supportive care: thermal regulation, IV fluids, nutritional support
Bronchopulmonary dysplasia (BPD)
Chronic lung disease following prolonged mechanical ventilation, oxygen exposure
Most common in preterm infants with RDS
Findings: tachypnea, retractions, oxygen dependence persisting beyond 28 days of life
Neural tube defects (NTDs) occur when the neural tube fails to close during weeks 3–4 of embryonic development; also classified as spina bifida
Meningocele: protrusion of a sac containing meninges and spinal fluid
Myelomeningocele: protrusion of a sac containing meninges, spinal fluid, AND a portion of the spinal cord and nerves (more severe)
Risk factors: insufficient folic acid intake during pregnancy, maternal medications/drugs, malnutrition, radiation/chemical exposure, maternal obesity/diabetes/hyperthermia, previous child with NTD
Findings: sac-like cyst protruding midline (usually lumbar/lumbosacral), sensory and neuromotor dysfunction below the defect, possible urinary dribbling and fecal incontinence
Preop care:
Protect the sac from injury — do not put pressure on it
Place infant in radiant warmer without clothing
Apply sterile, moist non-adhering dressing with 0.9% NS; re-wet as needed
Position prone or side-lying
Inspect sac for leakage; monitor for infection signs (fever, irritability, lethargy)
Avoid rectal temperatures
IV antibiotics as prescribed
Surgery within 24–72 hr of birth
Postop care: monitor VS, I&O, weight; assess for CSF leak and infection; maintain prone position until cleared; ROM to extremities; measure head circumference (hydrocephalus risk); assess fontanels for bulging
Complications:
Hydrocephalus — may require VP shunt; monitor for increased ICP (bulging fontanel, irritability, vomiting, sunset eyes)
Latex allergy — high risk; use latex-free products from birth; educate parents about latex in everyday products (diapers, gloves, water toys)
Skin pressure injury — frequent repositioning
Bladder dysfunction — urinary diversion may be needed; clean intermittent catheterization
Orthopedic issues — hip dysplasia, clubfoot; monitor for infection in braces/casts
Neonatal sepsis
Causes: GBS (Group B Streptococcus) most common, E. coli, Listeria, also S. aureus, S. epidermidis, H. influenzae, Klebsiella, Pseudomonas
Maternal risk factors: GBS+ status without prophylaxis, prolonged rupture of membranes, chorioamnionitis, maternal fever
Findings often nonspecific: temperature instability (hypothermia more common than fever in neonates), feeding intolerance, lethargy, apnea, respiratory distress, hypotonia, jaundice, hypotension
Empiric antibiotics: ampicillin + aminoglycoside (gentamicin) or third-generation cephalosporin for early-onset sepsis; start prior to culture results
Supportive care: thermal stability, fluids, respiratory and circulatory support
Prevention: maternal GBS screening at 36–37 weeks; intrapartum antibiotic prophylaxis (penicillin G or ampicillin IV) for GBS+ mothers; prophylactic eye treatment (erythromycin ointment) for all newborns; proper umbilical cord care; sterile/aseptic technique during delivery
Nursing care: assess infection risk (review maternal record), monitor VS continuously, strict I&O and daily weight, obtain specimens (blood, urine, CSF) before antibiotics, maintain IV therapy, restrict infected visitors, teach parents proper hand hygiene and infection control
Intraventricular hemorrhage (IVH)
Bleeding into the cerebral ventricles, common in very preterm infants (< 32 weeks)
Graded I–IV by severity
Findings vary: may be silent, or present with sudden deterioration (apnea, bradycardia, hypotonia, seizures, bulging fontanel)
Routine head ultrasound screening for preterm infants
Care: minimize stimuli, maintain BP and cerebral perfusion, head midline, careful fluid management; VP shunt if hydrocephalus develops
Retinopathy of prematurity (ROP)
Abnormal retinal vascularization in premature infants exposed to oxygen
Can cause retinal detachment and blindness if severe
Ophthalmologic screening for at-risk preemies starting at 4–6 weeks of life
Prevention: safe sleep practices (see TL;DR section above)
Provide nonjudgmental, compassionate support to bereaved families
Organ and tissue donation: discuss option with family at appropriate time per institutional policy and law; contact organ procurement organization (OPO); brain death must be established — defined as irreversible cessation of all brain function including brainstem (absent brainstem reflexes, no spontaneous respirations on apnea testing, confirmatory testing such as EEG or cerebral blood flow study); support family regardless of decision; allow time with the child
Inborn errors of metabolism
Phenylketonuria (PKU):
Autosomal recessive deficiency of phenylalanine hydroxylase → accumulation of phenylalanine
Universal newborn metabolic screen — heel stick blood spot analysis after the newborn has ingested protein, usually within 2 days of birth; some states require a repeat at 1–2 weeks
Guthrie test confirms diagnosis when blood spot analysis is positive
Expected reference range of phenylalanine in newborns: 0.5–1 mg/dL
Initial findings: growth failure, frequent vomiting, irritability, musty odor to urine, microcephaly, heart defects, blue eyes, very fair skin, light blonde hair
Untreated complications: severe cognitive impairment, hyperactivity with erratic behavior, head banging, arm biting, disorientation, spasticity or catatonic-like positions, seizures
Treatment:
Initiate dietary restriction within 7–10 days of birth
Low-phenylalanine formula (e.g., Lofenalac); intake 20–30 mg phenylalanine per kg of body weight per day
Target serum phenylalanine: 2–8 mg/dL
Breastfeeding: breast milk contains phenylalanine — exclusive breastfeeding may not be possible; monitor levels closely
Consult registered dietitian; provide parent referrals to PKU support groups
Maternal PKU: women with PKU must monitor levels 1–2× per week throughout pregnancy and maintain strict diet 3 months before conception through pregnancy; failure to adhere can cause fetal microcephaly, cognitive impairment, and heart defects
Galactosemia: inability to metabolize galactose; treat with strict elimination of milk and dairy (galactose- and lactose-free formulas)
Congenital hypothyroidism: absent or nonfunctioning thyroid; universal newborn screening (blood spot within 2 days; T3, T4, TSH levels); early diagnosis crucial — severe progressive physical and cognitive dysfunction if untreated
Findings (may not appear until 3–6 mo): excessive sleeping, enlarged tongue, respiratory difficulty, poor sucking, cool/dry skin, jaundice, subnormal temperature and pulse, short thick neck, hypotonia, abdominal distention, constipation
Treatment: synthetic thyroid hormone (sodium levothyroxine) — must be taken indefinitely; supplement vitamin D for rapid bone growth; monitor T3, T4, TSH levels regularly
Treatment: lifelong glucocorticoid (hydrocortisone); mineralocorticoid (fludrocortisone) if salt-wasting; stress-dose steroids for illness/surgery; medical alert ID
Failure to thrive (FTT) / faltering growth
Weight (or BMI) consistently below the 3rd–5th percentile, or crossing two major percentile lines downward
Substance-exposed infants and neonatal abstinence syndrome (NAS)
Maternal substance use during pregnancy (opioids, alcohol, benzodiazepines, cocaine, methamphetamine, marijuana, tobacco, SSRIs) can cause anomalies, neurobehavioral changes, and neonatal withdrawal
Neonatal abstinence syndrome (NAS): withdrawal in newborns whose mothers used addictive substances; onset depends on drug half-life (heroin ~24 hr; methadone 24–72 hr; buprenorphine 36–60 hr)
NAS findings (assessed with Finnegan Neonatal Abstinence Scoring System q3–4 hr):
Organ anomalies (heart defects including VSD, limb defects)
Behavioral: lack of stranger anxiety, poor judgment
Nursing care:
Reduce stimulation — quiet room, dim lights, swaddling
Cluster care to allow rest periods
Frequent small feedings of high-calorie formula; gavage if needed
Elevate head during/after feedings; have suction available
Score symptoms using Finnegan or Eat-Sleep-Console (ESC) approach
Protect skin from excoriation
Consult lactation — breastfeeding OK with methadone; contraindicated with cocaine, HIV, active substance use
Consult child protective services
Medications for NAS: morphine (first-line for opioid withdrawal), phenobarbital (for seizures or sedative withdrawal), clonidine (adjunct); gradual weaning protocol over 1–4 weeks
Labs: drug screen of urine or meconium, CBC, blood glucose, calcium, electrolytes; chest X-ray for FAS (rule out heart defects)
Plagiocephaly
Acquired cranial asymmetry from positional molding — flattening of the occiput from supine positioning
Prevention: daily supervised "tummy time" when awake; alternate head position during sleep; limit time in car seats, bouncers, swings
Treatment: skull-molding helmet worn 23 hr/day for ~3 months if needed; physical therapy for associated torticollis
Continue supine sleep position (SIDS prevention takes priority)
No evidence of permanent cognitive or neurologic damage from positional plagiocephaly
QUICK CHECK: A parent of a 2-month-old asks why the AAP recommends placing infants on their backs to sleep. What is the most accurate response? Answer: Back sleeping is the single most important factor that reduces the risk of sudden infant death syndrome (SIDS). Always place the infant on the back for every sleep, on a firm mattress, in a clear crib (no pillows, blankets, bumpers, or stuffed toys), room-share without bed-sharing for at least 6 months, and avoid overheating and tobacco smoke exposure.
Meningocele / Myelomeningocele (Spina bifida)
Neural tube defects that occur when the neural tube fails to close during the third to fourth week of embryonic development. Both are classified as forms of spina bifida.
Meningocele: protrusion of a sac-like cyst containing meninges and spinal fluid
Myelomeningocele: protrusion of a sac-like cyst containing meninges, spinal fluid, and a portion of the spinal cord and nerves (more severe)
Risk factors
Use of medications or illicit drugs during pregnancy
Malnutrition during pregnancy
Insufficient intake of folic acid during pregnancy (most modifiable risk)
Exposure to radiation or chemicals during pregnancy
Prepare family for the newborn's surgery (typically within 24–72 hr after birth)
Protect the sac from injury
Place the infant in a radiant warmer, without clothing
Position prone or side-lying; do not place supine (would crush sac)
Apply a sterile, moist, non-adhering dressing with 0.9% sodium chloride on the cyst, re-wetting as needed to prevent drying
Inspect the cyst closely for leakage of fluid or signs of irritation
Assess for signs of infection (fever, irritability, lethargy)
Administer IV antibiotics as prescribed
Avoid measuring temperatures rectally
Avoid putting pressure on the sac (no swaddling that would compress it)
Postoperative nursing care
Monitor vital signs, I&O, weight
Assess for signs of infection
Position prone or side-lying until incision heals
Measure head circumference daily — watch for hydrocephalus (a common complication; VP shunt placement may be required)
Assess neurological function and lower extremity movement
Monitor bladder and bowel function (often impaired below the level of the defect)
Long-term considerations
Latex allergy precautions — high prevalence in spina bifida patients due to repeated catheterizations and surgeries
Bladder and bowel management (intermittent catheterization, bowel program)
Orthopedic management (braces, mobility aids)
Educational supports
Congenital hypothyroidism
Absent or underdeveloped thyroid gland, or hypofunction; can be caused by maternal iodine deficiency or maternal antithyroid medications during pregnancy
Findings might not appear until 3 months of age in a formula-fed infant and 6 months in a breastfed infant
Early diagnosis is crucial — severe progressive physical and cognitive dysfunction occurs if untreated
Risk factors
Female gender
Low birth weight or birth weight > 4.5 kg (4,500 g)
Maternal low iodine levels during pregnancy
Physical assessment findings
Sleeping excessively
Enlarged tongue
Respiratory difficulty
Poor sucking
Cool, dry skin on extremities
Jaundice
Subnormal temperature, respiratory rate, and pulse
Short, thick neck
Hypotonia with decreased deep tendon reflexes
Abdominal distention and constipation
Labs and diagnostics
Newborn metabolic screen — blood spot within 2 days of birth
Crush tablet and mix in small amount of breast milk, formula, or water; give once daily in the morning
Avoid mixing with soy formula, iron, or calcium (decrease absorption)
Monitor TSH and T4 levels periodically; dose adjusted with growth
Substance-exposed infants and Neonatal Abstinence Syndrome (NAS)
Intrauterine drug exposure can cause anomalies, neurobehavioral changes, and evidence of withdrawal in the neonate. Effects depend on the specific drug(s), dosage, route, timing and length of exposure, and maternal/fetal metabolism.
Neonatal abstinence scoring system — findings to assess
CNS findings
Increased wakefulness
High-pitched, shrill cry
Incessant crying, irritability
Tremors
Hyperactive with increased Moro reflex
Increased deep tendon reflexes
Increased muscle tone
Abrasions/excoriations on face and knees
Convulsions
Metabolic, vasomotor, respiratory findings
Nasal congestion with flaring
Frequent yawning
Skin mottling
Tachypnea > 60/min
Sweating
Temperature > 37.2 °C (99 °F) or > 38.3 °C (101 °F)
Increased incidence of seizures, sleep disturbances, higher birth weights, higher risk of SIDS
Cocaine
May appear normal or have neurologic problems; high-pitched cry, abnormal sleep, excessive sucking, hypertonicity, tremors, irritability, inability to console, poor tolerance to routine changes
Methamphetamine
Small head circumference, SGA, agitation, vomiting, rapid respirations, bradycardia or tachycardia, jitteriness, sleep disturbances, emotional disturbances, delayed growth
Marijuana
Decreased newborn birth weight and length, fetal growth restriction
From the textbook — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.
Scenario
A nurse is planning care for a newborn who has a myelomeningocele. What actions should the nurse include in the plan of care?
NURSING CARE: Include nursing actions before and after surgery for a newborn who has a myelomeningocele.
Answer key
Nursing Care
Preoperative
Protect the sac.
Place the infant in a radiant warmer, without clothing.
Apply sterile, moist non-adhering dressing saturated with 0.9% sodium chloride. Re-wet as needed.
Assess cysts for findings of fluid leak or infection.
Administer prescribed antibiotics.
Avoid measuring temperature rectally.
Prepare the parents for the newborn’s surgery. Postoperative
Monitor vital signs.
Monitor I&O.
Assess the surgical site for redness, edema, and drainage.
Provide pain management.
Assess for leakage of CSF.
Maintain prone position until other positions are prescribed.
Application Exercises
Q1
A nurse is caring for a 36-hour-old newborn receiving phototherapy for hyperbilirubinemia. Which interventions are appropriate? (Select all that apply.)
A. Cover the eyes with opaque eye shields
B. Maximize skin exposure (diaper only)
C. Discontinue breastfeeding
D. Monitor temperature for hypo- and hyperthermia
E. Reposition the infant every 2 hours
Show rationale ▾
A.CORRECT. Eye shields protect from light damage to the retinas.
B.CORRECT. Maximum skin exposure increases phototherapy effectiveness.
C. Continue breastfeeding to promote bilirubin elimination via stool.
D.CORRECT. Phototherapy can cause temperature instability.
E.CORRECT. Repositioning exposes more skin and prevents pressure injuries.
NCLEX® Connection: Reduction of Risk Potential — Therapeutic Procedures
Q2
A nurse is caring for a premature infant in the NICU. Which findings would the nurse report as suspicious for necrotizing enterocolitis? (Select all that apply.)
A. Abdominal distention
B. Blood-tinged stools
C. Vigorous feeding behavior
D. Increased gastric residuals
E. Temperature instability
Show rationale ▾
A.CORRECT. Abdominal distention is a key feature of NEC.
B.CORRECT. Bloody stools suggest mucosal injury and NEC.
C. Feeding intolerance, not vigorous feeding, occurs with NEC.
D.CORRECT. Increased residuals indicate ileus and feeding intolerance.
E.CORRECT. Temperature instability often accompanies neonatal sepsis or NEC.
NCLEX® Connection: Reduction of Risk Potential — System Specific Assessments
Q3
A nurse is teaching parents of a newborn diagnosed with PKU. Which statement indicates correct understanding?
A. "My baby will outgrow this condition by age 2."
B. "I'll use a special phenylalanine-restricted formula and continue dietary restrictions lifelong."
C. "Aspartame-sweetened drinks are a good choice for my child."
D. "PKU is treated with daily insulin injections."
Show rationale ▾
A. PKU requires lifelong dietary management.
B.CORRECT. Special phenylalanine-restricted formula (e.g., Lofenalac) and lifelong low-phenylalanine diet prevent neurologic damage.
C. Aspartame contains phenylalanine and must be avoided.
D. PKU is not treated with insulin.
NCLEX® Connection: Health Promotion and Maintenance — Self-Care
Q4
A nurse is teaching parents safe sleep practices for their newborn. Which actions should the nurse recommend? (Select all that apply.)
A. Place the infant on the back for every sleep
B. Use a firm mattress with a fitted sheet only
C. Place stuffed animals in the crib for comfort
D. Share a room without sharing a bed for at least 6 months
E. Maintain a smoke-free environment
Show rationale ▾
A.CORRECT. Back sleeping is the single most important SIDS-prevention measure.
B.CORRECT. Firm mattress with fitted sheet only; nothing else in the crib.
C. Stuffed animals, pillows, blankets, and bumpers are SIDS hazards.
D.CORRECT. Room-sharing without bed-sharing for 6 months reduces SIDS risk.
NCLEX® Connection: Health Promotion and Maintenance — Health Promotion/Disease Prevention
Q5
A premature infant born at 30 weeks is exhibiting tachypnea, retractions, grunting, and nasal flaring within the first hour of life. The chest X-ray shows a "ground glass" pattern. Which treatment should the nurse anticipate?
A. Diuretics and fluid restriction
B. Surfactant administration via endotracheal tube and CPAP support
C. Broad-spectrum oral antibiotics
D. Discharge home with parental monitoring
Show rationale ▾
A. Not first-line for RDS.
B.CORRECT. Findings are consistent with respiratory distress syndrome from surfactant deficiency. Exogenous surfactant via ET tube with CPAP or mechanical ventilation is standard treatment.
C. Antibiotics may be used if infection is suspected but are not the primary treatment.
D. Discharge is inappropriate; this is a critical situation requiring NICU care.
NCLEX® Connection: Physiological Adaptation — Medical Emergencies
Pediatric emergencies covered in this chapter include drowning, foreign body aspiration and choking, brief resolved unexplained events (BRUE) / apparent life-threatening events (ALTE), poisoning and ingestion, heat- and cold-related emergencies, and severe shock. Across all of these, nursing priorities follow the same hierarchy: airway, breathing, circulation, then targeted intervention based on the specific emergency.
TL;DR · One-glance summary
Drowning: any standing water ≥ 1 inch deep can be fatal; never leave a child unattended near water. Choking infant: 5 back blows + 5 chest thrusts (no abdominal thrusts in < 1 yr). Choking child ≥ 1 yr: abdominal thrusts (Heimlich). Poisoning: call Poison Control 1-800-222-1222; do NOT induce vomiting; never use syrup of ipecac. Acetaminophen overdose antidote: N-acetylcysteine. Iron overdose: deferoxamine. Lead poisoning: chelation (DMSA, EDTA, BAL).
Choking management by age
Infant < 1 yr:
5 back blows (between scapulae) with infant face-down
Do not induce vomiting — repeat exposure during emesis
Do not give activated charcoal
Maintain airway; small sips of water or milk only if alert and tolerating; do not force
Endoscopy to assess injury
Hydrocarbons (gasoline, kerosene, lighter fluid):
Do not induce vomiting (aspiration causes pneumonitis)
Supportive care; monitor for respiratory complications
Plant ingestions: Poison Control guidance; many household plants are toxic; most are mild but some severe (oleander, foxglove, water hemlock)
Poisoning prevention
Lock all medications, cleaning products, alcohol, pesticides out of reach
Use childproof caps; never call medicine "candy"
Original containers only (no transferring to food containers)
Carbon monoxide detectors
Insect repellent safety: DEET-containing products effective against mosquitoes and ticks; apply to clothing and exposed skin (not under clothing); do NOT apply to hands, eyes, mouth of young children; wash off when indoors; concentration determines duration, not effectiveness (10–30% for children); avoid combination sunscreen-repellent products
Routine lead screening in at-risk populations
Temperature-related emergencies
Heat-related illness
Heat cramps: muscle spasms after exertion; rest, oral rehydration with electrolytes
Do not give antipyretics (do not work for environmental hyperthermia)
Prevention: hydration; limit strenuous activity in heat; never leave child in parked car
Cold-related illness
Hypothermia: core temperature < 35°C (95°F)
Mild: shivering, confusion
Severe: bradycardia, hypotension, arrhythmias, decreased LOC, coma
Remove wet clothing; passive rewarming (blankets) for mild; active rewarming (warm IV fluids, warm humidified O₂, warm gastric/peritoneal lavage) for severe
Handle gently — risk of ventricular fibrillation
Frostbite: tissue freezing
White or grayish patches, hard or waxy skin
Rewarm in warm water (37–39°C / 99–102°F); never rub (causes tissue damage)
Pain management; treat for shock
QUICK CHECK: A toddler is found drinking from a bottle of liquid drain cleaner. The parents ask the nurse if they should make their child vomit. What is the appropriate response? Answer: Do NOT induce vomiting. Caustic substances cause additional injury during emesis as they re-contact the esophagus. Do not give activated charcoal. Have the child rinse their mouth with water if alert. Bring the child and the original container to the ED immediately. Call Poison Control at 1-800-222-1222 for further guidance en route.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: System Disorder. Practice answering before reviewing the key.
Scenario
A nurse is teaching a group of caregivers about prevention of sudden infant death syndrome (SIDS). What should the nurse include in the teaching?
NURSING CARE: Identify at least seven methods to reduce the risk of SIDS.
Answer key
Nursing Care
methods to reduce the risk of sids
Place the infant on the back for sleep.
avoid exposure to tobacco smoke.
Prevent overheating.
Use a firm, tight‑fitting mattress in the infant’s crib.
remove pillows, quilts, and sheepskins from the crib during sleep.
ensure that the infant’s head is kept uncovered during sleep.
Offer pacifier at naps and night.
encourage breastfeeding.
avoid co‑sleeping.
Maintain immunizations up to date.
Application Exercises
Q1
A 6-month-old infant is choking on a small piece of food and is unable to cry or breathe. Which technique is appropriate?
A. Perform abdominal thrusts (Heimlich maneuver)
B. Five back blows followed by five chest thrusts
C. Blind finger sweep of the mouth
D. Begin chest compressions immediately
Show rationale ▾
A. Abdominal thrusts are not used in infants < 1 yr due to risk of organ injury.
B.CORRECT. For a conscious choking infant: 5 back blows (face-down between scapulae), then 5 chest thrusts (mid-sternum). Repeat until dislodged or unresponsive.
C. Blind finger sweeps may push the object deeper.
D. Chest compressions begin if infant becomes unresponsive.
NCLEX® Connection: Physiological Adaptation — Medical Emergencies
Q2
A 3-year-old ingested an unknown amount of acetaminophen 2 hours ago. The parent calls the nurse line. Which is the most appropriate initial response?
A. Induce vomiting with syrup of ipecac at home
B. Give activated charcoal at home
C. Call Poison Control (1-800-222-1222) and bring the child to the ED with the medication container
D. Observe at home for 24 hours
Show rationale ▾
A. Syrup of ipecac is no longer recommended; induced vomiting can cause harm.
B. Charcoal administration is a hospital decision; home administration is not recommended.
C.CORRECT. Call Poison Control for guidance, bring child and the original container to the ED. Acetaminophen overdose may require N-acetylcysteine — most effective within 8–10 hr.
D. Waiting can be life-threatening; serious liver damage develops later if untreated.
NCLEX® Connection: Physiological Adaptation — Medical Emergencies
Q3
A 2-year-old is recovering from a drowning incident in a backyard pool. The parents ask why their child must be admitted even though they appear fine. Which response is most appropriate?
A. "It's a precaution because of insurance requirements."
B. "Children who have drowned can develop respiratory and neurologic complications hours later, so they need monitoring."
C. "Your child will need surgery."
D. "The child is contagious."
Show rationale ▾
A. Inaccurate.
B.CORRECT. Drowning victims can develop delayed pulmonary edema, ARDS, and neurologic complications hours later — hospital observation is needed.
C. Surgery is not routinely required.
D. Drowning is not contagious.
NCLEX® Connection: Reduction of Risk Potential — Potential for Complications
Q4
A 4-year-old is brought to the ED after ingesting an unknown amount of an iron supplement. Which medication is the appropriate antidote?
A. N-acetylcysteine
B. Deferoxamine
C. Naloxone
D. Flumazenil
Show rationale ▾
A. N-acetylcysteine is for acetaminophen overdose.
B.CORRECT. Deferoxamine is the chelating agent used for iron toxicity. Activated charcoal does NOT bind iron and is not used.
C. Naloxone is the opioid antidote.
D. Flumazenil is the benzodiazepine antidote.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Medication Administration
Q5
A child is brought to the ED with heat stroke — temperature 40.5°C, altered mental status, hot dry skin. Which intervention is the priority?
A. Administer acetaminophen
B. Active cooling with cool packs, evaporative cooling, and IV fluids
C. Wrap in warm blankets
D. Wait for the child to recover spontaneously
Show rationale ▾
A. Antipyretics do not work for environmental hyperthermia.
B.CORRECT. Heat stroke requires rapid active cooling — remove clothing, apply cool packs to neck/axillae/groin, mist with water and use a fan, IV fluids, monitor for organ damage and seizures.
C. Warming worsens hyperthermia.
D. Heat stroke is a medical emergency requiring immediate intervention.
NCLEX® Connection: Physiological Adaptation — Medical Emergencies
The final chapter covers child maltreatment (physical abuse, sexual abuse, emotional abuse, neglect, and Munchausen by proxy/factitious disorder imposed on another), substance use disorders in adolescents, eating disorders, suicide risk, ADHD, depression, and bullying. Mandatory reporting, trauma-informed care, and connecting families to community resources are central nursing roles.
TL;DR · One-glance summary
All healthcare workers are mandated reporters of suspected child abuse — no need for proof; reasonable suspicion is enough. Suspicious injury patterns: spiral fractures in non-ambulatory infants, posterior rib fractures, immersion burns (stocking/glove distribution), injuries in different stages of healing, inconsistent histories. Munchausen by proxy: caregiver fabricates or induces illness in the child to gain attention. Anorexia nervosa: restriction → severe weight loss + body image distortion; refeeding syndrome risk (hypophosphatemia, hypokalemia, hypomagnesemia). Adolescent suicide risk: ask directly; remove means.
Reporting child abuse
All healthcare workers are mandated reporters
Report to child protective services and local law enforcement as required
Reasonable suspicion is sufficient — proof is not required to report
Reporters are protected from civil liability if report is made in good faith
Document objectively: child's words in direct quotes, observations, injuries
Do not interrogate the child or family — leave detailed investigation to authorities
Preserve evidence (clothing in paper bags, not plastic)
Critical "red flag" injuries
Spiral fractures in non-ambulatory infants
Posterior rib fractures (very specific for abuse)
Metaphyseal corner ("bucket handle") fractures
Immersion burns with sharp demarcation, stocking/glove pattern, sparing of palms/buttocks (held up)
Neglect: failure to provide basic needs — physical (food, shelter, hygiene, medical care), emotional, educational, supervisory
Munchausen syndrome by proxy / factitious disorder imposed on another: caregiver (often parent) fabricates or induces illness in the child to gain medical attention or sympathy
Red flags: symptoms only in caregiver's presence, recurrent unexplained illnesses, contradictory clinical findings, caregiver overly involved with medical staff, history of multiple providers/hospitals, siblings with similar history
Confidential, multidisciplinary investigation is essential
Physical abuse — assessment
Injury pattern inconsistent with developmental capability or reported mechanism
Mismatched stories between caregivers
Delay in seeking care
Old and new injuries
Patterned bruises or burns (loop, ligature, immersion, contact with hot object)
Subdural hemorrhage in infant (consider abusive head trauma; previously "shaken baby syndrome")
Retinal hemorrhages in infant + altered mental status — highly concerning
Vomiting, lethargy, seizures, apnea
No external evidence of trauma may be present
Sexual abuse — assessment
Physical: STI in a child, genital trauma, bruising, anal/genital changes
Behavioral: sexualized behavior beyond developmental norms, regression, sleep disturbances, nightmares, anxiety, depression, school problems, fear of specific people or places
Use anatomically correct dolls and trained interviewers
Forensic examination by trained provider (SANE/CSAANE programs)
Preserve evidence; coordinate with law enforcement
Behavioral interventions: structured meal plans, supervised meals, no bathroom for ~ 1 hr after eating, no exercise during refeeding
Cognitive behavioral therapy; family-based therapy (Maudsley method) effective in adolescents
SSRIs may be used for bulimia and co-occurring depression/anxiety
Mental health and behavior
Suicide risk and self-harm
Leading cause of death in adolescents
Risk factors: previous attempt, mood/anxiety disorders, substance use, family history, exposure to suicide, recent loss, bullying, LGBTQ+ identity in unsupportive environment, access to lethal means
Protective factors: connectedness, supportive relationships, access to mental health care, restricted access to lethal means, coping skills
Asking directly does not increase suicide risk — it can be life-saving
Use validated screening (Columbia Suicide Severity Rating Scale, PHQ-9 for adolescents)
If positive screen or active ideation:
Ensure safety; do not leave alone
Remove lethal means (firearms, medications)
Mental health evaluation
Inpatient psychiatric admission if imminent risk
Develop safety plan with the patient and family
Self-harm (cutting, burning): often non-suicidal; addresses emotional regulation; still requires mental health intervention
SSRIs (fluoxetine, escitalopram) when needed; trazodone may be used as adjunct for insomnia in adolescents with depression (serotonin modulator); NOT first-line
Black box warning for increased suicidal ideation in children/adolescents
Monitor closely, especially during first 4 weeks
Therapeutic effect develops over weeks
Family involvement and education
Bullying
Verbal, physical, social, or cyberbullying
Effects: anxiety, depression, school problems, suicidal ideation
Both victims and perpetrators benefit from intervention
Screen for bullying involvement at well-visits
Encourage open communication; involve school
QUICK CHECK: A nurse is preparing to start refeeding an adolescent admitted with severe anorexia nervosa. Which laboratory values are most important to monitor? Answer: Phosphorus, potassium, and magnesium. Refeeding syndrome occurs when carbohydrate intake triggers insulin release, which shifts these electrolytes intracellularly. Hypophosphatemia is the hallmark and can cause cardiac arrhythmias, respiratory failure, and seizures. Refeeding must be initiated slowly with frequent electrolyte monitoring and supplementation.
Active Learning Scenario
From the textbook — uses the ATI Active Learning Template: Basic Concept. Practice answering before reviewing the key.
Scenario
A nurse is teaching a group of caregivers about shaken baby syndrome. What Manifestations should be included in this presentation?
UNDERLYING PRINCIPLES: Include seven Manifestations. RN NURSING CARE OF CHILDREN
Answer key
Underlying Principles
Vomiting, poor feeding, and listlessness
Respiratory distress
Bulging fontanels
Retinal hemorrhages
Seizures
Posturing
Alterations in level of consciousness
Apnea
Bradycardia
Application Exercises
Q1
A nurse is admitting a 2-month-old infant with a femur fracture. The parent states the infant rolled off the changing table. Which actions are appropriate? (Select all that apply.)
A. Conduct a thorough physical exam for additional injuries
B. Document the parent's story word-for-word using quotation marks
C. Confront the parent about possible abuse
D. Notify the provider and child protective services per protocol
E. Provide nonjudgmental support to the family
Show rationale ▾
A.CORRECT. Look for additional injuries; the mechanism is inconsistent with this fracture in a non-ambulatory infant.
B.CORRECT. Direct quotes provide objective documentation.
C. Confrontation is not the nurse's role; objective documentation and reporting are.
D.CORRECT. A 2-month-old cannot roll independently; mandated reporting required.
E.CORRECT. Maintain therapeutic relationship while protecting the child.
NCLEX® Connection: Safety and Infection Control — Accident/Injury Prevention
Q2
A nurse is caring for an 8-year-old being admitted with recurrent unexplained symptoms that occur only when the mother is present. The mother is extensively involved with all caregivers and has reported similar illnesses in two other siblings. Which condition should the nurse suspect?
A. Autism spectrum disorder
B. Munchausen syndrome by proxy (factitious disorder imposed on another)
C. Cerebral palsy
D. ADHD
Show rationale ▾
A. Not consistent with the described pattern.
B.CORRECT. Symptoms only in caregiver's presence + extensive caregiver involvement with medical staff + history in siblings strongly suggest Munchausen syndrome by proxy. Confidential multidisciplinary investigation is essential.
A 16-year-old being treated for severe anorexia nervosa is admitted for refeeding. The nurse should monitor most closely for which complication?
A. Hyperglycemia and weight gain
B. Hypophosphatemia, hypokalemia, hypomagnesemia (refeeding syndrome)
C. Constipation
D. Wound healing problems
Show rationale ▾
A. Hyperglycemia is not the primary refeeding concern.
B.CORRECT. Refeeding syndrome is the most dangerous early complication. Severe electrolyte shifts can cause cardiac arrhythmias, respiratory failure, and seizures.
C. Constipation is common but not the priority monitoring concern.
D. Wound healing is a concern but not the most acute risk.
NCLEX® Connection: Reduction of Risk Potential — Laboratory Values
Q4
A nurse is teaching parents about methylphenidate prescribed for their 8-year-old's ADHD. Which side effects should the nurse include? (Select all that apply.)
A. Decreased appetite
B. Insomnia
C. Excessive weight gain
D. Headache
E. Slowing of growth velocity
Show rationale ▾
A.CORRECT. Decreased appetite is a common side effect.
B.CORRECT. Insomnia is common; give doses earlier in the day.
C. Weight gain is unusual; weight loss can occur.
D.CORRECT. Headaches can occur.
E.CORRECT. Growth velocity can slow with stimulants; monitor growth.
NCLEX® Connection: Pharmacological and Parenteral Therapies — Adverse Effects/Contraindications
Q5
A nurse is interviewing a 15-year-old at a routine well-visit. The teen mentions feeling hopeless and "wishing things would just end." Which is the most appropriate next action?
A. Avoid asking about suicide to prevent giving the teen ideas
B. Directly ask whether the teen has thoughts of suicide or a plan, and arrange immediate mental health evaluation if indicated
C. Reassure that things will get better
D. Tell the parents privately without involving the teen
Show rationale ▾
A. Asking does not increase risk and can save lives.
B.CORRECT. Direct, compassionate questioning about suicidal ideation, plan, intent, and access to means is appropriate and recommended. Ensure safety (do not leave alone), remove lethal means, and arrange immediate mental health evaluation.
C. Dismissing the teen's feelings is harmful and inappropriate.
D. Breaking trust without engaging the teen is counterproductive — though family will be involved, the teen should be part of the conversation.