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Ati paediatrics nursing assessment
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Showing 10 questions, Sign in for more6 months ago:
An 18-month-old toddler presents to the pediatrician's office for a routine check-up. The parents report no issues at home. The nurse discusses the toddler's milestones.
Fine motor: scribbles with a crayon, uses fingers to feed themself
Gross motor: walks independently
Language: can say 3 words
Play: participates in parallel play with their siblings
The toddler returns to the office for a routine 2-year-old check up. The parents report no issues at home, but state that the teachers at the child's daycare center are concerned that the child is behind.
Fine motor: rotates utensils to bring them to their mouth
Gross motor: walks independently, scoots on bottom up and down stairs
Language: uses one word sentences, can say 5 words
Play: participates in parallel play with their siblings, does not notice when others are upset
Height 86.4 cm (34)
Weight 11.3 kg (24.9 lb)
Today:
Heart rate 110/min
Respiratory rate 24/min
Temperature 37 C (98.6° F)
A nurse is caring for a toddler in the pediatrician's office.
Nurses Notes
Today
The toddler returns to the office for a routine 2-year-old check-up. The parents report no issues at home, but state that the teachers at the child's daycare center are concerned that the child is behind.
Fine motor: rotates utensils to bring them to their mouth
Gross motor: walks independently, scoots on bottom up and down stairs
Language: uses one-word sentences, can say 5 words
Play: participates in parallel play with their siblings, does not notice when others are upset
Height 86.4 cm (34)
Weight 11.3 kg (24.9 lb)
Explanation
Findings that indicate a developmental delay:
Language: uses one word sentences, can say 5 words- At age 2, toddlers are expected to use at least two-word phrases and have a vocabulary of about 50 words. This finding suggests a delay in expressive language development.
Play: does not notice when others are upset- At this age, toddlers begin to show empathy or awareness of others' emotions. Not noticing when others are upset could indicate a delay in social-emotional development.
Rationale for incorrect findings:
Fine motor: rotates utensils to bring them to their mouth- This is an age-appropriate fine motor skill.
Gross motor: scoots on bottom up and down stairs- Although some toddlers may walk up stairs by 2 years, scooting is still within developmental range.
3 days ago, 1100:
Child presents to the ED with their parent. The parent states, "Something doesn't seem right. My child has lost weight, and they recently started to drink a lot of water and urinating more frequently, especially at night." Child reports fatigue and blurred vision over the last few days. On assessment, child's skin is flushed and dry. Mucous membranes are dry and there is a sweet odor to breath. Findings reported to provider.
3 days ago, 1115:
Blood glucose results obtained. Results reported to provider.
3 days ago, 1130:
Provider admitted child for management of new diagnosis of type 1 diabetes mellitus.
3 days ago, 1100:
Blood pressure 96/58 mm Hg
Heart rate 115/min
Respiratory rate 26/min
Temperature 37° C (98.6° F)
Oxygen saturation 99% on room air
Today:
Blood pressure 104/60 mm Hg
Heart rate 96/min
Respiratory rate 22/min
Temperature 37° C (98.6° F)
Oxygen saturation 100% on room air
3 days ago, 1115:
Blood glucose 395 mg/dL (Child >2 years to adult, Casual: <200
mg/dL)
Today:
Blood glucose 82 mg/dL (Fasting: 70 to 110 mg/dL)
1115
Obtain blood glucose
A nurse is caring for a 7-year-old in the emergency department (ED).
Which of the following findings should the nurse include in today's teaching?
Select All That Apply.
0700:
A 6-year-old presents to the pre-operative area for planned outpatient tonsillectomy due to recurrent tonsillitis.
1000:
The child is transferred from the operating room to the PACU.
1030:
The child reports mild throat pain and some difficulty swallowing secretions. Child had one small emesis with dark brown blood. Ice collar provided for discomfort.
1130:
Child reports increased pain, states pain is at an 8 on a scale of 0 to 10. Child is observed frequently clearing their throat and swallowing frequently. Child is restless.
1000:
Blood pressure 108/69 mm Hg
Heart rate 115/min
Respiratory rate 20/min
Temperature 37° C (98.6°F)
1100:
Blood pressure 105/64 mm Hg
Heart rate 124/min
Respiratory rate 22/min
Temperature 37 C (98.6° F)
A nurse is caring for a child in the post-anesthesia care unit (PACU)
Explanation
The nurse should first: Notify the surgeon due to the child's: Throat clearing
Rationale for correct answer:
Frequent swallowing and throat clearing after tonsillectomy are early signs of bleeding, a serious postoperative complication. This requires immediate attention.
Rationale for incorrect answers:
Provide a diversional activity: Not priority in this urgent context.
Administer PRN pain medication: Important, but not first given the concern for bleeding.
Offer the child a popsicle: Contraindicated if bleeding is suspected.
Provide discharge education: Not appropriate until the child is stable.
Today, 1500:
An 8-year-old who has sickle cell anemia presents to the ED with severe leg and abdominal pain. The child participated in outdoor physical activities at school earlier today and the parents state the child, "may not have had enough fluids to drink." Child reports pain as a 7 on a scale of 0 to 10. The parents state that the child has about one blood transfusion per year. The child appears to be uncomfortable with facial grimacing. Mucous membranes are pale. Breath sounds clear bilaterally. S1, S2 present with no murmur. Parents state the child is not taking any home medication.
Today, 1500:
Blood pressure 100/59 mm Hg
Heart rate 115/min
Temperature 37.9 °C (100.2 °F)
Oxygen saturation 98% on room air
Weight 25 kg (55 lb)
Today, 1530:
Hemoglobin 7.6 g/dL (10 to 15.5 g/dL)
Hematocrit 22% (32% to 44%)
Ferritin 400 ng/mL (7 to 142 ng/mL)
Medication Administration Record
Today, 1530:
Acetaminophen 325mg PO Given
Child states there has been no improvement in pain. Reports pain is still a 7 on a of 0 to 10.
The nurse is caring for a child in the emergency department (ED).
Explanation
Cold compresses to painful areas: Expected
Nonpharmacologic method to help reduce pain and inflammation during vaso-occlusive crisis.
Bed rest: Expected
Conserves oxygen and prevents further sickling.
Blood type and cross match: Expected
Anticipated if anemia is severe or if transfusion is needed (Hemoglobin 7.6 g/dL).
NPO status: Unexpected
No GI procedures planned; child should stay hydrated to prevent sickling.
Morphine IV: Expected
Opioids are often necessary for severe sickle cell pain management.
Today, 0900:
A 3-month-old presents to the emergency department with parents due to concerns about the infant's bowel movements. The parents report that the infant has few bowel movements and the ones they do have are explosive watery diarrhea. They report that the infant's belly also seems swollen. The parents report that it took 5 days for the infant to pass the meconium stool at birth. Birth weight was 3400 g (7 lb, 8 oz). The abdomen is distended and the infant has a tight internal sphincter with rectum empty of feces.
Today, 1000:
Infant admitted for evaluation and treatment of gastrointestinal issues and failure to thrive.
Today, 0930:
Heart rate 120/min
Respiratory rate 32/min
Temperature 38.4° C (101.1°F)
Weight 4.1 kg (9 lb)
Today 0930
Contrast enema: transition zone between the dilated proximal colon and the distal segment.
A nurse is caring for an infant on an inpatient pediatric unit.
Select words from the choices below to fill in each blank in the following sentence.
When planning care for the infant, the nurse should
Explanation
When planning care for the infant, the nurse should prepare the infant for a rectal biopsy and frequently measure abdominal circumference.
Rationale for correct answers:
Prepare the infant for a rectal biopsy: Confirms diagnosis of Hirschsprung disease, which is suspected based on symptoms and enema findings.
Frequently measure abdominal circumference: Monitors abdominal distension, a key sign in bowel obstruction or worsening condition.
Rationale for incorrect answers:
Explain the purpose of the pyloromyotomy: This procedure is for pyloric stenosis, not Hirschsprung disease.
Transport the client for a radiologist guided gas enema: Contrast enema already performed.
Administer oral laxatives: Contraindicated in suspected bowel obstruction like Hirschsprung disease.
1 week ago:
A 7-year-old child presents to the office with fever and sore throat. Prescription given and child's parent educated on medication.
Physical Exam:
Head, Ears, Eyes, Nose, and Throat (HEENT); inflamed tonsils with exudate, tender anterior cervical lymphadenopathy Respiratory: bilateral breath sounds clear
Cardiovascular: S1, S2, no murmur
Skin: erythematous sandpaper-like rash
Today:
The child returns with their parent. The parent reports that their face was a little puffy last night and worse this morning. The child states they have a headache and pain when urinating
Physical Exam:
General: lethargy
HEENT: oropharynx clear, no exudates or redness, periorbital edema
Respiratory: breath sounds clear bilaterally
Cardiovascular: S1, S2, no murmur, 1+BLE edema
Skin: warm, dry
1 week ago:
Blood pressure 101/77 mmHg
Heart rate 99/min
Respiratory rate 20/min
Temperature 39.4° C (103° F)
Weight 25 kg (55 lb)
Today:
Blood pressure 141/88 mmHg
Heart rate 97/min
Respiratory rate 20/min
Temperature 37° C (98.6" F).
Weight 25.9 kg (57 lb)
1 week ago:
Rapid Strep test: positive (negative)
Today:
Urinalysis:
Appearance: cloudy (clear)
Color tea-colored (amber yellow)
pH 6 (4.6-8)
Protein 2+ (none)
Specific gravity 1.015 (1.01 to 1.025)
Leukocyte esterase negative (negative)
Nitrites negative (negative)
Blood 1+ (none)
Ketones none (none)
1 week ago:
Amoxicillin 400mg/5mL take 3.9mL PO BID x 10 days
A nurse is caring for a child in a pediatrician's office.
The nurse should recognize that the findings in the EMR are consistent with
Explanation
Correct answers: The nurse should recognize that the findings in the EMR are consistent with acute glomerulonephritis as evidenced by urinalysis.
Rationale for correct answers:
Acute Glomerulonephritis (AGN): AGN is a known complication that can occur 1–2 weeks after a streptococcal infection (positive strep test a week ago). The child now has periorbital edema, hypertension (BP 141/88), lethargy, and tea-colored urine- all classic signs.
The urinalysis shows proteinuria, hematuria, and cloudy tea-colored urine, which are hallmark findings in AGN.
Rationale for incorrect answers:
Urinary tract infection: Typically causes dysuria, urgency, frequency, and often a positive leukocyte esterase or nitrites.
Mononucleosis: Would show lymphadenopathy, sore throat, and fatigue but is not consistent with current urinary findings or hypertension.
A delayed allergic reaction: Would be more likely to present with urticaria, pruritus, or respiratory compromise.
Congestive heart failure: Rare in children with no cardiac history and wouldn't explain the urinalysis findings.
0930:
The child and their parent present to the ED. The child's parent is holding a towel under their nose with notable blood stains. Parent states that their child fell and bumped their nose, and now they can't get the nosebleed to stop. Provider assessing child.
0945:
Blood drawn and sent to the laboratory.
0930:
Blood pressure 108/70 mm Hg
Heart rate 100/min
Respiratory rate 18/min
Temperature 37° C (98.6° F)
1015:
Hemoglobin 11 g/dL (10 to 15.5 g/dL)
Hematocrit 37% (32% to 44%)
Platelets 165,000/mm3 (150,000 to 400,000/mm3)
Factor Villi 35% (60% to 140%)
A nurse is caring for a child in the emergency department (ED).
Explanation
|
Potential Intervention |
Expected |
Unexpected |
Rationale |
|
Have child tilt head back |
✅ |
Tilting the head back increases the risk of blood being swallowed, which can cause nausea or aspiration. |
|
|
Insert cotton into nostril |
✅ |
Cotton can be ineffective and may dislodge, worsening bleeding. Use gauze or a nasal tampon if needed. |
|
|
Apply ice to bridge of nose |
✅ |
Cold vasoconstricts blood vessels, helping reduce nasal bleeding. |
|
|
Apply pressure to tip of nose for at least 10 min |
✅ |
First-line measure for anterior epistaxis. Correct site is the soft part (lower third) of the nose. |
|
|
Prepare to administer factor VIII |
✅ |
The child has a Factor VIII deficiency (35%), which is diagnostic of Hemophilia A. Factor VIII replacement is the treatment. |
|
|
Prepare to administer topical antifibrinolytic agent |
✅ |
These agents help stabilize clots and are used for mucosal bleeds in hemophilia. |
|
|
Prepare to administer packed red blood cells |
✅ |
Not indicated unless there is severe blood loss with signs of anemia or hemodynamic instability, which is not present here. |
6 months ago:
A 1-year-old toddler presents to the office with their parents. The parents state that the toddler fell at home and has been limping since the injury two days ago. Left lower extremity casted.
1 month ago:
Toddler presents to the office with right wrist swelling and limited movement. The parents state they are unaware of any injury. Right arm casted. Child's sclera is blue and teeth are grey. Toddler referred to orthopedics for recurrent fractures. Bone biopsy prescribed.
Today:
The toddler presents with the parents to review bone biopsy results. Right upper extremity remains casted. Capillary refill less than 3 seconds.
6 months ago:
Left lower extremity x-ray: non-displaced fibula fracture
1 month ago
Right upper extremity x-ray: non-displaced right distal radial fracture
Today:
Bone biopsy: decreased trabecular and cortical bone volume consistent with osteogenesis imperfecta
Today:
Pamidronate 5mg IV daily x 3 days and then q2 months
A nurse is caring for a client in an outpatient orthopedist's office.
The toddler is at risk for developing
Explanation
The toddler is at risk for developing hearing loss as evidenced by the toddler’s bone biopsy results.
Rationale for correct answers:
Osteogenesis Imperfecta (OI): Confirmed by bone biopsy showing decreased trabecular and cortical bone volume. Classic features: recurrent fractures with minimal trauma, blue sclera, dentinogenesis imperfecta (grey teeth). OI can cause conductive hearing loss due to abnormalities in the bones of the middle ear.
Rationale for incorrect answers:
Hyperkalemia and hypercalcemia: Not supported by findings; there's no lab evidence or indication for this.
Compartment syndrome: No signs like severe pain, pallor, paresthesia, pulselessness, or pressure; capillary refill is normal (<3 seconds).
A nurse is assessing a toddler who is toilet-trained and has a temperature of 38.5° C (101.3° F). Which of the following findings should the nurse recognize as an indication of a urinary tract infection (UTI)?
A nurse is providing teaching to an adolescent who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following Instructions should the nurse include in the teaching?
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