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Ati Rn Paediatrics Nursing 2023 Proctored Exam
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Toddler presents to the ED with their guardian. Guardian reports that the toddler has vomited twice while eating and has had a sudden onset of episodes of drawing their knees to their chest and a high-pitch cry. Between episodes, the toddler appears comfortable and plays as usual. Toddler has been sleeping more and is irritable after eating. Guardian reports a decrease in the toddler's urine frequency and amount.
1030:
Guardian calls nurse to the room to report the toddler's bowel movement looks like "red jelly."
- Temperature 36.7° C (98.0° F)
- Heart rate 145/min
- Respiratory rate 25/min
- Blood pressure 90/48 mm Hg
- Oxygen saturation 98% on room air
A nurse in the emergency department (ED) is caring for a 2-year-old toddler.
Complete the diagram by dragging from the choices below to specify what condition the toddler is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the toddler's progress.
Explanation
Rationale for correct choices
• Intussusception: The toddler presents with sudden, episodic abdominal pain, drawing knees to chest, high-pitched crying, and intermittent periods of comfort. The “red currant jelly” stool is classic for intussusception, indicating intestinal bleeding and mucous. Vomiting and decreased urine output further support dehydration from obstructive bowel pathology.
• Maintain NPO status: Keeping the toddler NPO prevents further gastrointestinal compromise and prepares them for diagnostic procedures such as an air or contrast enema or potential surgery. Oral intake could worsen obstruction or lead to vomiting and aspiration.
• Prepare for surgery: Surgical intervention may be required if non-surgical reduction (e.g., air or contrast enema) is unsuccessful or if complications like perforation or peritonitis develop. Early preparation ensures timely intervention to prevent bowel necrosis.
• Abdominal distension: Monitoring for abdominal distension helps detect worsening obstruction or bowel compromise. Progressive distension may indicate that the intussusception has not reduced or that ischemia is developing.
• Signs of dehydration: Vomiting, decreased urine output, and irritability increase the toddler’s risk for dehydration. Monitoring for signs such as dry mucous membranes, lethargy, or tachycardia allows timely fluid replacement and prevents further complications.
Rationale for incorrect choices
• Prepare the toddler for an upper gastrointestinal series: An upper GI series is typically used to evaluate malrotation or other upper GI anomalies, not first-line for intussusception. A contrast or air enema is the preferred diagnostic and therapeutic procedure.
• Administer oral rehydration solution: Oral fluids are contraindicated because the toddler is at risk of vomiting due to bowel obstruction. Administering oral rehydration could worsen aspiration risk and delay surgical intervention.
• Educate the guardian about a gas enema: While a gas enema is a treatment option, education alone is not the immediate nursing priority. The toddler requires stabilization, NPO status, and preparation for possible surgical intervention.
• Celiac disease: Celiac disease presents with chronic malabsorption, growth delays, and diarrhea, not acute, intermittent abdominal pain with "red jelly" stools. The toddler’s sudden onset and episodic nature of symptoms do not fit this condition.
• Gastroesophageal reflux disease (GERD): GERD usually causes chronic regurgitation, irritability after feeds, and discomfort, but it does not cause "red jelly" stools or sudden episodes of severe abdominal pain. The acute presentation suggests a structural obstruction rather than reflux.
• Appendicitis: Appendicitis often presents with continuous abdominal pain, initially periumbilical migrating to the right lower quadrant, with fever and gradual onset. The episodic pain, bloody stools, and age of the toddler make appendicitis less likely.
• Urine specific gravity: While it can indicate hydration, direct monitoring for clinical signs of dehydration is more immediate and actionable in an acute setting.
• Epigastric pain 30 to 60 min after eating: This monitoring parameter is more relevant for GERD or peptic ulcer disease. The toddler’s pain is intermittent, sudden, and unrelated to meal timing, making it inappropriate for this assessment.
• Soft, brown stool: Monitoring for normal stool is not immediately useful because the toddler currently has bloody "red jelly" stools, which indicate active pathology. Focus of management should remain on detecting complications and dehydration.
A nurse is caring for a school-age child who underwent a tuberculin skin test 3 days ago and has a 3-mm induration at the test site. The nurse should identify this finding as which of the following?
A nurse is performing a physical assessment for a school-age child. Which of the following actions should the nurse take?
Day 1, 2100:
Adolescent admitted for an exacerbation of Crohn's disease. Adolescent reports diarrhea for the past 48 hr; watery, light brown, no visible blood, with generalized abdominal cramping pain. No joint pain reported. Adolescent reports decreased food and fluid intake since onset of diarrhea and states, "I'm just not hungry and I want this to stop." Lung sounds clear to all fields. Heart rhythm regular, no murmurs. NG tube is inserted to right nare. Adolescent tolerates well, verifies placement. Tube feeding is started via continuous infusion pump per provider's prescription. Head of bed is elevated, guardian at bedside, call bell is within reach.
Day 2,0730:
Adolescent sleeps in supine position. Gastric residual 300 mL NG tube feeding is stopped, provider is notified. Adolescent reports diarrhea twice during the night. Adolescent reports abdominal pain decreased to a 4 on a scale of 0 to 10.
Day 2, 0700:
- Temperature 37.2° C (99° F)
- Heart rate 108/min
- Respiratory rate 20/min
- Blood pressure 116/60 mm Hg
- Oxygen saturation 97% on room air
- Weight 40 kg (88 lb)
- BMI 19
Day 2,1115:
- Temperature 37.4° C (99.3° F)
- Heart rate 120/min
- Respiratory rate 22/min
- Blood pressure 128/76 mm Hg
- Oxygen saturation 95% on room air
Day 2,0600:
Sodium 136 mEq/L (136 to 145 mEq/L)
Potassium 4.3 mEq/L (3.4 to 4.7 mEq/L)
BUN 14 mg/dL (5 to 18 mg/dL)
Creatinine 0.6 mg/dL (0.4 to 1.0 mg/dL)
Complete Blood Count:
WBC count 15,000/mm3 (5,000 to 10,000/mm3)
RBC count 4.5 million/mm3 (4 to 5.5 million/mm3)
Hemoglobin 13 g/dL (10 to 15.5 g/dL)
Hematocrit 33% (32% to 44%)
C-reactive protein 2.1 mg/dL (less than 1 mg/dL)
Iron 41 mcg/dL (50 to 120 mcg/dL)
Vitamin B2 141 pg/mL (160 to 950 pg/mL)
Albumin 4.2 g/dL (4 to 5.9 g/dL)
Stool for occult blood: positive (negative)
Complete the following sentence by using the lists of options.
The nurse should identify that the adolescent is experiencing
Explanation
Rationale for correct choices
• Crohn’s exacerbation: The adolescent presents with acute worsening of diarrhea, abdominal cramping, and decreased intake, consistent with a flare of Crohn’s disease. Laboratory findings show elevated WBC (15,000/mm³) and C-reactive protein (2.1 mg/dL), indicating an active inflammatory response. Positive stool occult blood further supports gastrointestinal mucosal involvement.
• Inflammation: Crohn’s disease flares are driven by intestinal inflammation, which damages the mucosa and leads to diarrhea, abdominal pain, and systemic responses like tachycardia and low-grade fever. Elevated inflammatory markers (CRP, WBC) provide objective evidence of active inflammation. Targeting the inflammatory process is central to management through medications and supportive care.
Rationale for incorrect choices
• Gastroenteritis: Although diarrhea and abdominal cramping can occur with viral gastroenteritis, the adolescent’s chronic history of Crohn’s disease, positive stool occult blood, and elevated inflammatory markers indicate a flare rather than an acute viral infection. Gastroenteritis usually presents with sudden onset, fever, vomiting, and is self-limiting in otherwise healthy children.
• Constipation: The adolescent is experiencing diarrhea, not constipation. Constipation presents with hard, infrequent stools, abdominal bloating, and discomfort, which are not consistent with the current presentation. Focusing on constipation would not address the inflammatory flare.
• Viral infection: No evidence of viral infection, such as high fever, vomiting, or systemic malaise, is present. Laboratory findings do not indicate viral etiology, making this an unlikely cause of symptoms. The diarrhea and abdominal pain are more consistent with Crohn’s disease exacerbation.
• Dietary triggers: Although diet can influence Crohn’s symptoms, there is no recent change in dietary intake reported. The primary driver of the flare appears to be inflammatory activity rather than a new dietary trigger. Management focuses on inflammation control rather than diet alone.
Infant was full-term at birth. Birth weight was 3.5 kg (7.7 lb). Infant is not gaining weight as expected. One week ago at outpatient visit, weight was 3.6 kg (7.9 lb).
Parent reports for past 2 days infant is breathing faster during feedings and does not finish feedings. Parent also reports decreased appetite and puffiness around the infant's eyes. Parent states that the last wet diaper was about 10 hr ago. Infant admitted for diagnostic evaluation, failure to thrive, and nutritional/fluid support.
Admission:
Respirations: Tachypneic with moderate retractions and nasal flaring. Upon auscultation, crackles heard in all lung fields. No nasal drainage noted. Dry cough noted periodically.
Skin: Pallor, scalp is diaphoretic, lower extremities are cool to touch.
Cardiac: Tachycardic, regular rhythm, no murmur is heard. Peripheral pulses are full and bounding in the upper extremities and weak bilateral pedal pulses are noted.
Fluids: Mucous membranes are slightly dry and pink. Skin turgor is slightly decreased. Capillary refill is 3 seconds. Noted periorbital edema and nonpitting edema of feet. Anterior fontanel is soft and slightly depressed. Diaper remains dry.
Abdomen: Soft, full, round, bowel sounds are present and active.
Admission:
- Temperature 37.7° C (99.9° F)
- Heart rate 174/min while sleeping
- Respiratory rate 72/min while sleeping
- Blood pressure in right upper extremity 60/39 mm Hg
- Oxygen saturation 90%
Admission:
Chest x-ray: mild left ventricular hypertrophy is noted. Increased pulmonary vascular markings are noted in all lobes.
A nurse is caring for a 6-week-old infant.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Explanation
Rationale for correct choices
• Congestive heart failure: The infant exhibits signs of fluid overload and decreased cardiac output, including tachypnea, retractions, nasal flaring, crackles in all lung fields, tachycardia, bounding upper extremity pulses, weak pedal pulses, periorbital edema, dry mucous membranes, and poor weight gain. Chest x-ray shows mild left ventricular hypertrophy and increased pulmonary vascular markings, consistent with congestive heart failure.
• Anticipate a prescription for digoxin: Digoxin is used to improve cardiac contractility and decrease heart rate, thereby enhancing cardiac output in infants with heart failure. Preparing for administration allows the nurse to ensure appropriate dosing, monitor for toxicity, and educate caregivers regarding signs of overdose. Close monitoring of heart rate and rhythm is essential before each dose.
• Oxygen supplementation: The infant’s oxygen saturation is 90% on room air, indicating hypoxemia. Supplemental oxygen improves oxygen delivery to tissues, reduces work of breathing, and prevents further cardiac stress. Continuous monitoring ensures safe oxygenation and guides titration based on respiratory status.
• Intake and output: The infant shows signs of dehydration (dry diaper for 10 hours, decreased skin turgor) and fluid overload (edema). Monitoring intake and output assesses fluid balance, guides fluid replacement or restriction, and evaluates the effectiveness of diuretics or other interventions.
• Respiratory status: Tachypnea, retractions, nasal flaring, and crackles indicate respiratory compromise secondary to pulmonary congestion. Monitoring respiratory rate, effort, and oxygen saturation ensures early detection of deterioration and informs adjustments in oxygen therapy or pharmacologic management.
Rationale for incorrect choices
• Pyloric stenosis: Pyloric stenosis presents with projectile, non-bilious vomiting, a palpable “olive” mass in the abdomen, and signs of dehydration. The infant’s presentation with pulmonary congestion, edema, and tachypnea does not align with pyloric stenosis.
• Respiratory syncytial virus (RSV) bronchiolitis: RSV causes respiratory distress, wheezing, and hypoxia, but it does not explain poor weight gain, periorbital edema, bounding pulses, or left ventricular hypertrophy seen on chest x-ray. The systemic signs point to cardiac etiology rather than viral infection.
• Cystic fibrosis: Cystic fibrosis typically presents with failure to thrive, steatorrhea, recurrent respiratory infections, and salty skin. There is no evidence of digestive malabsorption or recurrent pulmonary infections, making CF less likely.
• Implement contact precautions: No infectious etiology is suggested; contact precautions are unnecessary. The priority is addressing heart failure and associated respiratory compromise.
• Place nasogastric tube for gastric decompression: There is no evidence of gastrointestinal obstruction or distension requiring decompression. Nutrition and fluid management are the focus rather than decompression.
• Provide chest physiotherapy and postural drainage: Chest physiotherapy is indicated for conditions with thick pulmonary secretions (e.g., cystic fibrosis) but is not indicated for pulmonary congestion secondary to heart failure, where fluid overload rather than mucus accumulation is the issue.
• Number of steatorrhea stools: Steatorrhea monitoring is relevant for malabsorption or cystic fibrosis but not for congestive heart failure. The infant’s issue is primarily cardiovascular.
• Blood glucose: Blood glucose is not immediately relevant to assessing the infant’s heart failure or fluid balance and is not needed for monitoring progress in this scenario.
A nurse is teaching an adolescent about the procedure for completing a 24-hr urine test. Which of the following statements by the adolescent indicates an understanding of the teaching?
A nurse is caring for a child who has bacterial meningitis. Which of the following findings should indicate to the nurse that the child can be removed from droplet precautions?
A nurse is preparing a 4-year-old child for a tonsillectomy. Which of the following statements should the nurse make?
A nurse is performing a dressing change for a child and notices that the gauze dressing is adhering to the wound bed. Which of the following actions should the nurse take?
A nurse is caring for a child who is postoperative following surgical correction of tetralogy of Fallot. Which of the following findings should the nurse identify as an indication of heart failure?
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