RN Pediatric Nursing (ATI)

The correct instruction to include in the teaching is: Discard the first voided specimen.

During a 24-hour urine collection, the first voided specimen is discarded because it may not represent the urine that is produced during the full 24-hour period. The collection starts after this initial void, and all subsequent urine output should be collected in the provided container for the entire 24-hour duration.

Why not the other options:

Void every hour: The goal of a 24-hour urine collection is to collect all urine produced during the 24-hour period, not every hour. It is important to collect every urine sample throughout the 24 hours, but not every hour specifically.

Save the final specimen in a separate container: All urine produced during the 24-hour period should be saved in the same container. The final specimen should not be saved in a separate container.

Cleanse the perineum with a povidone-iodine solution prior to voiding: There is no need to use povidone-iodine solution for cleansing the perineum prior to voiding unless specifically directed by the provider. In general, routine cleansing with soap and water is sufficient for a urine collection.

Summary

In summary, the correct teaching is to discard the first voided specimen, which ensures the collection starts accurately.

Correct Answer: Intercostal retractions.

Intercostal retractions are a sign of increased work of breathing, which can indicate respiratory distress or worsening asthma exacerbation. This is a finding that should be reported to the provider, as it suggests that the child is struggling to breathe and may require further intervention, such as additional medications or respiratory support.

Why Other Options are Wrong:

Respiratory rate 24/min: This respiratory rate is within the normal range for a preschool-age child. Normal respiratory rate for a preschooler is usually between 20 and 30 breaths per minute, so this is not concerning.

Peak flow rate of 80%: A peak flow rate of 80% of the child’s personal best is typically considered a yellow zone indicating moderate asthma control. However, it is not an immediate cause for concern compared to other findings, especially if the child’s symptoms are improving with treatment.

Elevated heart rate: An elevated heart rate can occur with the use of albuterol as a side effect, as it is a beta-agonist. This is usually a temporary effect, but it should be monitored. If the heart rate becomes excessively elevated or the child experiences palpitations, it should be reported to the provider.

Conclusion:

Intercostal retractions are a more serious and concerning finding, indicating respiratory distress, and should be reported to the provider immediately.

Correct answer: History of spina bifida

Children with a history of spina bifida are at a higher risk for developing a latex allergy due to their frequent exposure to latex-containing medical products (such as gloves, catheters, and surgical equipment) throughout their treatment for the condition. This repeated exposure can lead to latex sensitization, increasing the risk of an allergic reaction. Therefore, it's important for healthcare providers to be vigilant in assessing this risk and taking precautions when working with children who have spina bifida.

Why the other options are incorrect:

Suspected autism spectrum disorder:

While children with autism may have a range of sensitivities or conditions, autism spectrum disorder (ASD) itself does not specifically increase the risk for a latex allergy. The link between ASD and latex allergies is not established. Therefore, children with suspected autism do not necessarily have a higher risk of developing a latex allergy.

Previous cleft palate repair:

Having a cleft palate repair in the past does not inherently increase the risk for latex allergy. While children who have had multiple surgeries may have had some exposure to latex during medical procedures, the presence of a cleft palate or the repair surgery itself is not a direct risk factor for a latex allergy. The risk is more associated with the frequency and nature of latex exposure over time.

Diagnosis of hypospadias:

A diagnosis of hypospadias, which involves a condition where the urethra is not located at the tip of the penis, does not significantly increase the risk of a latex allergy on its own. While surgery to correct hypospadias may involve latex exposure, it is the frequency of exposure, not the diagnosis itself, that typically leads to a latex allergy.

Conclusion:

A history of spina bifida is the most relevant risk factor for a latex allergy due to the frequent and ongoing exposure to latex in medical settings. This history should be recognized by healthcare providers, prompting them to take appropriate precautions when caring for these children.

Correct Answer: Pallor of the distal extremity

Pallor of the distal extremity can indicate poor circulation, which is a serious concern in a child with a cast. The blood flow to the area might be compromised due to the pressure from the cast, and this can lead to compartment syndrome, a potentially life-threatening condition. It is important to assess for signs of impaired circulation, and pallor is one such sign that requires immediate attention and may need to be reported to the provider.

Why Other Options are Wrong:

Positive pedal pulse in the distal extremity:

A positive pedal pulse indicates that blood is flowing to the foot, which is a good sign. It suggests that circulation is adequate.

Mobility of the distal extremity:

Mobility might be reduced due to the cast, but the ability to move the toes (for example) is generally a sign that the nervous system and muscles are functioning. However, any abnormal mobility or loss of movement should be further assessed.

Warm temperature of the distal extremity:

A warm temperature typically indicates adequate blood flow to the area. If the area were cold, that could indicate poor circulation, but warmth is generally a reassuring sign.

Therefore, pallor is the finding that warrants reporting, as it could be a sign of circulation issues that need urgent attention.

Correct Answer: Hypothermia.

Explanation:

After a submersion injury (near drowning), one of the complications the nurse should anticipate is hypothermia. Cold water immersion can cause the body temperature to drop rapidly, leading to hypothermia. This is particularly a concern in cases where the child was submerged in cold water or remained in water for a prolonged period.

Why Other Options Are Wrong:

Hypertension: Typically, after a near-drowning event, hypotension (low blood pressure) is more likely due to fluid loss, shock, and respiratory compromise. Hypertension is not a common complication.

Edema: While edema could develop, especially in cases where there is fluid overload or ARDS (acute respiratory distress syndrome) due to inhaled water, hypothermia is more immediately concerning in the early stages following a submersion injury.

Oliguria: Oliguria (decreased urine output) may occur later due to renal failure from shock or hypoxia, but it is not an immediate complication. Hypothermia would be a more urgent concern in the acute phase following a submersion injury.

Conclusion:

In the immediate aftermath of a submersion injury, hypothermia is the most likely and dangerous complication that the nurse should anticipate and monitor for closely.

Correct Answer: Serum BUN and creatinine levels.

Explanation:

Before initiating an intravenous (IV) infusion with potassium (KCl), it is important to assess the renal function to ensure that the kidneys are able to handle the potassium. Serum BUN (blood urea nitrogen) and creatinine levels are key indicators of renal function. If the kidneys are not functioning well (as in cases of dehydration or renal impairment), administering potassium can lead to hyperkalemia, which can be dangerous.

Why Other Options Are Wrong:

Frequency of emesis in the last 8 hours:

While monitoring vomiting is important for assessing fluid loss and dehydration, it is not directly related to the safe administration of potassium. The primary concern is kidney function to handle potassium safely.

Current blood sugar level:

While it is important to monitor blood sugar in a hospitalized infant, particularly in cases where dextrose is being administered, the immediate priority before infusing potassium is to assess renal function to avoid complications with potassium administration.

Appearance of the stool:

The appearance of the stool is more relevant to diagnosing the cause of diarrhea or assessing dehydration, but it is not a priority when preparing to administer a potassium-containing solution.

Conclusion:

The nurse should assess the serum BUN and creatinine levels before administering dextrose, saline, and potassium to ensure that the kidneys are functioning properly and can handle the potassium without risk of hyperkalemia

Correct Answer: Remove nits from the child's hair using a fine-tooth comb.

Pediculosis capitis (head lice) is a common infestation, especially in school-age children. The treatment for head lice typically involves both medicated shampoos or lotions and physical removal of the nits (lice eggs) from the hair.

Key actions for treating pediculosis capitis include:

Using a fine-tooth comb to remove nits from the child's hair is a critical step in the treatment process. Even after using medicated treatments, it is important to physically remove the nits to prevent reinfestation.

Treatment usually requires a second application of medication 7-10 days later to kill any newly hatched lice. However, the nits must be manually removed from the hair.

Why Other Options are Wrong:

Soak the child's hair brushes in vinegar between uses:

While vinegar can sometimes help loosen nits, soaking brushes in vinegar is not a recommended method for managing pediculosis capitis. The brushes should be cleaned with hot water and soap, but the focus should be on treating the scalp and hair with medicated treatments and combing out the nits.

Apply medication to the child's scalp twice daily until the symptoms subside:

Most medicated treatments for head lice, such as permethrin or pyrethrins, are typically applied once and sometimes repeated after 7-10 days. Applying medication twice daily is not necessary and may be harmful.

Discard the child's non-washable items:

It is not necessary to discard non-washable items. Instead, non-washable items such as stuffed animals and hats can be placed in a sealed plastic bag for 48-72 hours to ensure that any lice or nits are killed. Items like clothing, bed linens, and towels should be washed in hot water and dried on high heat.

Conclusion:

The most important instruction for parents when treating pediculosis capitis is to remove nits from the child's hair using a fine-tooth comb to prevent reinfestation and to ensure complete eradication of lice.