ATI RN Pediatric Nursing 2023.
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Nurses' Notes: 0930: Parent presents child to provider's office. Parent reports the child has had a fever for 2 days and that the child has cried more than usual. Parent also reports the child has had a decreased appetite for the last 24 hr. Child febrile and lethargic. 0945: Notified provider of parent reports and child's fever. New prescriptions received. 1000: Urine sample obtained via sterile straight catheter.
Medical History: 0930: Three urinary tract infections over the past year treated with antibiotics. Diagnosed at 6 months old with vesicoureteral reflux.
Provider Prescriptions: 0945: Obtain urine sample for urinalysis and culture and sensitivity via sterile straight catheter.
Vital Signs: 0930: Temperature 38.4°C (101.1°F) | Heart rate 128/min | Respiratory rate 28/min
Diagnostic Results: 1030: Urinalysis: Appearance: cloudy and dark amber (clear) Specific gravity 1.035 (1.005 to 1.030) Leukocyte esterase: positive (negative) Nitrites: present (none) WBCs: 10 (0 to 4)
The child is at risk for developing _____ and _____.
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Polycystic kidney
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Acute glomerulonephritis
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Nephrotic syndrome
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Renal scarring
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Pyelonephritis
Explanation
Correct Answer: D. Renal scarring and E. Pyelonephritis.
E. Pyelonephritis — The child presents with fever, lethargy, decreased appetite, and abnormal urinalysis findings including cloudy urine, elevated specific gravity, positive leukocyte esterase, presence of nitrites, and elevated WBCs. Combined with a history of vesicoureteral reflux and three prior UTIs, these findings are classic indicators of an ascending urinary tract infection progressing to pyelonephritis.
D. Renal scarring — Children with vesicoureteral reflux are at significant risk for renal scarring due to repeated episodes of pyelonephritis. Backflow of infected urine into the renal parenchyma causes inflammation and permanent scarring that can lead to chronic kidney disease over time.
Why other options are incorrect:
A. Polycystic kidney is a genetic structural disorder not associated with UTIs or vesicoureteral reflux.
B. Acute glomerulonephritis typically follows streptococcal infection and presents with hematuria, proteinuria, edema, and hypertension, not with the UTI findings seen here.
C. Nephrotic syndrome is characterized by massive proteinuria, hypoalbuminemia, and edema, none of which are present in this clinical picture.
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Hypokalemia
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Metabolic alkalosis
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Oliguria
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Hypercalcemia
Explanation
Oliguria, defined as urine output less than 1 mL/kg/hr in children, is a hallmark finding of acute renal failure. When the kidneys fail, they lose their ability to filter blood and produce adequate urine, resulting in significantly decreased urine output. This is one of the earliest and most reliable indicators of acute renal failure and reflects the severity of renal impairment.
Why the other options are incorrect:
A. Hypokalemia is not expected in acute renal failure. The kidneys normally excrete potassium, so when renal function fails, potassium accumulates in the blood, leading to hyperkalemia rather than hypokalemia. Hyperkalemia is one of the most dangerous complications of acute renal failure due to its effects on cardiac conduction.
B. Metabolic alkalosis is not the expected acid-base disturbance in acute renal failure. The kidneys normally excrete hydrogen ions and reabsorb bicarbonate to maintain acid-base balance. When renal function fails, hydrogen ions accumulate and bicarbonate is lost, leading to metabolic acidosis, not metabolic alkalosis.
D. Hypercalcemia is not expected in acute renal failure. The kidneys play a role in activating vitamin D and regulating calcium and phosphorus balance. In acute renal failure, phosphorus retention occurs and calcium levels typically decrease, leading to hypocalcemia rather than hypercalcemia.
Assessment Findings — Acute Laryngotracheobronchitis — Pneumonia
Stridor — Acute Laryngotracheobronchitis — Pneumonia
Temperature — Acute Laryngotracheobronchitis — Pneumonia
Irritability — Acute Laryngotracheobronchitis — Pneumonia
Cough findings at 0800 — Acute Laryngotracheobronchitis — Pneumonia
Exhibit 1 — Nurses' Notes
0730:
Child presents to the emergency department. Guardians report the child woke up coughing with a low-grade fever. Child appears alert and restless in guardian's arms. Respirations easy, no cough noted.
0800:
Child became agitated. Hoarse cry noted with audible inspiratory stridor. Barking, non-productive cough present.
Exhibit 2 — Vital Signs
0730:
Tympanic temperature 38.1° C (100.6° F) Heart rate 95/min Respiratory rate 20/min Oxygen saturation 98% on room air
0800:
Tympanic temperature 38.2° C (101° F) Heart rate 112/min Respiratory rate 24/min Oxygen saturation 96% on room air
- Stridor — Acute Laryngotracheobronchitis
- Temperature — Acute Laryngotracheobronchitis and Pneumonia
- Irritability — Acute Laryngotracheobronchitis and Pneumonia
- Cough findings at 0800 — Acute Laryngotracheobronchitis
Explanation
Stridor — Acute Laryngotracheobronchitis
Temperature — Acute Laryngotracheobronchitis and Pneumonia
Irritability — Acute Laryngotracheobronchitis and Pneumonia
Cough findings at 0800 — Acute Laryngotracheobronchitis
Stridor is consistent with Acute Laryngotracheobronchitis only because inspiratory stridor is the hallmark finding of croup, resulting from subglottic edema and narrowing of the upper airway. The audible inspiratory stridor noted at 0800 along with the hoarse cry is the classic presentation of acute laryngotracheobronchitis. Stridor is not a feature of pneumonia, which affects the lower airways and alveoli rather than the upper airway.
Temperature is consistent with both Acute Laryngotracheobronchitis and Pneumonia because both conditions are associated with fever as part of the infectious and inflammatory process. This child has a low-grade fever of 38.1° C at 0730 rising to 38.2° C at 0800, which is consistent with either condition. Croup typically presents with a low-grade fever, while pneumonia can present with higher fever, but low-grade fever does not exclude pneumonia.
Irritability is consistent with both Acute Laryngotracheobronchitis and Pneumonia because both conditions cause discomfort, respiratory distress, and general malaise that lead to irritability and restlessness in young children. The child was noted to be restless at 0730 and became agitated at 0800, which is consistent with the increasing respiratory distress seen in both conditions.
Cough findings at 0800 are consistent with Acute Laryngotracheobronchitis only because the cough described at 0800 is a barking, non-productive cough, which is the pathognomonic cough of croup. This distinctive seal-bark quality cough results from subglottic inflammation and edema affecting the trachea and bronchi. Pneumonia typically produces a wet, productive cough with crackles on auscultation rather than a barking non-productive cough.
Why the other options are incorrect:
Stridor is not consistent with Pneumonia because pneumonia affects the lower respiratory tract including the bronchioles and alveoli. The breath sounds in pneumonia include crackles, decreased breath sounds, and dullness to percussion rather than the upper airway stridor characteristic of croup.
Cough findings at 0800 are not consistent with Pneumonia because the barking, non-productive cough is specific to croup and upper airway inflammation. Pneumonia produces a different type of cough that is typically wet and productive, accompanied by crackles and decreased breath sounds in the affected lung fields.
Exhibit 1 — Nurses' Notes
3 months ago:
Past medical history: Eczema, recurrent otitis media, born small for gestational age at 40 weeks of gestation, weighing 2,580 g (5 lb 11 oz)
Surgical history: Status-post tympanostomy tube placement at 14 months of age
Family history: Client's sister has asthma, mother has hypertension
Social history: Lives at home with parents and siblings, father smokes cigarettes
Height: 114.3 cm (45 in) Weight: 18.2 kg (40 lb) BMI: 13.9 kg/m²
Today, 1300:
The client presents to the ED with their parents. The parents state, "Something isn't right. My child is short of breath and anxious."
Physical examination: General: Diaphoretic, sitting upright, agitated Respiratory: Coarse wheezing throughout, intercostal retractions, prolonged expiration Cardiovascular: Tachycardia, regular rhythm
Today, 1330:
Physical examination: General: Drowsy, quiet Respiratory: Tachypnea, no wheezing auscultated, paradoxic thoracoabdominal movement Cardiovascular: Bradycardia, regular rhythm
Select the 3 actions the nurse should take.
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A 5-year-old male child presents to the office with their parents. The parents state the child has a chronic cough that just won't go away. The parents state the child often coughs at night when they are sleeping, and the parents are worried this is making the child tired and contributing to poor school performance.
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Alert the hospital's rapid response team.
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Inform the child's parents that the child may need intubation.
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Return for reassessment in 30 min.
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Request a prescription for an anti-anxiety medication.
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Push oral fluids.
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Continuously monitor oxygen saturation levels.
Explanation
Correct Answers: (A) Alert the hospital's rapid response team, (B) Inform the child's parents that the child may need intubation, (F) Continuously monitor oxygen saturation levels
Alerting the hospital's rapid response team is the most critical and immediate action because the child's condition at 1330 has deteriorated significantly and represents impending respiratory failure. The disappearance of wheezing in a child with severe asthma is an ominous sign, not an improvement, as it indicates that airflow has become so severely reduced that there is not enough air movement to produce wheeze. Combined with drowsiness, bradycardia, tachypnea, and paradoxical thoracoabdominal movement, these findings indicate the child is in a life-threatening respiratory crisis requiring immediate activation of the rapid response team.
Informing the child's parents that the child may need intubation is a necessary and urgent action because the clinical picture at 1330 shows a child in impending respiratory arrest. Paradoxical thoracoabdominal movement, where the chest and abdomen move in opposite directions during breathing, is a sign of severe respiratory muscle fatigue and exhaustion. Bradycardia in a child with respiratory distress is a pre-arrest finding. The parents must be informed of the child's deteriorating condition and the potential need for mechanical ventilation to support informed decision-making and to prepare them for what may follow.
Continuously monitoring oxygen saturation levels is essential because the child is in acute respiratory failure and any further drop in oxygen saturation below critical thresholds must be detected immediately to guide resuscitative interventions. Continuous pulse oximetry allows the nurse and rapid response team to track the child's respiratory status in real time and respond immediately to any further deterioration.
Why the other options are incorrect:
C. Returning for reassessment in 30 minutes is completely inappropriate given the severity of the child's current condition. A child showing signs of impending respiratory arrest requires immediate intervention, not a delayed reassessment. Waiting 30 minutes in this situation could be fatal.
D. Requesting a prescription for an anti-anxiety medication is contraindicated in this situation. The child's drowsiness and quiet demeanor at 1330 are not signs of anxiety but rather signs of neurological depression from hypoxia and hypercapnia indicating respiratory failure. Administering sedating anti-anxiety medications to a child in impending respiratory arrest could suppress respiratory drive and accelerate respiratory collapse.
E. Pushing oral fluids is inappropriate and potentially dangerous in a child who is drowsy with impending respiratory failure. A drowsy, obtunded child is at high risk for aspiration, and oral intake is contraindicated. Intravenous fluid access and management would be appropriate as part of the resuscitative effort rather than oral fluid administration.
- 15
Explanation
Correct Answer: 15 mL
Formula: Calculate total daily dose → Divide by number of doses → Calculate volume. Step 1 — Total daily dose: 30 kg × 50 mg/kg = 1,500 mg/day. Step 2 — Per dose (every 6 hr = 4 doses/day): 1,500 mg ÷ 4 = 375 mg/dose. Step 3 — Calculate volume: (375 mg ÷ 125 mg) × 5 mL = 15 mL.
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Weight loss
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Bradycardia
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Exercise intolerance
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Decreased respirations
Explanation
Exercise intolerance is a classic sign of heart failure in a postoperative child following tetralogy of Fallot repair. When the heart is failing, it cannot generate sufficient cardiac output to meet the body's metabolic demands during activity. As a result, the child becomes easily fatigued, short of breath, and unable to tolerate physical exertion that would normally be appropriate for their age. This finding indicates that the heart is not functioning effectively following surgical correction.
Why the other options are incorrect:
A. Weight loss is not a typical sign of heart failure. Heart failure in children more commonly causes weight gain due to fluid retention and edema. Unexplained weight gain rather than weight loss would be a concerning finding in a postoperative cardiac patient.
B. Bradycardia is not a characteristic sign of heart failure. Heart failure typically causes compensatory tachycardia as the body attempts to maintain adequate cardiac output by increasing heart rate. Bradycardia would be more concerning for a conduction abnormality or medication side effect rather than heart failure.
D. Decreased respirations are not associated with heart failure. Heart failure causes increased respiratory rate and respiratory distress due to pulmonary congestion and fluid accumulation in the lungs. Tachypnea and increased work of breathing, not decreased respirations, are the expected respiratory findings in heart failure.
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Odorless urine
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Temperature 37.2° C (99° F)
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No report of pain with voiding
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Urine output 256 mL over 8 hr
Explanation
Correct Answer: (D) Urine output 256 mL over 8 hr
In nephrotic syndrome, the kidneys lose large amounts of protein in the urine, leading to edema and decreased urine output. An improving urine output of 256 mL over 8 hours indicates that the kidneys are responding to treatment and fluid balance is being restored. This is a key sign of treatment effectiveness.
Why the other options are incorrect:
A. Odorless urine is a normal characteristic of urine and does not specifically indicate improvement in nephrotic syndrome.
B. A temperature of 37.2° C (99° F) is essentially normal and does not reflect improvement in nephrotic syndrome specifically.
C. No report of pain with voiding is not a relevant indicator for nephrotic syndrome, as pain with voiding is more associated with urinary tract infections, not nephrotic syndrome.
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"I will notify the provider of your concerns about this surgery."
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"Let me explain the consequences of not having this surgery."
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"You have the best cardiovascular surgical team."
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"You have already signed the consent form for surgery."
Explanation
Correct Answer: (A) "I will notify the provider of your concerns about this surgery."
When a parent expresses doubt or concern about a planned surgical procedure, the nurse's priority is to communicate those concerns to the provider. This respects the parent's right to informed consent and ensures the provider can address the parent's questions and concerns directly, supporting autonomous decision-making.
Why the other options are incorrect:
B. Explaining the consequences of not having surgery can come across as coercive and does not first acknowledge or validate the parent's concerns or right to make an informed decision.
C. Reassuring the parent about the surgical team, while potentially well-intentioned, does not address the parent's specific concern and may feel dismissive.
D. Reminding the parent they have already signed the consent form is inappropriate and dismissive. Consent can be withdrawn at any time before the procedure, and this statement undermines the parent's autonomy.
Exhibit 1 — Nurses' Notes
3 months ago:
Past medical history: Eczema, recurrent otitis media, born small for gestational age at 40 weeks of gestation, weighing 2,580 g (5 lb 11 oz)
Surgical history: Status-post tympanostomy tube placement at 14 months of age
Family history: Client's sister has asthma, mother has hypertension
Social history: Lives at home with parents and siblings, father smokes cigarettes
Physical examination: General: No acute distress Respiratory: Faint expiratory wheezing, prolonged expiration Cardiovascular: S1, S2, no murmur or rub Skin: Warm, dry
Height: 114.3 cm (45 in) Weight: 18.2 kg (40 lb) BMI: 13.9 kg/m²
Today, 1300:
The client presents to the ED with their parents. The parents state, "Something isn't right. My child is short of breath and anxious."
Physical examination: General: Diaphoretic, sitting upright, agitated Respiratory: Coarse wheezing throughout, intercostal retractions, prolonged expiration Cardiovascular: Tachycardia, regular rhythm
Complete the following sentence by using the lists of options.
The nurse should __________ in order to __________.
First Blank Options: administer humidified oxygen place the client in a supine position request a stat ABG
Second Blank Options: determine PaO₂ and PCO₂ levels reduce airway resistance maintain an oxygen saturation greater than 92%
- administer humidified oxygen
- place the client in a supine position
- request a stat ABG
- determine PaO₂ and PCO₂ levels
- reduce airway resistance
- maintain an oxygen saturation greater than 92%
Explanation
Correct Answer: The nurse should administer humidified oxygen in order to maintain an oxygen saturation greater than 92%.
Administer humidified oxygen is the correct first blank because the child is now presenting in the emergency department with an acute asthma exacerbation evidenced by diaphoresis, agitation, coarse wheezing throughout all lung fields, intercostal retractions, prolonged expiration, and tachycardia. These are signs of significant respiratory distress and hypoxia. Administering humidified oxygen is the immediate priority nursing intervention to correct hypoxemia, reduce the work of breathing, and prevent respiratory failure. Humidified oxygen is preferred over dry oxygen in children to prevent drying of the airways and mucous membranes.
Maintain an oxygen saturation greater than 92% is the correct second blank because the goal of oxygen therapy in an acute asthma exacerbation is to maintain oxygen saturation at or above 92% to ensure adequate tissue oxygenation. An SpO₂ below 92% indicates significant hypoxemia requiring urgent intervention, and maintaining saturation above this threshold is the standard clinical target in pediatric asthma management.
Why the other options are incorrect:
Place the client in a supine position is incorrect because placing a child in respiratory distress in a supine position worsens breathing by increasing the work of breathing and reducing lung expansion. The child is already naturally sitting upright, which is the correct therapeutic position as it maximizes diaphragmatic excursion and lung expansion during an acute asthma exacerbation.
Request a stat ABG is not the immediate priority intervention in this situation. While an arterial blood gas may be obtained to assess the severity of respiratory compromise, it is a diagnostic measure rather than a direct therapeutic intervention. The priority is to first treat the hypoxemia with oxygen before pursuing diagnostic testing.
Determine PaO₂ and PCO₂ levels is the purpose of requesting a stat ABG rather than the goal of oxygen administration. While knowing blood gas values is important for assessing severity, the immediate therapeutic goal of oxygen administration in this acute setting is to maintain adequate oxygen saturation above 92% rather than simply to obtain diagnostic values.
Reduce airway resistance is the goal of bronchodilator therapy such as albuterol, not oxygen administration. While reducing airway resistance is an important treatment goal in asthma, it is achieved through bronchodilators and corticosteroids rather than through oxygen supplementation.
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Use open-ended questions when asking the adolescent about their health history.
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Communicate sympathy when asking the adolescent about their chief complaint.
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Provide an opinion when discussing the adolescent's sexual history.
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Interview the parent first when collecting the adolescent's health history.
Explanation
Using open-ended questions is the most therapeutic and effective interviewing technique when conducting a health history with an adolescent. Open-ended questions encourage the adolescent to share information freely in their own words rather than responding with simple yes or no answers. This approach promotes trust, establishes rapport, and allows the nurse to gather more complete and accurate health information from the adolescent.
Why the other options are incorrect:
B. Communicating sympathy rather than empathy is not the recommended therapeutic communication technique. Empathy, which involves acknowledging and validating the adolescent's feelings, is more appropriate and effective than sympathy, which implies feeling sorry for the adolescent and can create emotional distance rather than therapeutic connection.
C. Providing an opinion when discussing the adolescent's sexual history is inappropriate and unprofessional. The nurse should remain nonjudgmental and objective when discussing sensitive topics such as sexual history. Offering personal opinions can cause the adolescent to feel judged, which will deter them from disclosing important health information.
D. Interviewing the parent first is incorrect when the primary client is the adolescent. The nurse should interview the adolescent directly and privately, without the parent present for sensitive portions of the health history. Interviewing the parent first can undermine the adolescent's autonomy, trust, and willingness to disclose personal health information.
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