PEDIATRIC NURSING EXAM #1 STUDY GUIDE INFANT/TODDLER [5 Questions] (INFANT) Physical exam/assessment: Measuring an infant o Length supine (done up until 36 months) o Fully extend body holding head midline o Measure top of head to heels of feet (dorsi flexed position) o Standing measurement is height Obtaining a weight o Use infant scale o Balance scale before each weight o Weigh nude Obtaining head circumference Smile and let baby touch equipment Have parent hold baby during exam Start from least intrusive to most intrusive (listen to heart & lungs before anything else such as BP) Tearless cry normal until 3 months old Posterior fontanel closes by 2 months o The younger the baby the WIDER the fontanel o If not closing worried about microcephaly…brain needs room to grow Anterior fontanel closes by 12 months Teeth eruption 4 to 8 teeth by 1 year Check ear alignment o Worried about head shape, genetics o Ears lower than normal could indicate possible Down Syndrome Lower edge of liver sometimes felt Legs appear bowed until lower back & leg muscles are well developed o Haven’t developed the tone to straighten legs yet Looking for uneven gluteal folds or Ortolani’s click/clunk Feet may turn in or out OK if feet return to normal position o If you can’t…club foot & needs casting Blood-tinged vaginal mucous OK if newbornfrom utero or the mother Foreskin not retractable until 1-2 years old Nose breathers until 5 months old o Don’t know how to open mouth to breathe Plot height, weight, & head circumference on growth chart EVERY visit BMI for those > 2 years old Positive red reflex bilaterally Denver IIdevelopmental screening tool FLACC Pain Scale o Face 0: No expression 1: Occasional grimace 2: Frequent to constant quivering chin o Legs 0: Normal position or relaxed 1: Uneasy restless, tense 2: Kicking or legs drawn up o Activity 0: Lying quiet 1: Squirming, shifting back & forth, tense 2: Arched, rigid, or jerking o Cry 0: No cry 1: Moans or whimpers 2: Crying steadily o Consolability 0: Content, relaxed 1: Reassurance, hugging 2: Difficult to console
(INFANT) Anticipatory guidance: Sleep o Birth-3 months10-16 hours o 3-6 months14 hours o 6-12 months12-14 hours o As they get older, they need sleep less & less o Put baby in dark, quiet room o Provide blanket o Have a constant routine o Put baby in crib while still awakelearn to fall asleep & calm themselves o Back to sleepprevent SIDS, concerned about this before they can turn over Oral health o Wipe gums 1-2 times/dayespecially after last feeding, warm water & wash cloth o No bottle in beddental caries o When teething offer safe cool teething toys for comfort Mental health o Good growth o Child & parent interactioneye contact, secure holding/cuddling, comforting o Also concerned about health of mother (postpartum depression?) o Infant’s ability to self comfort Play o Play with infant daily o Vocalize frequently, 12-15 inches from face) o Read to infant6 months o Floor time aka “tummy time” Back of head gets flat from being on back, loss of muscle tone in neck o Grasp large toys, shakes rattle Disease prevention o Vaccines Injury prevention o Infant car seat (rear facing for neck protection) o Crib safety (rails up, avoid toys in crib) o Sleep on back o Toy safety o Violence in the home (never shake the baby) o Install gates/guards on stairs & windows o Use safety plugs for outlets o Avoid string toys, necklaces, cords near the infant o Poison control (INFANT) Nutrition: Feedings should be “on demand”depends on size of the baby & the baby itself Newborn-3 months o 1-6 oz. every 2-4 hours o No solid foods 4-6 months o 6-8 oz. every 4-6 hours o Iron fortified cereals, fruits, & vegetables 7-11 months o 6-8 oz. every 6-8 hours o Maximum of 32 oz./day o Offer finger foodmore about oral motor skills, good head control, picking up food to mouth, & chewing Milk based formula Soy based formula Preparations: o Ready to feed o Concentrate o Powder
Can’t have cow’s milkdoes not have the right combo of calories, vitamins, and is not pre-digested, infants don’t have the right enzymes to break this down, therefore they cannot absorb it and will not grow properly Fruit juices NOT recommended dental caries & obesity associated with high sugar, also some correlation to ADHD Formula can be mixed with tap or bottled water Use cold water & run tap for 2 minutes beforelead tends to bind to hot water Refrigerate formula once mixed to decrease bacteria o Lead toxicity can cause developmental delays Discard any formula the baby doesn’t drink…do not reuse Breast milk/formula used till 1 year old
(TODDLER) Physical exam/assessment: Allow “warm-up” time prior to touching child Only remove clothing needed for each part of assessment Least to most intrusive Give choice when possible Primary dentition (20 teeth) completed by 30 months (TODDLER) Anticipatory guidance: Sleep o 8-13 hours/day o Naps 16-20 monthsmorning nap eliminated One long afternoon nap (1-3 hours) o Nightmares during early sleep o Night terrors during second half of sleep Due to active imagination & increased dream state Can be related to stress or anxiety Oral health o Dental caries increased o Brush teeth twice daily (soft brush, not a lot of fluoride toothpaste) o Limit sweet drinks & snacks o Visit dentist every 6 months Mental health o Temper tantrums Common Screaming, crying, kicking Way to express anger Should decrease with age Usually occurs when they are tired Help avoid tantrums with distraction at early signs Separate from others (avoids attention getting) Play o Parallel play (you play with your toy, I play with mine) o Imitation o Push-pull toys, balls, riding toys, finger paint, crayons, puzzles with large pieces, blocks Toilet training o Child is ready when… Diaper dry more than 2 hours Child can pull pants on & off Imitates parents/siblings in the bathroom Able to follow instructions Shows interest in toileting activites Most children ready at 2-2 ½ years old o Have them pick out “big boy” or “big girl” underwear o Potty chair in bathroom o Have a routine o Reward & praise success o If child doesn’t cooperate, wait a few weeks & try again
Lead levels o Toxicity can cause growth problems, behavior problems, & difficulty hearing o Exposed by swallowing it or breathing it in o First was in paint, but banned in 1978 o Also in water (run for ~1 minute before use) o < 9 asymptomatic with some neurological deficits o 10-19 mild impairment in growth & cognition, anemia o 20-44 fatigue, motor impairment, difficulty concentrating, tremors, abdominal pain, weight loss, & anemia o 45-69 severe abdominal pain, anorexia, vomiting, irritable, & lethargic o > 70 encephalopathy, seizures, coma, & death o > 5 = should be seen by physician till levels read 3 (lowest reading) o Anything greater than 5 gets reported to health departmentdetermines where lead is coming from o Treatment: remove lead from environment, test for iron deficiency/anemia, > 45 chelation therapy (agent that binds with lead, decreases its effects, increases rate of excretion), stick NG tube in tar to get lead out Disease prevention o Vaccines Injury prevention o MVA, falls, poisoning, burns, drownsteach to call 911
(TODDLER) Nutrition: Toddlers need LESS calories/day than infants Preschoolers need 90 calories/kg…1800 calories/day 3 meals & 2-3 snacks per day Avoid juice/soda No more than 2 cups of milk per day o Filing up on just milk can lead to anemia o Calcium doesn’t allow body to absorb iron Food jags (only eats a few foods)concerned if all they want is same thing over & over No force feeding Mealtime should be enjoyable (INFANT/TODDLER) Safety: Parents know their child best, listen to them If child doesn’t “look right” respond immediately Check environmental surroundings Recheck/respond to vital signs if “off” Know your team Good communication Pay close attention to dosage calculations (mg/kg) If parent questions whether a medication should be given , listen, answer their questions, double check orders, involve the team in the process Pay close attention to child’s fluid status Crib rails up at ALL times (SCHOOL AGE) Physical exam/assessment: Explain everything Respect need for privacy Use words child will understand Go from head to toe Permanent teeth begin to come in Assess for scoliosis Begin to see secondary sex characteristics
(SCHOOL AGE) Anticipatory guidance: Sleep Oral health Mental health Disease prevention o Obesity BMI most reliable indicator of fatness (greater than or equal to 95 th percentile = obesity) Overweight= 85th-94th percentile Obese children have a 70-80% chance of becoming obese adult Higher risk to develop: DM type 2, HTN, asthma, obstructive sleep apnea, non-alcoholic liver disease, early puberty/menstruation, anorexia/bulimia, depression, low self-esteem, & anxiety Genetics plays a role Use of technology, TV, limited physical activity, increased portion size Parents also play a role Treatment: decrease calories, increase physical activity, calcium & iron, 5 fruit/vegetables daily, follow-up appointments Injury prevention o Car safety! Children over 40 pounds (4-8 years old)forward facing booster seat in the back Children 4’ 9” and tallerregular car seat with lap & shoulder belt 12 and older can legally sit in front, but recommended all children sit in back It’s about height not age o Head injuriesbicycle helmets important (SCHOOL AGE) Nutrition: Dietary screenings o Beverages consumed? (Stop soda/juices, can lose up to 15 pounds/year) o Typical eating schedule? o What is child’s appetite like? o Any allergies? o Any concerns about eating habits? o Want to avoid heart changes & diabetic problems Other:
We compare child to his/herself NOT other kids to make sure growing and developing at a good/normal rate The earlier we pick something up, the better we are able to intervene in order to for them to reach their potential
MEDICATION ADMINISTRATION [5 Questions] Dosage Calculations: Daily I/O calculations: o Maintenance IV: <10 kg; 100ml/kg/day 11-20 kg; 1000ml + 50ml/kg/day (for each kg over 10) >20 kg; 1500 ml + 20 ml/kg/day (for each kg over 20) o Output: For weight to mL: 1 oz = 30 mL or 1 gm wet diaper = 1 mL of urine Output should be 1-2 mL/kg/hour Acetaminophen dosing: o Pediatric: 10 – 15 mg/kg/dose Q 4-6 hours o Max dose: 4g/24 hr., 5 doses/24 hr. (can lead to hepatotoxicity; use mucomyst to treat OD) Medication Rights: 1. Right patient 2. Right vaccine 3. Right time 4. Right dose 5. Right route, needle length, & technique 6. Right site 7. Right documentation Pediatric Variations: Multiple shots must be 1” apart DO NOT have parent hold down the infant during the procedure Comfort measures: o Breast feed o Distraction o Most painful last o Topical analgesics o Administer fast o Dual administration o Antipyretics Reactions within 21 days should be reported, if bad the lot # gets removed Have Epinephrine & Benadryl available Oral medications: o Most commonly given (elixir, syrup, suspension) o Children under 5 cannot swallow pills/capsules o Avoid putting medication in juice or bottle (won’t know how much the take of the medication if not finished) o Some tablets can be crushed & mixed with applesauce or pudding o Use oral syringe & give slowly o Aim inside cheek o Preschoolers may prefer medicine cup Eye drops: o Lower lid down o Child look up o Administer drops into the lower conjunctival sac Ear drops: o Pinna down & back (< 3 years old) o Pinna up & back (> 3 years old) Nasal drops: o Hyperextend head o Place dropper just at nasal opening Nasal spray: o Upright position o Tip of spray just inside nasal opening & squeeze container
DEVELOPMENTAL MILESTONES [8 Questions] INFANT (Birth-1 month) Age & Physical Growth Gross Motor o Reflexes present o *No head control, but can briefly hold head midline o Head lag o Assumes flexed position o When supine, assumes tonic neck flex position o Rounded back when sitting o Rolls over accidently Fine Motor o Hands closed o *Strong palmar & plantar grasp Cognitive, Sensory, & Language o Touch is the FIRST sense to develop o Smell: can recognize mother, has taste preference for sweets o Hearing well developed, becomes quiet when hears familiar voice o Limited visual acuity (20/100) o Fascinated with faces, follows moving objects, contrasting colors o Cries to express unmet needs o Smiles during sleep Psychosocial & Play o Relieves anxiety through oral sensations (ie: breastfeeding, sucking on fist) o *Makes comfort sounds when eating o Interaction with parents & caregivers INFANT (1-2 months) Age & Physical Growth Gross Motor o Less head lag when pulled to sitting position o *Head lift slightly when prone (45 degrees) o Improved head control o Can turn head from side to side o Some head control when upright Fine Motor o *Holds hands open o Absent grasp reflex o Can pull at clothes/blanket o Bats at object Cognitive, Sensory, & Language o *When supine follows dangling toys o Visually searches for sounds o Easily consoled by being held or spoken to o Turns head to sound o *Coos, social smile Psychosocial & Play o Learns to calm self o Solitary play stimulates sensorimotor development with simple imitative games o Interaction with parents & caregivers through games INFANT (3-6 months) Age & Physical Growth Gross Motor o Can hold head up better when sitting o *Slight before 6 months/no head lag at 6 months o Raises head 45-90 degrees of floor o *Sitting position (tripod)back straight, balances head well o When held in standing position, can bear some weight o Rolls from back to side, & then abdomen to back o When supinepulls feet to mouth o Starts to creep on hands & knees Fine Motor o Pulls blanket over face o Rakes objects
o Palmer grasp o Shakes rattle & holds bottle o Eventually able to bang two objects together o Carries objects to mouth o Transfers objects from hand to hand o *Reaches & bangs toys on table o Likes mirror images Cognitive, Sensory, & Language o Sees small objects o Develops binocular vision o Follows object 180 degrees o Responds to name o Recognizes parent’s voice & touch o *Coos, babbles, laughs o *By 6 months says “dada” & “baba” o Begins to distinguish emotion based on tone of voice Psychosocial & Play o Interaction with parents/caregivers through games o Learns to relieve anxiety through oral sensations o Begins to trust caregiver o Solitary play stimulates sensorimotor development with simple imitative games
INFANT (9-12 months) Age & Physical Growth Gross Motor o *Creeps on hands and knees o *Pulls self to standing position o Stands while holding onto furniture and begins to cruise o *Stands alone o Changes from prone to sitting position o Can reach backwards while sitting o Begins to walk holding hand and then independently- takes 1st step Fine Motor o *Uses pincer grasp o Hand dominance now evident o Releases and rescues an object, when sitting o Purposely reaches around back to retrieve object o Can randomly turn pages in a book o Can make a simple mark on paper o *Waves bye-bye and plays pat-a-cake, begins to feed self finger foods Cognitive, Sensory, & Language o Increasing depth perception o Moves toward sound, thoroughly explores and experiences objects o Points to simple objects o *Can say mama, dada o Understands a few words o Responds to own name o Exhibits stranger anxiety o Begins to distinguish colors o Increasing ability to see things in the distance Psychosocial & Play o Completes Erikson’s stage of trust vs. mistrust o Able to calm self o Solitary play stimulates sensorimotor development with simple games, finger painting, ball rolling, high chair fishing
TODDLER (1-3 years) Age & Physical Growth Gross Motor o Stands without support o Walks independently o Walks backward o Creeps up stairs o Pulls toys while walking o Runs with wide stance o Jumps in place with both feet o Climbs o Throws a ball; eventually kicks the ball o Rides a tricycle by 3 o Begins to stand on one foot, can walk up and down stairs with alternate feet o Blows kisses Fine Motor o Holds a pencil or a large crayon o Makes artwork that is more representative of the object o Copies a circle and cross by age 3, copies a circle and cross by age 3 o Knows colors o Feeds self with a spoon and drinks from a cup o Constantly throws objects on floor o Builds tower of 3-4 cubes, eventually building tower of 7-8 cubes o Turns pages in a book one page at a time o Turns knobs o Removes shoes and socks and begins to dress themselves o Toilet training Cognitive, Sensory, & Language o Experiments and learns new behaviors o Begins to learn cause and effect o Imitates behaviors of parents and caretakers o Well-developed vision o Can identify geometric objects o Intense interest in picture books and listens to stories o Distinguishes food preferences based on senses o Simple words/phrases o Follows simple instructions Psychosocial & Play o Increases control of self and environment; explores, learns about safety and boundaries but may test those boundaries o Parallel play with other children
EARLY CHILDHOOD (3-6 years) Age & Physical Growth Gross Motor o Dresses self o Throws and catches ball o Pedals tricycle o Kicks ball forward o Stands on one foot for 5-10 seconds o Skips and hops on one foot o Walks down steps with alternate feet o Jumps from bottom step o Balances on alternate feet with eyes closed Fine Motor o Moves around in a more balanced fashion o Builds tower of 9-10 cubes o Draws stick figure with 6 parts o Uses scissors to cut outline of picture o Copies and traces geometric patterns o Ties shoelaces o Uses utensils, colors o Prints letters o Mostly independent in toileting and dressing Cognitive, Sensory, & Language o Focus is on self o Uses language to convey concepts o Concrete thinking o Well-developed senses o Preferences based on the use of sense o Learns address and phone number o Recognizes most letters o Vocabulary up to 2,000 words o Sings songs o Enjoys silly words o Ask why a lot Psychosocial & Play o Begins to regulate own behavior o Learns about rules o Increases confidence to try new things o Recognizes the differences between boys and girls o Associative play
SCHOOL AGE (6-12 years) Age & Physical Growth Gross Motor o Gradually increases in dexterity and becomes limber o Improves coordination o Strength, balance, and rhythm, climbs, bikes, jumps rope, learns to swim, skate, etc. Fine Motor o Good hand-eye coordination o Balance improves o Good at arts and crafts o Video games o Handwriting improves, prints and writes o Likes activities that improve dexterity such as musical instruments & building things Cognitive, Sensory, & Language o Increased logical thinking leads child to be able to solve problems o Wants to know how things wok o Understands that actions have consequences o Aware of own thinking and how conclusions were reached o 20/20 visual acuity, color discrimination is fully developed o Mature sense of smell o Hearing deficits may be discovered as language develops o Accelerated vocabulary up to 15,000 words o Jokes o Experiments with profanity Psychosocial & Play o Increases peer group involvement o Same-sex friends o Increased self-confidence o Cooperative play teaches how to bargain, increased social skills, & team sports *These were specifically on lecture slides as well as the textbook
IMMUNIZATION ADMINISTRATION [5 Questions] RN responsibilities with vaccine administration: No ordersthere are standing orders for immunizations that RNs can administer Must provide vaccine information BEFORE administering (Federal Law) Ask parents if they have any questions Obtain consent IM injections= 1” needle SubQ injections= 5/8” needle All immunizations are IM EXCEPT MMR & Varicellathese two are LIVE vaccines Best spot is anterior aspect of the thigh Passive immunity from mom protects baby for first 6 months High fever= no vaccine, could be from immunization & can also decrease immunization response Be aware of allergies HOSPITAL CARE: INFANT/TODDLER [2 Questions] Safety comes first! Minimize separation anxiety o Rooming in o Assessment of daily routines o Establish similar daily patterns o Constant staff members o Assist parents in communicating their absences Minimize loss of control o Promote freedom of movement (ie: walking around with IV) o Maintain child’s routine o Encourage independence o Promote understanding Perform procedures in the procedure room, NOT hospital bed/crib Don’t allow choices when none are available Allow child to cry/scream IVveins are small & fragile, want to frequently assess site Reactions to pain: irritable, poor feeding, restlessness, disturbed sleep patterns, tachycardia, increased RR, and/or lethargy Encourage siblings to visit
