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Chapter 10: Health Problems of Infants Hockenberry: Wong’s Essentials of Pediatric Nursing, 10th Edition MULTIPLE CHOICE 1. Recent studies indicate that a deficiency of which vitamin correlates with increased morbidity

and mortality in children with measles? a. A b. C c. Niacin d. Folic acid ANS: A

Vitamin A deficiency is correlated with increased morbidity and mortality in children with measles. This vitamin deficiency also is associated with complications from diarrhea, and infections are often increased in infants and children with vitamin A deficiency. No correlation exists between vitamin C, niacin, or folic acid and measles.

DIF: Cognitive Level: Remember REF: p. 331 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity 2. Which vitamin is recommended for all women of childbearing age to reduce the risk of neural

tube defects such as spina bifida? a. A b. C c. Niacin d. Folic acid ANS: D

The vitamin supplement that is recommended for all women of childbearing age is a daily dose of 0.4 mg of folic acid. Folic acid taken before conception and during pregnancy can reduce the risk of neural tube defects by 70%. No correlation exists between vitamins A, C, or folic acid and neural tube defects.

DIF: Cognitive Level: Remember REF: p. 331 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity 3. A nurse is assessing a child with kwashiorkor disease. Which assessment findings should the

nurse expect? a. Thin wasted extremities with a prominent abdomen b. Constipation c. Elevated hemoglobin d. High levels of protein ANS: A

The child with kwashiorkor has thin, wasted extremities and a prominent abdomen from edema (ascites). Diarrhea (persistent diarrhea malnutrition syndrome) not constipation commonly occurs from a lowered resistance to infection and further complicates the electrolyte imbalance. Anemia and protein deficiency are common findings in malnourished children with kwashiorkor.

DIF: Cognitive Level: Understand REF: p. 332 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity 4. A nurse is preparing to accompany a medical mission’s team to a third world country.

Marasmus is seen frequently in children 6 months to 2 years in this country. Which symptoms should the nurse expect for this condition? a. Loose, wrinkled skin b. Edematous skin c. Depigmentation of the skin d. Dermatoses ANS: A

Marasmus is characterized by gradual wasting and atrophy of body tissues, especially of subcutaneous fat. The child appears to be very old, with loose and wrinkled skin, unlike the child with kwashiorkor, who appears more rounded from the edema. Fat metabolism is less impaired than in kwashiorkor; thus, deficiency of fat-soluble vitamins is usually minimal or absent. In general, the clinical manifestations of marasmus are similar to those seen in kwashiorkor with the following exceptions: With marasmus, there is no edema from hypoalbuminemia or sodium retention, which contributes to a severely emaciated appearance; no dermatoses caused by vitamin deficiencies; little or no depigmentation of hair or skin; moderately normal fat metabolism and lipid absorption; and a smaller head size and slower recovery after treatment.

DIF: Cognitive Level: Understand REF: p. 332 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity 5. Rickets is caused by a deficiency in: a. vitamin A. b. vitamin C. c. vitamin D and calcium. d. folic acid and iron.

ANS: C

Fat-soluble vitamin D and calcium are necessary in adequate amounts to prevent the development of rickets. No correlation exists between vitamins A, C, folic acid, or iron and rickets.

DIF: Cognitive Level: Remember REF: p. 330 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity 6. A nurse is preparing to administer an oral iron supplement to a hospitalized infant. Which

should not be given simultaneously with the iron supplement?

a. b. c. d.

Milk Multivitamin Fruit juice Meat, fish, poultry

ANS: A

Many foods interfere with iron absorption and should be avoided when the iron is consumed.

These foods include phosphates found in milk, phytates found in cereals, and oxalates found in many vegetables. Multivitamins may contain iron; no contraindication exists to taking the two together. Vitamin C–containing juices enhance the absorption of iron. Meat, fish, and poultry do not have an effect on absorption.

DIF: Cognitive Level: Understand REF: p. 331 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity 7. Parents report that they have been giving a multivitamin to their 1-year-old infant. The nurse

counsels the parents that which vitamin can cause a toxic reaction at a low dose? a. Niacin b. B6 c. D d. C ANS: C

Hypervitaminosis of vitamin D presents the greatest problem because this fat-soluble vitamin is stored in the body. Vitamin D is the most likely of all vitamins to cause toxic reactions in relatively small overdoses. The water-soluble vitamins, primarily niacin, B6, and C, can also cause toxicity but not at the low dose that occurs with vitamin D. DIF: Cognitive Level: Understand REF: p. 331 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity 8. The nurse is helping parents achieve a more nutritionally adequate vegetarian diet for their

child. Which is most likely lacking in their particular diet? a. Fat b. Protein c. Vitamins C and A d. Complete protein ANS: D

The vegetarian diet can be extremely healthy, meeting the overall nutrition objectives for Healthy People. Parents should be taught about food preparation to ensure that complete proteins are available for growth. When parents use a strict vegetarian diet, likelihood exists of inadequate protein for growth and calories for energy. Fat and vitamins C and A are readily available from vegetable sources. Plant proteins are available. Foods must be combined to provide complete proteins for growth.

DIF: Cognitive Level: Understand REF: p. 331 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity

9. Which describes marasmus? a. Deficiency of protein with an adequate supply of calories b. Not confined to geographic areas where food supplies are inadequate c. Syndrome that results solely from vitamin deficiencies d. Characterized by thin, wasted extremities and a prominent abdomen resulting from

edema (ascites) ANS: B

Marasmus is a syndrome of emotional and physical deprivation. It is not confined to geographic areas were food supplies are inadequate. Marasmus is a deficiency of both protein and calories. It is characterized by gradual wasting and atrophy of body tissues, especially of subcutaneous fat. The child appears very old, with flabby and wrinkled skin.

DIF: Cognitive Level: Remember REF: p. 332 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity 10. Although infants may be allergic to a variety of foods, the most common allergens are: a. fruit and eggs. b. fruit, vegetables, and wheat. c. cow’s milk and green vegetables. d. eggs, cow’s milk, and wheat.

ANS: D

Milk products, eggs, and wheat are three of the most common food allergens. Ingestion of these products can cause sensitization and, with subsequent exposure, an allergic reaction.

Eggs are a common allergen, but fruit is not. Wheat is a common allergen, but fruit and vegetables are not. Cow’s milk is a common allergen, but green vegetables are not.

DIF: Cognitive Level: Remember REF: p. 333 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity 11. Cow’s milk allergy (CMA) is diagnosed in a 6-month-old infant. Which should the nurse

recommend as a substitute formula? a. Nutramigen b. Goat’s milk c. Similac d. Enfamil ANS: A

Treatment of CMA is elimination of cow’s milk–based formula and all other dairy products.

For infants fed cow’s milk formula, this primarily involves changing the formula to a casein hydrolysate milk formula (Pregestimil, Nutramigen, or Alimentum). Goat’s milk (raw) is not an acceptable substitute because it cross-reacts with cow’s milk protein, is deficient in folic acid, has a high sodium and protein content, and is unsuitable as the only source of calories.

Cow’s milk protein is contained in both Enfamil and Similac.

DIF: Cognitive Level: Apply REF: p. 336 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity

12. A nurse is teaching parents about prevention and treatment of colic. Which should the nurse

include in the teaching plan? a. Avoid use of pacifiers. b. Eliminate all second-hand smoke contact. c. Lay infant flat after feeding. d. Avoid swaddling the infant.

ANS: B

To prevent and treat colic, teach parents that if household members smoke, avoid smoking near infant; preferably confine smoking activity to outside of home. A pacifier can be introduced for added sucking. The infant should be swaddled tightly with a soft, stretchy blanket and placed in an upright seat after feedings.

DIF: Cognitive Level: Apply REF: p. 336 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity 13. A parent of an infant with colic tells the nurse, “All this baby does is scream at me; it is a

constant worry.” What is the nurse’s best action? a. Encourage parent to verbalize feelings. b. Encourage parent not to worry so much. c. Assess parent for other signs of inadequate parenting. d. Reassure parent that colic rarely lasts past age 9 months.

ANS: A

Colic is multifactorial, and no single treatment is effective for all infants. The parent is verbalizing concern and worry. The nurse should allow the parent to put these feelings into words. An empathic, gentle, and reassuring attitude, in addition to suggestions about remedies, will help alleviate the parent’s anxieties. The nurse should reassure the parent that he or she is not doing anything wrong. Colic is multifactorial. The infant with colic is experiencing spasmodic pain that is manifested by loud crying, in some cases up to 3 hours each day. Telling the parent that it will eventually go away does not help him or her through the current situation.

DIF: Cognitive Level: Apply REF: p. 342 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Psychosocial Integrity 14. Parent guidelines for relieving colic in an infant include: a. avoiding touching abdomen. b. avoiding using a pacifier. c. changing infant’s position frequently. d. placing infant where family cannot hear the crying.

ANS: C

Changing the infant’s position frequently may be beneficial. The parent can walk holding the child face down and with the child’s chest across the parent’s arm. The parent’s hand can support the child’s abdomen, applying gentle pressure. Gently massaging the abdomen is effective in some children. Pacifiers can be used for meeting additional sucking needs. The child should not be placed where monitoring cannot be done. The child can be placed in the crib and allowed to cry. Periodically, the child should be picked up and comforted.

DIF: Cognitive Level: Apply REF: p. 342 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity 15. Clinical manifestations of failure to thrive caused by behavioral problems resulting in

inadequate intake of calories include: a. avoidance of eye contact. b. an associated malabsorption defect. c. weight that falls below the 15th percentile. d. normal achievement of developmental landmarks.

ANS: A

One of the clinical manifestations of nonorganic failure to thrive is the child’s avoidance of eye contact with the health professional. A malabsorption defect would result in a physiologic problem, not behavioral. Weight (but not height) below the 5th percentile is indicative of failure to thrive. Developmental delays, including social, motor, adaptive, and language, exist.

DIF: Cognitive Level: Understand REF: p. 337 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity 16. Which is an important nursing consideration when caring for an infant with failure to thrive? a. Establish a structured routine and follow it consistently. b. Maintain a nondistracting environment by not speaking to child during feeding. c. Place child in an infant seat during feedings to prevent overstimulation. d. Limit sensory stimulation and play activities to alleviate fatigue.

ANS: A

The infant with failure to thrive should have a structured routine that is followed consistently.

Disruptions in other activities of daily living can have a great impact on feeding behaviors.

Bathing, sleeping, dressing, playing, and feeding are structured. The nurse should talk to the child by giving directions about eating. This will help the child maintain focus. Young children should be held while being fed, and older children can sit at a feeding table. The child should be fed in the same manner at each meal. The child can engage in sensory and play activities at times other than mealtime.

DIF: Cognitive Level: Apply REF: p. 337 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity 17. What is an important nursing responsibility when dealing with a family experiencing the loss

of an infant from sudden infant death syndrome (SIDS)? a. Explain how SIDS could have been predicted and prevented. b. Interview parents in depth concerning the circumstances surrounding the child’s death. c. Discourage parents from making a last visit with the infant. d. Make a follow-up home visit to parents as soon as possible after the child’s death.

ANS: D

A competent, qualified professional should visit the family at home as soon as possible after the death and provide the family with printed information about SIDS. An explanation of how SIDS could have been predicted and prevented is inappropriate. SIDS cannot be prevented or predicted. Discussions about the cause will only increase parental guilt. The parents should be asked only factual questions to determine the cause of death. Parents should be allowed and encouraged to make a last visit with their child.

DIF: Cognitive Level: Apply REF: p. 343 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Psychosocial Integrity 18. Which is an appropriate action when an infant becomes apneic? a. Shake vigorously b. Roll head side to side c. Hold by feet upside down with head supported d. Gently stimulate trunk by patting or rubbing ANS: D

If the infant is apneic, the infant’s trunk should be gently stimulated by patting or rubbing. If the infant is prone, turn onto the back. The infant should not be shaken vigorously, the head rolled side to side, or held by the feet upside down with the head supported. These can cause injury.

DIF: Cognitive Level: Apply REF: p. 349 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity 19. To prevent plagiocephaly, the nurse should teach parents to: a. place infant prone for 30 to 60 minutes per day. b. buy a soft mattress. c. allow infant to nap in the car safety seat. d. have infant sleep with the parents.

ANS: A

Prevention of positional plagiocephaly may begin shortly after birth by implementing prone positioning or “tummy time” for approximately 30 to 60 minutes per day when the infant is awake. Soft mattresses or sleeping with parents (co-sleeping) are not recommended because they put the infant at a higher risk for a sudden infant death incident. To prevent plagiocephaly, prolonged placement in car safety seats should be avoided.

DIF: Cognitive Level: Apply REF: p. 348 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity 20. An infant has been pronounced dead from sudden infant death syndrome (SIDS) in the

emergency department. Which is an appropriate question to ask the parents? a. “Did you hear the infant cry out?” b. “Why didn’t you check on the infant earlier?” c. “What time did you find the infant?” d. “Was the head buried in a blanket?”

ANS: C

During a SIDS incident, if the infant is not pronounced dead at the scene, he or she may be transported to the emergency department to be pronounced dead by a physician. While they are in the emergency department, the parents are asked only factual questions, such as when they found the infant, how he or she looked, and whom they called for help. The nurse avoids any remarks that may suggest responsibility, such as “Why didn’t you go in earlier?” “Didn’t you hear the infant cry out?” “Was the head buried in a blanket?”

DIF: Cognitive Level: Apply REF: p. 347 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Psychosocial Integrity 21. An infant experienced an apparent life-threatening event (ALTE) and is being placed on home

apnea monitoring. Parents have understood the instructions for use of a home apnea monitor when they state? a. “We can adjust the monitor to eliminate false alarms.” b. “We should sleep in the same bed as our monitored infant.” c. “We will check the monitor several times a day to be sure the alarm is working.” d. “We will place the monitor in the crib with our infant.”

ANS: C

The parents should check the monitor several times a day to be sure the alarm is working and that it can be heard from room to room. The parents should not adjust the monitor to eliminate false alarms. Adjustments could compromise the monitor’s effectiveness. The monitor should be placed on a firm surface away from the crib and drapes. The parents should not sleep in the same bed as the monitored infant.

DIF: Cognitive Level: Apply REF: p. 349 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity 22. What should the nurse suggest to the parents of an infant who has a prolonged need for

middle-of-the-night feedings? a. Decrease daytime feedings. b. Allow child to go to sleep with a bottle. c. Offer last feeding as late as possible at night. d. Put infant to bed after asleep from rocking.

ANS: C

To manage an infant who has a prolonged need for middle-of-the-night feedings parents should be taught to offer last feeding as late as possible at night. Parent should increase daytime feeding intervals to 4 hours or more (may need to be done gradually), offer no bottles in bed, put to bed awake and when child is crying, check at progressively longer intervals each night; reassure child but do not hold, rock, take to parent’s bed, or give bottle or pacifier.

DIF: Cognitive Level: Apply REF: p. 349 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Psychosocial Integrity 23. A nurse is preparing to feed a 12-month-old infant with failure to thrive. Which intervention

should the nurse implement? a. Provide stimulation during feeding.

b. Avoid being persistent during feeding time. c. Limit feeding time to 10 minutes. d. Maintain a face-to-face posture with the infant during feeding.

ANS: D

The nurse preparing to feed an infant with failure to thrive should maintain a face-to-face posture with the infant when possible. Encourage eye contact and remain with the infant throughout the meal. Stimulation is not recommended; a quiet, unstimulating atmosphere should be maintained. Persistence during feeding may need to be implemented. Calm perseverance through 10 to 15 minutes of food refusal will eventually diminish negative behavior. Although forced feeding is avoided, “strictly encouraged” feeding is essential. The length of the feeding should be established (usually 30 minutes); limiting the feeding to 10 minutes would make the infant feel rushed.

DIF: Cognitive Level: Apply REF: p. 342 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity 24. A nurse is teaching a parent of an infant about treatment of seborrhea dermatitis (cradle cap).

Which should the nurse include in the instructions? a. Shampoo every three days with a mild soap. b. The hair should be shampooed with a medicated shampoo. c. Shampoo every day with an antiseborrheic shampoo. d. The loosened crusts should not be removed with a fine-toothed comb.

ANS: C

When seborrheic lesions are present, the treatment is directed at removing the crusts. Parents are taught the appropriate procedure to clean the scalp. Shampooing should be done daily with a mild soap or commercial baby shampoo; medicated shampoos are not necessary, but an antiseborrheic shampoo containing sulfur and salicylic acid may be used. Shampoo is applied to the scalp and allowed to remain on the scalp until the crusts soften. Then the scalp is thoroughly rinsed. A fine-tooth comb or a soft facial brush helps remove the loosened crusts from the strands of hair after shampooing.

DIF: Cognitive Level: Apply REF: p. 346 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity MULTIPLE RESPONSE 1. After the introduction of the Back to Sleep campaign in 1992, an increased incidence has been

noted of which of the following pediatric disorders? (Select all that apply.) a. SIDS b. Torticollis c. Failure to thrive d. Apnea of infancy e. Plagiocephaly ANS: B, E

Plagiocephaly is a misshapen head caused by the prolonged pressure on one side of the skull.

If that side becomes misshapen, facial asymmetry may result. The sternocleidomastoid muscle may tighten on the affected side, causing torticollis. SIDS has decreased by more than 40% with the introduction of the Back to Sleep campaign. Apnea of infancy and failure to thrive are unrelated to the Back to Sleep campaign.

DIF: Cognitive Level: Understand REF: p. 346 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity 2. A nurse is conducting education classes for parents of infants. The nurse plans to discuss

sudden infant death syndrome (SIDS). Which risk factors should the nurse include as increasing an infant’s risk of a sudden infant death syndrome incident? (Select all that apply.) a. Breastfeeding b. Low Apgar scores c. Male sex d. Birth weight in the 50th or higher percentile e. Recent viral illness ANS: B, C, E

Certain groups of infants are at increased risk for SIDS: low birth weight, low Apgar scores, recent viral illness, and male sex. Breastfed infants and infants of average or above average weight are not at higher risk for SIDS. DIF: Cognitive Level: Understand REF: p. 336 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Health Promotion and Maintenance 3. An infant has been diagnosed with cow’s milk allergy. What are the clinical manifestations

the nurse expects to assess? (Select all that apply.) a. Pink mucous membranes b. Vomiting c. Rhinitis d. Abdominal pain e. Moist skin ANS: B, C, D

An infant with cow’s milk allergy will possibly have vomiting, rhinitis, and abdominal pain.

The mucous membranes may be pale due to anemia from blood lost in the GI tract, and the skin will be itchy with the possibility of atopic dermatitis.

DIF: Cognitive Level: Understand REF: p. 346 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity 4. Which interventions should the nurse implement when caring for a family of a sudden infant

death syndrome (SIDS) infant? (Select all that apply.) a. Allow parents to say goodbye to their infant. b. Once parents leave the hospital, no further follow-up is required. c. Arrange for someone to take the parents home from the hospital. d. Avoid requesting an autopsy of the deceased infant.

e. Conduct a debriefing session with the parents before they leave the hospital.

ANS: A, C, E

An important aspect of compassionate care for parents experiencing a SIDS incident is allowing them to say good-bye to their infant. These are the parents’ last moments with their infant, and they should be as quiet, meaningful, peaceful, and undisturbed as possible.

Because the parents leave the hospital without their infant, it is helpful to accompany them to the car or arrange for someone else to take them home. A debriefing session may help health care workers who dealt with the family and deceased infant to cope with emotions that are often engendered when a SIDS victim is brought into the acute care facility. An autopsy may clear up possible misconceptions regarding the death. When the parents return home, a competent, qualified professional should visit them after the death as soon as possible.

DIF: Cognitive Level: Understand REF: p. 340 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Psychosocial Integrity 5. Where do the lesions of atopic dermatitis (eczema) most commonly occur in the infant?

(Select all that apply.) a. Cheeks b. Buttocks c. Extensor surfaces of arms and legs d. Back e. Trunk f. Scalp ANS: A, C, E, F

The lesions of atopic dermatitis are generalized in the infant. They are most commonly on the cheeks, scalp, trunk, and extensor surfaces of the extremities. The buttocks and back are not common locations for the lesions of atopic dermatitis in infants.

DIF: Cognitive Level: Understand REF: p. 340 TOP: Integrated Process: Nursing Process: Assessment MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential 6. The nurse is talking to a parent of an infant with severe atopic dermatitis (eczema). Which

response(s) should the nurse reinforce with the parent? (Select all that apply.) a. “You can use warm wet compresses to relieve discomfort.” b. “You will need to keep your infant’s skin well hydrated by using a mild soap in the bath.” c. “You should bathe your baby in a bubble bath two times a day.” d. “You will need to prevent your baby from scratching the area by using a mild antihistamine.” e. “You can try a fabric softener in the laundry to avoid rough cloth.” f. “You should apply an emollient to the skin immediately after a bath.”

ANS: B, D, F

The eczematous lesions of atopic dermatitis are intensely pruritic. Scratching can lead to new lesions and secondary infection; an antihistamine can be used. Keeping the skin hydrated is a goal of treating atopic dermatitis. Applying an emollient immediately after a bath helps to trap moisture and prevent moisture loss. Cool wet compresses should be used for relief. Bubble baths and harsh soaps should be avoided, as is bathing excessively, since this leads to drying.

Fabric softener should be avoided because of the irritant effects of some of its components.

DIF: Cognitive Level: Apply REF: p. 340 TOP: Integrated Process: Teaching/Learning MSC: Area of Client Needs: Physiologic Integrity: Reduction of Risk Potential SHORT ANSWER 1. An infant is having an anaphylactic reaction, and the nurse is preparing to administer

epinephrine 0.001 mg/kg. The child weighs 22 pounds. What is the epinephrine dose the nurse should administer? (Record your answer using two decimal places.)

ANS:

0.01 Convert the 22 pounds to kilograms by dividing 22 by 2.2 = 10. Multiply the 10 by 0.001 mg of epinephrine = 0.01 mg as the dose to be given.

DIF: Cognitive Level: Apply REF: p. 334 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity OTHER 1. A school nurse observes a child, with a peanut allergy, in obvious distress, wheezing and

cyanotic, after ingestion of some trail mix containing peanuts. Place the interventions the nurse should implement in order of the highest priority to the lowest priority. Provide answer using lowercase letters separated by commas (e.g., a, b, c, d). a. Call Jason’s parents and notify them of the situation. b. Call Jason’s family practitioner to obtain further orders for medication. c. Promptly administer an intramuscular dose of epinephrine. d. Call 911 and wait for the emergency response personnel to arrive.

ANS:

c, d, b, a The nurse should first administer epinephrine IM to a child with a food allergy who is in obvious distress, wheezing, and cyanotic. 911 should be called after the epinephrine is administered. The physician should be contacted for further orders and, last, the parents notified of the situation.

DIF: Cognitive Level: Apply REF: p. 350 TOP: Integrated Process: Nursing Process: Implementation MSC: Area of Client Needs: Physiologic Integrity