Pediatric nursing: practice questions with explanations

1Children are not small adults

Pediatric nursing cares for children from birth to adolescence, and for their families. Children differ from adults in their size, physiology, development and way of understanding illness.

• Doses are calculated by weight, so an accurate weight in kilograms is essential.
• Young infants breathe mainly through the nose, and their small airways block easily.
• Children compensate for shock for a long time with tachycardia and vasoconstriction. Low blood pressure is a late sign.
• In a hypoxic child, bradycardia is a sign that cardiac arrest may be close.

Typical resting ranges (sources differ, so use your local chart):

• Newborn: heart rate about 110–160/min, respiratory rate about 30–60/min.
• Infant: heart rate about 100–160/min, respiratory rate about 30–60/min.
• Toddler: heart rate about 90–150/min, respiratory rate about 24–40/min.
• School-age child: heart rate about 70–120/min, respiratory rate about 18–30/min.
• Adolescent: close to adult values.

2Growth and development

Growth is plotted on growth charts. A child who stays on a low percentile may be healthy; crossing two major percentile lines needs assessment. Birth weight roughly doubles by 4–6 months and triples by 12 months.

Typical milestones (there is a normal range around each):

• Social smile: about 2 months. Head control: about 4 months.
• Sitting without support: about 6–8 months. Pincer grasp: about 9–12 months.
• Walking alone: about 12 months. Not walking by 18 months is a red flag.
• Two-word phrases: about 2 years.

Loss of skills at any age, and a clear hand preference before about 18 months, are red flags.

Erikson: trust versus mistrust (infant), autonomy versus shame and doubt (toddler), initiative versus guilt (preschool), industry versus inferiority (school age), identity versus role confusion (adolescent).

Piaget: sensorimotor (0–2 years, object permanence), preoperational (2–7, magical thinking), concrete operational (7–11) and formal operational (from about 12).

Play changes with age: parallel play in toddlers, associative play in preschoolers and cooperative play with rules in school-age children.

3The child and family in hospital

Family-centred care treats parents as partners: they share information, take part in decisions and may stay during procedures if they wish.

Separation is the main stress for children from about 6 months to 3 years. A separated young child goes through protest, despair and detachment. Temporary regression, such as bedwetting, is common and should not be punished.

Match explanations to the stage of development:

• Toddler and preschooler: short, simple words just before the procedure, medical play with dolls, a plaster to “close” the skin.
• School-age child: diagrams and real equipment, time for questions and some choices.
• Adolescent: privacy, more detail, time alone with the nurse and clear limits of confidentiality.

Atraumatic care: do painful procedures in a treatment room, not in the bed or playroom, and use topical anaesthetic in time.

4Pain, immunisation and safety

Pain assessment depends on age and ability:

• FLACC (Face, Legs, Activity, Cry, Consolability; 0–10) for preverbal or non-verbal children.
• Wong–Baker FACES for children from about 3 years who can point to a face.
• A numeric 0–10 scale for older children who understand numbers.

Newborns feel pain: breastfeeding, skin-to-skin contact and oral sucrose reduce procedural pain. Codeine and tramadol are not recommended under 12 years.

Immunisation principles (schedules differ by country):

• A mild illness is not a reason to delay.
• Live vaccines are generally avoided in severe immune suppression and pregnancy.
• Anaphylaxis to a previous dose is a contraindication; mild fever and a sore arm are not.
• Several vaccines can be given at one visit, in separate sites; in infants use the vastus lateralis.
• Preterm babies are vaccinated by chronological age.

Safety: back to sleep on a firm flat surface, rear-facing car seats as long as possible, no honey under 12 months, no aspirin in viral illness, safe storage of medicines and chemicals, and urgent care for any swallowed button battery.

5Common conditions

• Croup: barking cough and stridor; corticosteroids, and nebulised epinephrine if severe.
• Epiglottitis: drooling, sitting forward, anxious. Do not examine the throat; get airway experts.
• Bronchiolitis (usually RSV): supportive care, nasal suction, hydration, oxygen if needed. Watch for apnoea in young infants.
• Pyloric stenosis: projectile, non-bilious vomiting at 2–8 weeks. Intussusception: colicky pain and red-currant jelly stool. Hirschsprung disease: no meconium within 48 hours.
• Nephrotic syndrome: heavy proteinuria and oedema. Post-streptococcal glomerulonephritis: cola-coloured urine and hypertension.
• Sickle cell disease: fluids, pain relief and oxygen in a crisis; fever is urgent. Haemophilia: no IM injections, rectal temperatures or aspirin.
• Cystic fibrosis: sweat chloride test; pancreatic enzymes with all meals and snacks.

Any fever of 38 °C or more in an infant under about 3 months needs urgent medical assessment.

6A worked example

Work through the case using ABC and the child’s age.

7How exam questions look

• Easy (key terms and facts): milestones, Erikson and Piaget stages, typical vital-sign ranges, pain scales, safe sleep.
• Medium (applying the concepts): preparing a child of a given age, recognising a condition from its signs, vaccination principles, precautions for a condition.
• Hard (cases and analysis): which child to see first, which finding needs immediate follow-up, which order to question.

In hard questions, compare the answer with the child’s age and development, and remember that children deteriorate fast once their compensation fails.