Peds Exam 1

What is the BIGGEST psychosocial task of infancy according to Erikson?

Trust vs. mistrust.
Infants learn whether caregivers consistently meet needs.

Application:

• Consistent caregivers reduce stress.

• Separation from parents is the major fear.

What stage is an infant in according to Piaget?

Sensorimotor stage.

Application:
Infants learn through:

• touch

• sound

• movement

• putting objects in mouth

So nursing care should include:

• pacifiers

• soft touch

• rattles

• parent voice

What do hospitalized infants fear MOST?

Separation from parents.

Application Nursing Interventions:

• Encourage parental presence

• Maintain routines

• Use soothing voice

• Allow favorite blanket/toy

• Use atraumatic care

An 8-month-old cries when the nurse approaches. Is this expected?

Yes. Stranger anxiety is normal around 6–8 months.

NCLEX thinking:
This is NORMAL development, not “bad behavior.”

What milestone would concern the nurse in a 5-month-old?

Persistent head lag.

Why?
Head lag should disappear by 4–5 months.

A 10-month-old is not pulling to stand. Why is this important?

Pulling to stand is expected around 9 months.

Application:
Possible developmental delay → further assessment needed.

Best pain scale for infants?

NIPS.

Why?
Infants are nonverbal, so pain is assessed behaviorally:

• crying

• facial grimace

• body movement

What nursing action BEST reduces stress during an infant assessment?

Use a flexible sequence and keep parent nearby.

Why?
Infants become distressed with strangers and separation.

What is Erikson’s stage for toddlers?

Autonomy vs. shame and doubt.

Meaning:
Toddlers want independence and control.

What is a toddler’s BIGGEST fear during hospitalization?

Loss of control and separation from parents.

What this looks like:

• tantrums

• “NO!”

• resisting procedures

Why should toddlers be given choices?

Why should toddlers be given choices?

A: It supports autonomy.

GOOD choices:

• “Red or blue medicine cup?”

• “Do you want me to listen to your heart first or your belly first?”

BAD choice:
“Do you want your shot?”

(Shot is not optional.)

A toddler regresses and starts using a bottle in the hospital. Should the nurse be concerned?

No. Regression is a normal stress response.

Appropriate discipline for a 2-year-old?

A:

• redirection

• consistent limits

• simple explanations

• brief time-out

NOT:

• long lectures

• spanking

• yelling

What pain scale is commonly used for toddlers?

FLACC.

Why?
Toddlers cannot reliably quantify pain numerically.

FLACC evaluates:

• Face

• Legs

• Activity

• Cry

• Consolability

A hospitalized toddler screams when separated from parents. What should the nurse do FIRST?

Encourage parental presence.

NCLEX logic:
Toddlers cope poorly with separation.

Why are toddlers at high risk for injury?

Curiosity without judgment.

Application:
Safety teaching is critical:

• choking hazards

• falls

• poisoning

What is Erikson’s stage for preschoolers? (3-5)

Initiative vs. guilt.

Meaning:
They enjoy:

• helping

• pretending

• trying new things

What is a preschooler’s biggest fear during hospitalization?

Bodily harm/mutilation.

Examples:

• fear blood will leak out

• fear body won’t work again

• fear of needles

Why is a Band-Aid important to preschoolers after procedures?

It reassures them their body is “fixed.”

This is a FAVORITE NCLEX concept.

Why should preschoolers receive simple concrete explanations?

They are still concrete thinkers.

BAD:

• “We’re putting you to sleep.”

GOOD:

• “This medicine helps your body rest during surgery.”

A preschooler believes hospitalization is punishment. Is this normal?

Yes.

Preschoolers are egocentric and may think:
“I was bad, so I got sick.”

Best pain scale for a verbal preschooler?

Wong-Baker FACES.

What type of play is expected in preschoolers?

Associative play.

Meaning:
Children play together loosely but rules are not organized.

Best nursing intervention before a painful procedure for a preschooler?

Therapeutic play and simple explanations.

What is Erikson’s stage for school-age children? (6-12)

Industry vs. inferiority.

Meaning:
Children want achievement and competence.

What is the major fear of school-age children during hospitalization?

Loss of body integrity.

Examples:

• fear of surgery

• fear of disability

• fear body won’t function normally

Why should school-age children be taught about procedures?

They can understand cause and effect.

Teaching reduces anxiety.

What type of play is expected in school-age children?

Cooperative play.

Examples:

• sports

• board games

• organized rules

Appropriate discipline for school-age children?

• clear rules

• praise

• logical consequences

• loss of privileges

A hospitalized 8-year-old acts brave but clenches fists during procedures. Interpretation?

School-age children may hide pain to appear brave.

What pain scales can school-age children usually use?

Wong-Baker FACES or VAS.

What is Erikson’s stage for adolescents? (12-18)

Identity vs. role confusion.

Meaning:
Teens are trying to figure out:

• who they are

• how they fit in socially

What is an adolescent’s major concern during hospitalization?

Loss of independence, privacy, and peer relationships.

MOST important nursing intervention for adolescents?

Respect privacy.

Examples:

• knock before entering

• involve them in decisions

• allow confidential conversations

Why might adolescents underreport pain?

They want to appear mature or in control.

Appropriate discipline for adolescents?

• logical consequences

• collaborative rule setting

• avoid belittling

• avoid lectures

Why has pediatric pain historically been undertreated?

Misconceptions such as:

• children don’t feel pain like adults

• infants won’t remember pain

• opioids are too dangerous

What is atraumatic care?

Preventing or minimizing physical and psychological distress.

Examples:

• numbing cream before IV

• treatment rooms instead of bed

• distraction

• parent presence

A nurse gives morphine to a child. What must happen next?

Reassess pain and monitor side effects.

Major side effects:

• respiratory depression

• constipation

Which nonpharmacologic interventions help pediatric pain?

• distraction

• sucrose

• swaddling

• massage

• heat/cold

• therapeutic play

BIRTH–1 MONTH

Think: “newborn reflex potato”

• root/startle reflex

• fists closed

• marked head lag

If a newborn is:

• cruising

• rolling

• sitting unsupported

→ obviously abnormal

2 MONTHS

Think: “beginning head control”

• lifts head 45°

• hands opening

KEY IDEA:
The baby is STARTING to uncurl and interact.

3 MONTHS

Think: “social baby”

• coos

• smiles

• holds rattle

• visual tracking

• forearm support

KEY EXAM POINT:
Grasp reflex disappears.

That’s a favorite.

4 MONTHS

Think: “stronger upper body”

• good head control

• props sitting

• brings objects to mouth

• rolls to side

KEY IDEA:
Baby is becoming stable.

5 MONTHS

Think: “movement becomes intentional”

• NO head lag

• voluntary grasp

• belly to back

If head lag is still present → concern.

That’s HIGH yield.

6 MONTHS

Think: “mobile noisy baby”

• rolls both ways beginning

• holds bottle

• jabbers

• feet to mouth

KEY IDEA:
More independence.

7–8 MONTHS

Think: “sitting + hand coordination”

• sits unsupported

• transfers objects

• raking grasp

• crude pincer

9 MONTHS

Think: “moving everywhere”

• crawls

• pulls to stand

• bangs cubes

BIG EXAM FAVORITE.

10–11 MONTHS

Think: “almost toddler”

• cruises

• waves bye

• mama/dada specific

• neat pincer grasp

12 MONTHS

Think: “mini toddler”

• walking

• points

• 1–3 words

• page turning

INFANT DETAILS Object permanence (VERY testable)

Around 8–12 months infants realize:

“Mom still exists even when I can’t see her.”

This is WHY separation anxiety increases after 6 months.

Application question:

Why does peek-a-boo entertain infants?

Answer:
Because object permanence is developing.

Baby reflex gone by 5-6 months

Extrusion reflex gone by 5–6 months

(Baby stops automatically pushing food out with tongue.)

Moro/startle reflex gone by 6 months

If still present later → possible neuro concern.

TODDLER DETAILS Egocentrism

Toddlers cannot see another person’s perspective.

This explains:

• tantrums

• “mine!”

• frustration

Medical equipment coming to life

This comes from magical/limited thinking.

A toddler may believe:

• BP cuff is alive

• suction is scary

• equipment can hurt them intentionally

This is VERY peds-specific.

Painful procedures→ when to tell toddlers

Tell toddlers RIGHT before procedure.

Not hours ahead.

Pre-K and magic thinking

Preschoolers think:

“My thoughts caused this.”

Example:
“I broke my arm because I was bad.”

SUPER testable.

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Animism

They think objects can come alive.

Example:

• stethoscope = snake

• IV pump = monster

BEST coping intervention

Let preschoolers:

• touch equipment

• play doctor

• use teddy bears

This gives control and reduces fear.

Timing for preparation for Pre-K

Planned hospitalization:

3–5 days ahead

Painful procedure:

1–2 hours ahead

This timing stuff LOVES showing up on exams.

SCHOOL-AGE DETAILS Literal thinking

This is VERY NCLEX.

If you say:

“This will feel like a pinch”

they may imagine actual pinching.

Avoid idioms:

• “put to sleep”

• “cut open”

• “take blood”

Use literal concrete language.

Fears and coping for school age

Waking during surgery

VERY common school-age fear.

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Journaling as coping

Easy SATA option.

ADOLESCENT DETAILS Deductive/futuristic reasoning

Teens can think abstractly and long-term.

They may worry:

• “Will this affect my future?”

• “Will I look different?”

• “Will peers judge me?”

HUGE adolescent nursing concept:

Talk directly to the teen FIRST.

Then involve parents.

This is extremely testable.

Temperment types and their characteristics

Temperament Type	Characteristics
Easy child	adaptable, regular routines
Difficult child	irregular routines, intense reactions
Slow-to-warm-up	cautious, adapts slowly

• temperament affects coping

• discipline should match temperament

WHAT THE DENVER II LOOKS AT

It screens 4 developmental areas:

Area	What it Assesses
Personal-social	interacting with others, self-care
Fine motor-adaptive	hand movements, grasping, drawing
Language	speech and understanding
Gross motor	sitting, walking, jumping

Review of Baby circulation

In a baby before birth:

• Lungs are not working

• Oxygen comes from the placenta (mom)

• So blood does NOT need to go through lungs yet

1. DUCTUS VENOSUS = liver bypass

Blood from placenta enters baby → goes:

“skip the liver, go straight to heart”

2. FORAMEN OVALE = heart shortcut

Inside the heart, blood goes:

right side → directly to left side

👉 This is important:
It skips the lungs completely

3. DUCTUS ARTERIOSUS = lung bypass

Blood tries to go to lungs but says:

“nope, lungs are off”

So it goes:

pulmonary artery → aorta (body instead of lungs)

Basic overview of perfusion alterations in pediatrics

Pattern	What it means
L → R shunt (PDA, ASD, VSD)	“Too much blood in lungs → CHF baby”
R → L shunt (TOF)	“Not enough blood to lungs → cyanosis”
Kawasaki	“Inflamed arteries → coronary risk”
Rheumatic	“Post-strep → valve destruction”

What is it/ why is it dangerous all perfusion abnormalities

Disorder (Full Name)	What is happening in the body	Why it’s dangerous
Patent Ductus Arteriosus (PDA)	The fetal vessel (ductus arteriosus) that should close after birth stays open → blood flows from the aorta back into the pulmonary arteries (L → R shunt)	Overloads lungs with too much blood → pulmonary congestion → heart has to work harder → can lead to CHF and pulmonary hypertension
Atrial Septal Defect (ASD)	Hole between right and left atria → oxygenated blood from left atrium leaks into right atrium (L → R shunt)	Extra blood sent to lungs over time → enlarges right heart → can cause dysrhythmias, pulmonary hypertension, and heart failure later in life
Ventricular Septal Defect (VSD)	Hole between ventricles → high-pressure left ventricle pushes blood into right ventricle (L → R shunt)	Large volume of blood recirculates to lungs → severe CHF in infants, poor growth, pulmonary hypertension if untreated
Tetralogy of Fallot (TOF)	4 defects cause narrowing to lungs (pulmonary stenosis) → blood bypasses lungs through VSD (R → L shunt)	Not enough oxygenated blood reaches body → severe hypoxia (cyanosis), “tet spells,” risk of sudden hypoxic episodes
Kawasaki Disease	Blood vessels (especially coronary arteries) become inflamed throughout the body (vasculitis)	Inflammation can weaken coronary arteries → aneurysms → clotting or rupture → risk of heart attack/sudden death in children
Rheumatic Heart Disease	Immune system attacks heart valves after untreated strep infection (autoimmune reaction)	Progressive valve scarring and narrowing (especially mitral valve) → long-term heart failure, poor cardiac output, lifelong damage

What changes at birth convert fetal circulation to adult circulation?

• Cord clamped → ↑ systemic vascular resistance

• ↑ LA pressure closes foramen ovale

• ↓ prostaglandins + ↑ O₂ → closes ductus arteriosus (24–48 hrs)

• Ductus venosus closes after birth

Why are infants at higher risk for heart failure?

• ↓ ventricular compliance (stiff heart)

• Fixed stroke volume (can’t increase much)

• CO depends on heart rate

• High O₂ demand + metabolic rate

• Fluid overload poorly tolerated

How do you classify congenital heart defects?

• ↑ pulmonary flow → L→R shunt (PDA, ASD, VSD)

• ↓ pulmonary flow → R→L shunt (TOF)

• Obstructed systemic flow (coarctation)

• Mixed blood flow (TGA, HLHS)

What is the key problem in left-to-right shunts?

• Blood recycles through lungs → pulmonary overload

• Leads to:

  • CHF

  • Pulmonary HTN

  • Poor growth

What are early signs of CHF in infants?

• Tachypnea

• Fatigue with feeding

• Diaphoresis

• Poor weight gain

• Crackles

• Hepatomegaly

What is PDA + treatment?

• Failure of ductus arteriosus to close

• L→R shunt

• Treatment:

  • Indomethacin / ibuprofen (closes duct)

  • Cath closure or surgery

Key features of ASD?

• Atrial septum opening → L→R shunt

• Often asymptomatic early

• Later: arrhythmias, CHF, pulmonary HTN

• Closure: device or surgery

Key clinical concerns with VSD?

• Ventricular septal opening → L→R shunt

• Most common CHD

• Large VSD → CHF early

• May close spontaneously or require surgery

What causes cyanosis in TOF?

• Pulmonary stenosis → ↓ blood to lungs

• R→L shunt through VSD

• Deoxygenated blood enters systemic circulation

First action during a tet spell? sudden, severe drops in blood oxygen levels

• Knee-chest position

• ↑ systemic vascular resistance → ↑ lung blood flow

• Calm child + oxygen

• Morphine may be used

What confirms Kawasaki diagnosis?

• Fever ≥ 5 days + 4/5:

  • Rash

  • Conjunctivitis

  • Strawberry tongue

  • Hand/foot swelling or peeling

  • Cervical lymph nodes

Why give IVIG + aspirin in Kawasaki?

• IVIG → reduces coronary inflammation

• Aspirin → ↓ inflammation + prevents clotting

• Prevents coronary aneurysms

What causes RHD?

• Untreated Group A strep → autoimmune response

• Damages heart valves

What confirms rheumatic fever?

• 2 major OR 1 major + 2 minor

• Major:

  • Carditis

  • Polyarthritis

  • Chorea

  • Rash

CHD meds

Front: Match meds to purpose:

( Digoxin, furosemide, ACE inhibitors, indomethacin, IVIG, antibiotics)

• Digoxin → ↑ contractility

• Furosemide → ↓ fluid overload

• ACE inhibitors → ↓ afterload

• Indomethacin → closes PDA

• IVIG → Kawasaki

• Antibiotics → RHD

What must nurse check before giving digoxin?

• Apical HR (hold if low)

• K+ level (low = toxicity risk)

• Toxicity signs:

  • Bradycardia

  • N/V

  • Dysrhythmias

Priority post-cardiac cath care?

• Check bleeding at site

• Keep leg straight

• Monitor distal pulses

• Frequent vitals (Q5–15 min early)

What’s the nursing priority in CHD?

• First: oxygenation (SpO₂, work of breathing)

• Second: perfusion (pulses, cap refill, I&O)

Why do infants with CHD fail to thrive?

• Feeding increases O₂ demand

• Fatigue → poor intake

• ↑ metabolic demand → weight loss

Key difference Kawasaki vs RHD?

• Kawasaki → coronary arteries + IVIG

• RHD → heart valves + antibiotics

Which child will deteriorate first?” L→R or R→L

• L→R = CHF problem (lungs overloaded)

• R→L = oxygenation crisis (life-threatening cyanosis)

AGE-BASED EXPECTATIONS (hidden inside CHD questions)

• infant should double weight by 6 months → CHD baby won’t

• feeding fatigue = red flag in infants (not “normal picky eating”)

Why are children at higher risk for neurologic injury?

Head is large, neck muscles weak, thin skull bones, and immature spinal support → ↑ risk for trauma.

What is the most important indicator of neurologic status in children?

Level of Consciousness (LOC)

What does myelination do in children?

Speeds up nerve impulses → allows motor control, coordination, and cognitive development.

When is myelination complete?

Around age 4 years (progresses head → toe)

Normal fontanel finding?

Flat, soft, and pulsatile

Bulging fontanel indicates what?

increased intracranial pressure (ICP), often meningitis

Sunken fontanel indicates what?

Dehydration

Early sign of neurologic decline in children?

Change in LOC (confusion, lethargy)

Order of worsening LOC (best → worst)?

Confusion → lethargy → stupor → coma

Best possible pediatric GCS score?

15 = normal LOC

Worst possible pediatric GCS score?

3 = deep coma

What is the most important trend in GCS?

Declining score = worsening neurologic status