ENPC Study Guide

Chapter 1: Children Around the World

1. What are the most common pediatric presentations where you work?

2. What health promotion initiatives are needed in your area?

Chapter 2: Preparing for Pediatric Emergencies

1. How can health promotion and injury prevention topics be incorporated into the routine
assessment and care of pediatric patients in the emergency department?

2. How do you incorporate patient- and family-centered care concepts into your care of
pediatric patients?

3. Does your facility have a Pediatric Emergency Care Coordinator?

4. What opportunities exist at your facility to improve pediatric readiness and care for
pediatric patients?

5. Does your facility receive children needing a higher level of care, or does your facility
typically transfer children requiring a higher level of care? Are there formal transfer
agreements in place? What are the responsibilities of the transferring and receiving
facilities?

6. In most cases, consent for evaluation and treatment of minors must be obtained from the
parent or legal guardian. In your jurisdiction, are there exceptions as to when a minor
needs a parent/guardian to provide consent? What is your facility’s policy for obtaining
consent when a minor is unaccompanied by their legal guardian?

Chapter 3: Pediatric Differences

1. How can understanding the stages of development help you when caring for pediatric
patients of varying ages?
a. Airway
i. Infants up to around 6 months prefer to breathe out of their noses. If nose
gets obstructed, they are more likely to get hypoxic.
ii. Larger tongue relative to oral pharyngeal cavity, easier to
obstruct
iii. Child has weak cartilage rings leading to airway collapse with
neck flexion or increased inspiratory effort. (think of a straw)
iv. Large head can cause airway occlusion when supine. Placing pad
under neck relieves this problem.
v. Short neck = slight flexion of neck can easily extubate.
b. Breathing
i. Retractions + respiratory distress
c. Cardiorespiratory system
i. Fixed stroke volume due to lack of myocardial stretch but increased
cardiac output = high HR. As child develops HR decreases
ii. Faster respiratory rate due to increased oxygen consumption and lack of
tidal reserves
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d. Circulation
i. Infants have limited ability to increase stroke volume/contractility
ii. Cardiac output is heart rate dependent
iii. Bradycardia in a pediatric patient can be an ominous sign
iv. Sinus dysthymias can be a normal finding in children
v. Children can be in severe shock and still have an acceptable BP
vi. Circulating blood volume is higher in pediatrics, up to 90 ml/kg

e. Developmental Considerations
i. Metabolic rate is much higher than adults. thus, oxygen and glucose
stores can be used up quickly
ii. Infections: newly born and young infants can manifest infections with
HYPOthermia vs hyperthermia
iii. Body surface ratio: children have higher body surface area and are more
prone to hypothermia than adults
iv. Egocentric: toddlers and school age children believe that if they see the
car the driver sees them
v. Procedures: less invasion to most invasive-count respirations before
taking rectal temp
vi. Weight: medications are weight based
vii. Distracted: adolescents may be easily distracted by mobile phones
f. SHOCK
i. HR rather than SV increases to maintain CO
ii. Tachycardia is considered a sign of inadequate tissue perfusion until
proven otherwise
iii. A slow or irregular RR in a acutely ill infant or child is an ominous clinical
sign
iv. Infants with shock have an increased risk of dehydration
1. Hypotension occurs after 30% loss of volume
2. 10 kg pt 30% < 300 ml
g. Trauma related
i. Head is disproportionately large and heavy. Neck muscles weak
1. Predisposing to neck trauma
ii. Cranium is thinner and more pliable
1. Intracranial tissue more susceptible to injury
iii. Protuberant abdomen
1. Immature abdominal muscles, ribs sitting higher in the abdominal
cavity and smaller pelvis offer little protection to organs
iv. Larger solid organs
ENPC Study Guide

1. Solid organs and kidneys are relatively larger and more prone to
injury
v. Sigmoid/colon
1. Not fully attached to the peritoneal cavity
2. More prone to injury from acceleration and deceleration forces
h. Developmental considerations
i. Infants are mobile
ii. Coordination evolves
iii. Easily distracted
iv. Oncoming vehicles – unable to judge speed and distance
v. Recognizing danger
vi. Lower eye level
vii. Risk taking
i. Stages of development

2. What are some signs of pain that can be observed in children who are nonverbal?
3. Why is it important to incorporate caregivers in the assessment and care of the pediatric
patient?
4. Where does your facility keep pediatric-size equipment? Is there any equipment that you
do not currently have that would help optimize the assessment and care of pediatric
patients?
5. What options are available at your facility to manage procedural pain? How easy are
they to obtain and use?
6. How comfortable are you caring for pediatric patients today?
7. What do you hope to learn in this course that would increase your confidence in caring
for this population?
Also see:
Pediatric Differences pre-course module

Chapter 4: Prioritization

1. What findings in the pediatric patient in the following areas would indicate a need for a
higher priority and/or more urgent need for care?
a. Appearance
b. Breathing
c. Circulation
d. Vital Signs
e. Other
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2. What are three situations where a child with no abnormalities in the PAT might be given
a higher triage acuity?
3. What triage system is used at your facility? Does it include pediatric considerations?
Also see:
Pediatric Assessment Triangle pre-course module, Initial Assessment group discussion, all PNPs

Chapter 5: Initial Assessment

1. Why is it important to follow a standardized process for patient assessment?
2. Why do you think the Pediatric Nursing Process (PNP) systematic approach does not
call for a full set of vital signs to be obtained right away?
3. In most situations, there are multiple clinicians caring for a critically ill patient and
multiple things are happening at the same time. Why do you think this course puts so
much emphasis on the PNP systematic approach if that’s not how it works in the “real
world?”
4. What is the procedure at your facility for rapid administration of warmed fluids to a
pediatric patient? What equipment and/or supplies are used? Who is allowed to insert an
intraosseous needle?
Also see:
Pre-course modules (PNP step-by-step and PNP video demo), Initial Assessment group discussion, and all PNPs

Chapter 6: The Neonate

1. What is the most important and effective intervention for neonatal resuscitation? What
are some troubleshooting steps to ensure this intervention is as effective as possible?
2. What assessment findings in the neonate may indicate hypoglycemia?
3. What assessment findings in the neonate may indicate underlying congenital heart
disease?
4. What equipment does your facility have for newborn stabilization and care (incubators,
warmers, phototherapy lights, other)? Do you know how to use this equipment? If not,
how can you learn?
5. What are the “safe haven” laws or other options for safe newborn surrender in your
state/country? Does your facility have policies or protocols related to newborn
surrender?
Also see:
PNP medical scenario

Chapter 7: The Child in Need of Stabilization

1. What is the definition of shock? Describe shock in your own words.

2. How can you differentiate compensated, decompensated/hypotensive, and irreversible
shock?
3. List three pediatric differences relevant to shock. Describe the clinical significance of
each difference.
4. How can a lactate level be used to identify and manage shock?
5. What are the four types of shock? Name one cause for each type.
6. Name one goal-directed therapy for each type of shock.
7. What are the most likely causes of pediatric cardiac arrest?
8. You find a child who is unresponsive with no signs of normal breathing and no palpable
pulse. What are your initial actions?
9. Do you have a pediatric resuscitation team? Who responds?
ENPC Study Guide

Also see:
PNP resuscitation scenarios

Chapter 8: The Child with a Cough

1. What are three ways to differentiate respiratory distress and respiratory failure in the
pediatric patient?
2. What assessment findings can be used to differentiate between the following common
pediatric respiratory illnesses?
a. Bronchiolitis
b. Croup
c. Asthma
d. Pneumonia
3. What are three important discharge teaching topics for children with asthma?
4. Chest radiographs are not obtained as often in pediatric patients as in adults. Why do
you think that is the case?
5. What standardized scoring systems are used at your facility to assess severity of
respiratory illness in pediatric patients?
6. What protocols are available at your facility for care of pediatric patients with respiratory
illnesses?

Also see:
The Child with a Cough group discussion, PNP respiratory scenarios

Chapter 9: The Child with an Injury

1. What age-specific developmental characteristics put children at increased risk of injury?

a. Infants
b. Toddlers/preschoolers c. School-age
c. Adolescents
2. What additional information would be helpful for predicting the types and severity of
injuries for the following complaints?
a. Fall
b. Motor vehicle collision
c. Bicycle crash
3. What are the dangers of logrolling a patient with an unstable spine or pelvic injury? What
transfer devices or techniques are available to minimize motion of the unstable spine or
pelvis?
4. What discharge education is provided for a child with a mild traumatic brain injury?
5. What are the car seat laws in your area?
6. Does your facility have a process for providing car seats to families when theirs are
damaged in motor vehicle collision?
7. Does your facility have pediatric cervical collars and pelvic binders? What alternatives
are available if you do not?

Also see:
The Child with an Injury group discussion, PNP injury scenarios

Chapter 10: The Child with a Fever

ENPC Study Guide

1. In what patient populations is the presence of a fever (regardless of other symptoms) an

urgent concern?
2. What are some red flags that cause increased concern in the pediatric patient with a
fever?
3. What characteristics can help distinguish a febrile seizure from other types of seizures?
a. Febrile seizure
b. Other types of seizures
4. What methods are used at your facility to measure temperature in pediatric patients?
5. Does your facility have a protocol for identifying and managing pediatric sepsis?

Also see:
The Child with a Fever group discussion, PNP medical scenario

Chapter 11: The Child with Vomiting

1. What are three potentially life-threatening causes of vomiting in the pediatric patient?
2. What are three non-gastrointestinal causes of vomiting in the pediatric patient?
3. What associated symptoms may indicate a surgical abdomen in the pediatric patient?
4. How would you teach a parent to provide oral rehydration therapy (ORT) to their child?

Also see:
The Child with an Abdominal Concern group discussion, PNP scenarios

Chapter 12: The Child with Abdominal Pain

1. What are four genitourinary emergencies that may present with abdominal pain?
2. When is it advisable to give a child oral food or fluids? When is it best to keep a child
NPO?
3. How do you obtain a urine sample from a child who is not toilet trained? How do you
obtain a urine sample from a child who is toilet trained?
4. What questions can you ask to obtain an accurate sexual health history?
5. At your facility, can you guarantee an adolescent patient that sensitive test results
(pregnancy, sexually transmitted infection cultures) will not be shared with their
guardian?

Also see:
The Child with an Abdominal Concern group discussion

Chapter 13: The Child with a Rash

1. How do you screen for the possibility of an infectious disease?

2. What prompts initiation of isolation precautions at your facility? How do you isolate
potentially contagious children?
3. When assessing the pediatric patient with a rash, what findings could indicate a more
serious underlying cause?
4. What assessment findings can be used to differentiate between the following causes of
pediatric rashes?
a. Roseola infantum
b. Molluscum contagiosum
c. Varicella (chicken pox)
d. Rubeola (measles)
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5. Do you know how to find the infectious disease rates and trends in your area? What
infectious diseases are reportable? (Hint: Your local health department is a great
resource.)

Chapter 14: The Child with an Altered Mental Status

1. What are the two most common causes of altered mental status in a child?
2. What questions can you ask to help determine the cause of pediatric altered mental
status?
3. What toxidromes are you most familiar with?
4. How do you treat pediatric hypoglycemia? What concentrations of intravenous dextrose
do you have readily available?
5. What unique seizure activity in children is easily missed if you do not know what to look
for?
6. Does your facility have a pediatric diabetic ketoacidosis (DKA) order set? At what point
do you add dextrose to maintenance intravenous fluids for a child being treated for
DKA?

Also see:
The Child with an Altered Mental Status group discussion

Chapter 15: The Child with a Behavioral Health Concern

1. What pediatric behavioral health resources are available in your area?

2. How does your facility provide a safe and therapeutic environment for pediatric
behavioral

1. health patients? Are there any opportunities to enhance the care you provide for this
population?
2. How do you screen for suicidal ideation? What suicide precautions are required by your
facility’s policy?

Also see:
Behavioral Health and Crisis group discussion

Chapter 16: The Child with a Suspicious Presentation

1. What strategies should be considered when caring for a child who may have
experienced maltreatment?
2. Does your facility have any processes in place for identification and/or reporting of
suspected human trafficking? What resources can you offer?
3. What is your process for reporting child maltreatment?
4. Has a colleague ever attempted to minimize your concern for a patient with a suspicious
presentation? Have you ever been discouraged from reporting child maltreatment by a
colleague? What was your response?

Chapter 17: The Child, Family, and Healthcare Team in Crisis

1. Describe an interaction with a patient or family member that resulted in

escalation/agitation/violence.
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2. Describe an interaction with an upset patient or family member that deescalated the
situation.
3. What resources are available to you through your workplace to help cope with
compassion fatigue, burnout, or secondary traumatic stress?
4. Does your facility incorporate “The Pause” after a patient death?
5. How would you describe moral injury?
6. What does resilience mean to you?
7. How does your work give you purpose?

Chapter 18: The Child with Special Healthcare Needs

1. There are a multitude of rare pediatric conditions that will increase the need for
healthcare services. What conditions have you become familiar with after caring for
children with special healthcare needs? What resources did you use to learn more about
care implications associated with the condition?
2. Are you comfortable relying on families as experts for their children with special
healthcare needs?
3. What medical devices have you encountered while caring for children with special
healthcare needs? How would you troubleshoot a device that was not functioning
properly?
4. What is the difference between “person first” and “identity first” language?
5. What documentation influences how you think about the patient or family before you
even meet them?