Child Health Nursing - Complete Answers

LONG ESSAY (2 × 15 = 30 Marks)

Q1a. Define Low Birth Weight Baby. Discuss nursing management of children with low-birth-weight baby.

• LBW: < 2500 g
• Very Low Birth Weight (VLBW): < 1500 g
• Extremely Low Birth Weight (ELBW): < 1000 g

• Place in a pre-warmed incubator or radiant warmer; maintain temperature 36.5-37.5°C
• Use polyethylene wrap immediately after birth for ELBW
• Kangaroo Mother Care (KMC): skin-to-skin contact with mother, stabilizes temperature, promotes bonding

• Monitor respiratory rate, SpO2 continuously
• Administer oxygen via nasal cannula, CPAP, or mechanical ventilation as needed
• Observe for apnea of prematurity; use caffeine citrate as prescribed

• Initiate feeds as early as possible (within 1-2 hours if stable)
• Encourage breast milk - provides antibodies and ideal nutrition
• Nasogastric (NG) feeds for babies < 32 weeks or unable to suck
• Monitor weight daily; aim for 15-20 g/kg/day weight gain
• Total Parenteral Nutrition (TPN) for very sick/ELBW babies

• Strict hand hygiene before handling
• Minimize invasive procedures
• Monitor for signs of sepsis: lethargy, poor feeding, temperature instability, bulging fontanelle
• Umbilical cord care

• Continuous cardiac and respiratory monitoring
• Regular blood glucose monitoring (hypoglycemia risk)
• Monitor for jaundice (phototherapy if needed)
• Daily weight, head circumference, length

• Teach parents KMC technique
• Educate on feeding, care at home
• Emotional support, encourage parental involvement

• Retinopathy of prematurity (ROP) screening
• Hearing assessment
• Developmental follow-up

Q1b. Explain the factors influencing growth and development

• Genetic constitution determines ultimate height, body type, intelligence potential
• Sex: boys generally taller/heavier; girls mature faster
• Race and ethnicity influence patterns

• Adequate proteins, calories, vitamins, and minerals are essential
• Malnutrition - especially in first 2 years - causes permanent stunting
• Breastfeeding promotes optimal development

• Maternal nutrition during pregnancy
• Infections (TORCH - Toxoplasma, Rubella, CMV, Herpes)
• Teratogens: alcohol, drugs, radiation
• Placental insufficiency

• Growth Hormone (GH) - primary regulator of postnatal growth
• Thyroid hormone - essential for brain development and bone maturation
• Insulin - anabolic, promotes growth
• Sex hormones - responsible for pubertal growth spurt

• Higher income = better nutrition, healthcare, and stimulation
• Poverty linked to stunting and developmental delays

• Stimulating home environment promotes cognitive development
• Exposure to toxins (lead, mercury) impairs development
• Altitude - high altitude may retard growth

• Emotional deprivation and neglect cause psychosocial dwarfism
• Positive parent-child interaction enhances development
• Stress and abuse negatively affect development

• Chronic illnesses (heart disease, renal disease) retard growth
• Recurrent infections deplete nutritional stores

Q2. Define Protein Energy Malnutrition (PEM). Explain management of child with severe malnutrition and prevention of malnutrition.

• Weight for height < -3 SD (Z score)
• MUAC < 115 mm (in children 6-59 months)
• Bilateral pitting edema

1. Treat/prevent hypoglycemia - give 10% dextrose or glucose water
2. Treat/prevent hypothermia - warm environment, clothing, KMC
3. Treat/prevent dehydration - ReSoMal (Rehydration Solution for Malnutrition), not standard ORS
4. Correct electrolyte imbalance - potassium, magnesium supplementation
5. Treat infections - broad spectrum antibiotics (ampicillin + gentamicin)
6. Correct micronutrient deficiencies - Vitamin A, zinc, folic acid (no iron initially)
7. Start cautious feeding - F-75 formula (75 kcal/100 ml) every 2-3 hrs

• Monitor weight daily
• Accurate fluid intake/output
• Oral hygiene, skin care
• Monitor for refeeding syndrome
• Parent education on feeding practices

1. Nutrition education - promote breastfeeding, complementary feeding at 6 months
2. Supplementation programs - Vitamin A, iron, zinc in vulnerable populations
3. Mid-Day Meal Scheme and government nutrition programs
4. Growth monitoring - regular weighing, plotting on growth chart, early identification
5. Immunization - prevents infections that worsen nutritional status
6. WASH - Water, Sanitation, Hygiene to prevent diarrheal diseases
7. Socioeconomic improvement - food security, poverty alleviation
8. Antenatal care - ensure adequate maternal nutrition

SHORT ESSAYS (5 × 5 = 25 Marks)

Q3. Internationally accepted rights of children (UN Convention on the Rights of the Child - UNCRC 1989)

1. Non-discrimination
2. Best interests of the child
3. Right to life, survival, and development
4. Respect for views of the child

• Right to Identity - name, nationality, family relations (Art. 7-8)
• Right to Education - free primary education, access to secondary (Art. 28)
• Right to Health - highest attainable standard of health, access to healthcare (Art. 24)
• Right to Protection - from abuse, neglect, exploitation, trafficking (Art. 19, 32-36)
• Right to Play and Leisure - rest, recreation, cultural activities (Art. 31)
• Right to Family - live with parents unless harmful, maintain contact (Art. 9)
• Right to Freedom from Torture - no cruel punishment (Art. 37)
• Right to Special Care - children with disabilities (Art. 23)
• Right of Refugee Children - special protection (Art. 22)
• Right to Opinion - children's views heard in matters affecting them (Art. 12)

Q4. Common accidents during childhood and prevention

1. Falls - most common in all age groups
2. Poisoning - household chemicals, medications
3. Burns and scalds - hot liquids, flames
4. Drowning - in tubs, buckets, pools
5. Road traffic accidents (RTAs)
6. Foreign body aspiration - nuts, coins, small toys
7. Electrocution - inserting objects into sockets

1. Environmental safety - stair gates, window guards, socket covers, non-slip mats
2. Supervision - constant adult supervision for infants/toddlers
3. Safe storage of medicines, chemicals in locked cabinets
4. Road safety - helmets, seat belts, reflective clothing
5. Water safety - never leave child unattended near water, fence pools
6. Fire safety - smoke detectors, fire drills, keep hot liquids away
7. Education - teach children about road safety, saying "No" to strangers
8. Product safety - age-appropriate toys, child-resistant packaging

Q5. Case management of Anemia as per IMNCI guidelines

• Severe Anemia: Palmar pallor + Hb <7 g/dL - URGENT referral
• Anemia: Some palmar pallor - treat with iron
• No Anemia: No palmar pallor

• Urgent referral to hospital
• Give first dose of treatment before referral
• Do NOT give iron (may worsen refeeding in severe malnutrition)

• Iron supplementation:
  • 3-6 mg/kg/day elemental iron for 3 months
  • Given between meals for better absorption
• Folic acid: if deficiency suspected
• Treat malaria if in endemic area
• Deworm: Albendazole 400 mg stat (if child > 2 years and not dewormed in 6 months)
• Vitamin A: If not given in past 6 months

• Iron-rich foods: green leafy vegetables, meat, fish, eggs, legumes
• Vitamin C to enhance iron absorption
• Avoid tea/coffee with meals (reduces absorption)

Q6. Types of fracture and care of child with compound fracture

1. Complete - bone broken into two pieces
2. Incomplete (Greenstick) - common in children; one side breaks, other bends
3. Simple (Closed) - skin intact
4. Compound (Open) - bone pierces skin, risk of infection
5. Comminuted - bone shattered into multiple fragments
6. Stress - hairline crack from repetitive force
7. Pathological - fracture through diseased bone
8. Buckle/Torus - compression fracture in children
9. Spiral - twisting injury
10. Transverse - perpendicular to bone axis

• Airway, Breathing, Circulation assessment
• Control bleeding with sterile pressure dressing
• Do NOT attempt to push bone back
• Immobilize the limb as found - splint above and below fracture site
• Cover wound with sterile dressing

1. Wound care - thorough irrigation with normal saline, debridement in OT
2. Antibiotic therapy - IV antibiotics (penicillin/cephalosporin + aminoglycoside) to prevent osteomyelitis
3. Tetanus prophylaxis - tetanus toxoid if not immunized
4. Surgical fixation - external fixator or internal fixation (ORIF) as indicated
5. Reduction - restore bone alignment
6. Casting - after wound is clean

• Pain assessment and management (analgesics as ordered)
• Neurovascular assessment - 5 P's: Pain, Pallor, Pulselessness, Paresthesia, Paralysis
• Monitor for compartment syndrome
• Elevate limb to reduce swelling
• Monitor wound for infection signs
• Ensure adequate nutrition for bone healing (calcium, Vitamin D, protein)
• Psychosocial support for child and parents
• Discharge teaching: cast care, signs of complications, follow-up

Q7. Juvenile Delinquency

1. Family factors - broken homes, parental neglect, abuse, domestic violence, alcoholic parents
2. Socioeconomic factors - poverty, unemployment, peer pressure
3. School-related - school failure, truancy, bullying
4. Peer influence - bad peer group, gang involvement
5. Psychological - low self-esteem, conduct disorder, ADHD
6. Community factors - living in high-crime neighborhoods, lack of recreational facilities
7. Media influence - exposure to violence, gaming addiction
8. Substance abuse - alcohol and drug use

• Theft, robbery, vandalism
• Substance abuse
• Sexual offenses
• Cybercrime
• Truancy, running away from home

1. Family strengthening - parenting programs, counseling
2. School-based programs - life skills education, anti-bullying programs
3. Community centers - provide recreational, vocational activities
4. Counseling/Psychotherapy - cognitive behavioral therapy
5. Juvenile Justice System - Juvenile Justice (Care and Protection) Act, 2015 (India)
6. Rehabilitation - vocational training, not just punishment
7. Role of Nurses - identify at-risk children early, refer for counseling, educate families

SHORT ANSWERS (4 × 2 = 8 Marks)

Q8. Define Diaphragmatic Hernia

• Most common site: Bochdalek hernia (left posterolateral, 80-90%)
• Less common: Morgagni hernia (anterior, right side)
• Presents at birth with: respiratory distress, cyanosis, scaphoid abdomen, bowel sounds in chest
• Management: respiratory stabilization, surgical repair

Q9. Causes of Juvenile Diabetes Mellitus (Type 1 DM)

1. Autoimmune destruction - T-cell mediated destruction of beta cells (most common)
2. Genetic predisposition - HLA-DR3, HLA-DR4 gene associations
3. Environmental triggers:
   • Viral infections: Coxsackievirus B, mumps, rubella, CMV
   • Cow's milk protein exposure in early infancy (proposed)
   • Certain medications (steroids can unmask diabetes)
4. Islet cell antibodies (anti-GAD, anti-insulin antibodies) detected
5. Results in absolute insulin deficiency

Q10. Define Drowning

• Near-drowning (Submersion injury): Survived at least 24 hours after submersion
• Dry drowning: Laryngospasm prevents water entry; ~10-15% of cases
• Wet drowning: Water enters lungs; ~85% of cases
• Secondary drowning: Delayed pulmonary edema hours after submersion

• Leading cause of accidental death in children aged 1-4 years
• Prevention: pool fencing, supervision, life vests, swimming lessons

Q11. Dengue Fever

• Sudden high fever (2-7 days), "breakbone fever"
• Severe headache, retro-orbital pain
• Myalgia, arthralgia
• Maculopapular rash (3-4 days after fever)
• Hemorrhagic manifestations - petechiae, bleeding gums

• Severe abdominal pain, persistent vomiting
• Bleeding, rapid breathing
• Thrombocytopenia (<100,000/mm³), hematocrit rise >20%

• No specific antiviral; supportive treatment
• Adequate hydration (oral or IV fluids)
• Paracetamol for fever (avoid aspirin/NSAIDs)
• Platelet transfusion if severe thrombocytopenia with bleeding
• Monitor for dengue shock syndrome

MULTIPLE CHOICE QUESTIONS (12 × 1 = 12 Marks)

Note on Q15: The standard WHO IMNCI covers 0 to 5 years (0-2 months as young infant, 2 months-5 years as older child). However, India has extended the approach under IMNCI to cover 0 to 5 years in most programs. If "A" (upto 2 months and 2 months upto 19 years) is an option based on the integrated adolescent health, then A would be selected. If strict WHO IMNCI is followed, the coverage is 0-5 years - making option A the closest correct answer as it captures both age divisions used in IMNCI.

Summary of MCQ Answers: 12-B, 13-C, 14-B, 15-A

• 0 to 2 months (Young Infant)
• 2 months to 5 years (Older Child)

• A. Upto 2 months and 2 months upto 19 year
• B. Upto 2 months and 2 months upto 10 year
• C. Upto 2 months and 2 months upto 5 years
• D. All of the above