Nokea
The healthcare provider is evaluating the effects of thyroid therapy used to treat a 5-month-old with hypothyroidism. Which behavior indicates that the treatment has been effective?
- A. Laughs readily, turns from back to side.
- B. Has strong Moro and tonic neck reflexes.
- C. Keeps fists clenched, opens hands when grasping an object.
- D. Can lift head but not chest when lying on abdomen.
Correct Answer: A
Rationale: In infants, laughing readily and turning from back to side are developmental milestones that indicate effective thyroid therapy and normal development. These actions demonstrate improved muscle tone, coordination, and overall growth, which are key indicators of successful treatment for hypothyroidism in infants. Choices B, C, and D describe behaviors that are not specific indicators of thyroid therapy effectiveness in treating hypothyroidism in infants.
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The healthcare provider is caring for a 3-year-old child who is hospitalized with dehydration. The child is now receiving IV fluids and has started to produce urine. What is the best indicator that the child's dehydration is improving?
- A. The child's urine output has increased
- B. The child's skin turgor is normal
- C. The child's weight has increased
- D. The child's vital signs are stable
Correct Answer: A
Rationale: An increase in urine output is a reliable indicator that the child's hydration status is improving. Adequate urine output signifies that the kidneys are functioning properly and that the body is effectively eliminating waste and excess fluids, indicating improved hydration levels. The other options are not as direct indicators of hydration status. Skin turgor and weight changes can be influenced by various factors, and stable vital signs do not specifically reflect hydration status.
A 3-year-old with HIV infection is staying with a foster family who is caring for 3 other foster children in their home. When one of the children acquires pertussis, the foster mother calls the clinic and asks the nurse what she should do. Which action should the nurse take first?
- A. Remove the child with HIV from the foster home.
- B. Report the exposure of the child with HIV to the health department.
- C. Place the child with HIV in reverse isolation.
- D. Review the immunization documentation of the child with HIV.
Correct Answer: D
Rationale: The priority action for the nurse is to review the immunization documentation of the child with HIV. This step ensures that the child has received the necessary vaccines to protect against pertussis and other preventable diseases. It is essential to verify the immunization status to provide appropriate care and prevent further transmission of infectious diseases within the foster home. Removing the child from the foster home (Choice A) may not be necessary if the child is adequately protected through immunization. Reporting the exposure to the health department (Choice B) is important but not the first action. Placing the child in reverse isolation (Choice C) is not indicated for pertussis exposure.
A 3-year-old child is admitted to the hospital with severe dehydration. The healthcare provider prescribes an IV infusion of 0.9% normal saline. The nurse notes that the child's heart rate is 150 beats per minute, and the blood pressure is 90/50 mm Hg. What should the nurse do first?
- A. Administer the IV fluids as prescribed
- B. Notify the healthcare provider
- C. Check the child's urine output
- D. Reassess the child's vital signs in 30 minutes
Correct Answer: A
Rationale: In a pediatric patient with severe dehydration and signs of compromised hemodynamics such as tachycardia (heart rate of 150 bpm) and hypotension (blood pressure of 90/50 mm Hg), the priority intervention is to administer IV fluids as prescribed. Immediate fluid resuscitation is essential to restore hydration, improve perfusion, and stabilize the child's vital signs. While it's important to monitor urine output, initiating fluid resuscitation takes precedence in this situation. Notifying the healthcare provider can cause a delay in critical intervention, and waiting to reassess vital signs in 30 minutes can be detrimental in a child with severe dehydration and compromised hemodynamics.
A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?
- A. The mother is a single parent and lives with her parents
- B. The mother states the baby is irritable during feedings
- C. The infant's formula has been changed twice
- D. The diaper area shows severe skin breakdown
Correct Answer: D
Rationale: Severe skin breakdown in the diaper area is significant as it indicates a potential severe issue that needs immediate attention to prevent further complications. Skin breakdown can lead to infections and discomfort for the infant, making it a priority in planning care for this family. The other findings, such as the mother's living situation, baby's irritability during feedings, or formula changes, are important but do not pose immediate risks to the infant's health compared to severe skin breakdown.
A child with acute lymphocytic leukemia (ALL) who is receiving chemotherapy via a subclavian IV infusion has an oral temperature of 103 degrees. In assessing the IV site, the nurse determines that there are no signs of infection at the site. Which intervention is the most important for the nurse to implement?
- A. Obtain a specimen for blood cultures.
- B. Assess the CBC.
- C. Monitor the oral temperature every hour.
- D. Administer acetaminophen as prescribed.
Correct Answer: A
Rationale: Obtaining a specimen for blood cultures is crucial in this situation as it helps identify the source of infection, if present, and guide appropriate treatment. This is important in a child with leukemia receiving chemotherapy to prevent potential complications and ensure timely intervention. Assessing the CBC may provide overall information on the child's condition but may not specifically identify a potential infection. Monitoring the oral temperature is important but obtaining blood cultures takes precedence in this scenario. Administering acetaminophen can help reduce fever but does not address the need to identify a possible infection source.