Nokea
While assessing an 18-month-old child, a nurse observes that the toddler can crawl upstairs but needs assistance when climbing the stairs upright. What does this action indicate to the nurse?
- A. Presence of talipes equinovarus
- B. Reflective of neurologic damage
- C. Expected behavior in a toddler of this age
- D. Existence of developmental dysplasia of the hip
Correct Answer: C
Rationale: At 18 months of age, needing assistance to climb stairs upright is considered normal behavior for a toddler. Crawling upstairs is a different motor skill and does not necessarily correlate with the ability to climb stairs. The child is still developing gross motor skills, and climbing stairs upright typically requires more coordination and strength, which may not be fully developed at this age. Choices A, B, and D are not relevant in this scenario as the observed behavior is within the expected range of development for an 18-month-old child.
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A nurse is inspecting the skin of a child with atopic dermatitis. What would the nurse expect to observe?
- A. Erythematous papulovesicular rash
- B. Dry, red, scaly rash with lichenification
- C. Pustular vesicles with honey-colored exudates
- D. Hypopigmented oval scaly lesions
Correct Answer: B
Rationale: In atopic dermatitis, the nurse would expect to observe a dry, red, scaly rash with lichenification. Lichenification is thickened skin due to chronic scratching. Choices A, C, and D are incorrect. Erythematous papulovesicular rash is more characteristic of contact dermatitis, pustular vesicles with honey-colored exudates are seen in impetigo, and hypopigmented oval scaly lesions are typical of pityriasis alba.
Upon assessing a newborn immediately after delivery, you note that the infant is breathing spontaneously and has a heart rate of 90 beats/min. What is the most appropriate initial management for this newborn?
- A. Begin positive pressure ventilations
- B. Provide blow-by oxygen with oxygen tubing
- C. Assess the newborn's skin condition and color
- D. Start chest compressions and contact medical control
Correct Answer: A
Rationale: In a newborn, a heart rate below 100 beats/min indicates the need for positive pressure ventilation to improve oxygenation. Providing blow-by oxygen or assessing skin condition/color may not address the primary issue of inadequate oxygenation due to the low heart rate. Starting chest compressions and contacting medical control is not warranted as the newborn is breathing spontaneously and only has a slightly low heart rate, which can be managed initially with positive pressure ventilations.
What is the priority intervention for a child with acute laryngotracheobronchitis upon admission?
- A. Pad the side rails of the crib.
- B. Arrange for a quiet, cool room.
- C. Place a tracheotomy set at the bedside.
- D. Obtain a recliner for a parent to stay.
Correct Answer: C
Rationale: The correct priority intervention for a child with acute laryngotracheobronchitis is to place a tracheotomy set at the bedside. Acute laryngotracheobronchitis can lead to airway obstruction, making it essential to have the equipment readily available in case of emergency. Padding the side rails, arranging for a quiet room, or obtaining a recliner for a parent are not the immediate priorities in managing a child with this condition.
A nurse is discussing the care of an infant with colic with the parents. What should the nurse explain is the cause of colicky behavior?
- A. Inadequate peristalsis
- B. Paroxysmal abdominal pain
- C. An allergic response to certain proteins in milk
- D. A protective mechanism designed to eliminate foreign proteins
Correct Answer: B
Rationale: The correct answer is B: Paroxysmal abdominal pain. Colic in infants is characterized by paroxysmal abdominal pain, leading to excessive crying and fussiness. It is not caused by inadequate peristalsis (Choice A), an allergic response to certain proteins in milk (Choice C), or a protective mechanism designed to eliminate foreign proteins (Choice D). Understanding that colic is primarily associated with abdominal pain helps healthcare providers provide appropriate care and support to parents dealing with colicky infants.
A child with a diagnosis of bronchiolitis is admitted to the hospital. What is the most important nursing intervention?
- A. Administering bronchodilators
- B. Providing respiratory therapy
- C. Monitoring oxygen saturation
- D. Encouraging fluid intake
Correct Answer: B
Rationale: The most important nursing intervention for a child with bronchiolitis is providing respiratory therapy. This intervention helps to maintain airway patency and improve breathing by assisting with mucus clearance and ventilation. Administering bronchodilators (Choice A) may be considered in some cases, but it is not the most crucial intervention for bronchiolitis. Monitoring oxygen saturation (Choice C) is important but is not as directly impactful as providing respiratory therapy. Encouraging fluid intake (Choice D) is important for hydration but does not directly address the respiratory distress associated with bronchiolitis.