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: The correct answer is C. Needing assistance to climb stairs is considered expected behavior for an 18-month-old toddler. At this age, children are still developing their gross motor skills, coordination, and balance, which can vary in proficiency. It is common for toddlers to be able to crawl upstairs before mastering the skill of climbing stairs upright. Options A, B, and D are incorrect because at 18 months, it is normal for children to require help and practice with climbing stairs and does not necessarily point to any specific medical conditions or developmental issues.
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What is the nurse's priority intervention when preparing for admission of a child with acute laryngotracheobronchitis?
- 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 so that a parent can stay.
Correct Answer: C
Rationale: The correct answer is to place a tracheotomy set at the bedside. Acute laryngotracheobronchitis can cause airway obstruction, which may require an emergency tracheotomy. Having the tracheotomy set readily available ensures quick access in case of respiratory distress. Padding the side rails of the crib, arranging for a quiet, cool room, and obtaining a recliner for a parent are important aspects of care but are not the priority when managing a potentially life-threatening airway emergency.
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: A heart rate below 100 beats/min in a newborn indicates the need for positive pressure ventilation to improve oxygenation. Providing positive pressure ventilations helps in assisting the newborn's breathing efforts to ensure adequate oxygenation. Choice B, providing blow-by oxygen, may not be sufficient to address the underlying issue of inadequate breathing. Choice C, assessing the newborn's skin condition and color, is important but not the most immediate action needed for a heart rate below 100 beats/min. Choice D, starting chest compressions, is not indicated as the infant is breathing spontaneously and has a heart rate, albeit lower than normal, which does not warrant chest compressions.
After corrective surgery for hypertrophic pyloric stenosis (HPS) is completed, and the infant is returned to the pediatric unit with an IV infusion in place, what is the priority nursing action?
- A. Apply adequate restraints.
- B. Administer a mild sedative.
- C. Assess the IV site for infiltration.
- D. Attach the nasogastric tube to wall suction.
Correct Answer: C
Rationale: The priority nursing action after corrective surgery for hypertrophic pyloric stenosis (HPS) is to assess the IV site for infiltration. This is crucial as it ensures proper fluid administration and prevents complications such as phlebitis or infiltration-related tissue damage. Applying restraints (Choice A) would not be appropriate in this situation as it is not related to the immediate post-operative care of an infant with an IV infusion. Administering a mild sedative (Choice B) is not indicated as the primary concern post-surgery is monitoring the IV site and the infant's response to the surgery. Attaching the nasogastric tube to wall suction (Choice D) is not the priority at this time, as assessing the IV site takes precedence to prevent potential complications.
A 7-year-old child has an altered mental status, high fever, and a generalized rash. You perform your assessment and initiate oxygen therapy. En route to the hospital, you should be most alert for:
- A. vomiting
- B. seizures
- C. combativeness
- D. respiratory distress
Correct Answer: B
Rationale: In a pediatric patient presenting with altered mental status, high fever, and a generalized rash, seizures are a significant concern. Febrile seizures can occur in children with high fevers and may lead to further complications. It is crucial to monitor for seizures and be prepared to manage them promptly. Vomiting, combativeness, and respiratory distress are also important considerations in pediatric patients; however, given the clinical presentation described, seizures take priority as they are a common complication in this scenario.
A 3-year-old child is being discharged after being treated for dehydration. What should the nurse include in the discharge teaching?
- A. Monitor for signs of infection
- B. Monitor for signs of dehydration
- C. Monitor for signs of hypovolemia
- D. Monitor for signs of malnutrition
Correct Answer: B
Rationale: Correct! When a child is being discharged after treatment for dehydration, it is important to educate caregivers about monitoring for signs of dehydration to prevent reoccurrence. Dehydration is the primary concern in this scenario, as the child's fluid levels need to be closely monitored. Choices A, C, and D are incorrect because while infection, hypovolemia, and malnutrition are also important considerations in pediatric care, the immediate focus after treating dehydration should be on preventing its recurrence by monitoring for signs of dehydration.