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A 1-year-old child with respiratory syncytial virus (RSV) has been admitted to the pediatric unit. The nurse observes that the child has a fever, rhinorrhea, frequent coughing, and sneezing. Which additional finding should alert the nurse that the child is in acute respiratory distress?
- A. Flaring of the nares.
- B. Bilateral bronchial breath sounds.
- C. Diaphragmatic respirations.
- D. A resting respiratory rate of 35 breaths/min.
Correct Answer: A
Rationale: Nasal flaring indicates increased respiratory effort, a sign of acute respiratory distress.
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A child who weighs 18 pounds receives a prescription for amoxicillin 25 mg/kg/day by mouth in divided doses every 12 hours. The bottle is labelled, 'Amoxicillin for Oral Suspension, USP 400 mg per 5 mL.' How many mL should the nurse administer with each dose?
- A. 1.3 mL
Correct Answer: A
Rationale: The dose is calculated as 18 lbs ÷ 2.2 = 8.18 kg, 25 mg/kg/day x 8.18 kg = 204.5 mg/day, divided into 102.25 mg/dose. Then, 102.25 mg ÷ (400 mg/5 mL) = 1.3 mL.
A six-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child?
- A. List of achievement timeline for developmental milestones.
- B. Reactions to any previous hospitalizations.
- C. A history of rubella, rubeola, or chicken pox.
- D. Mother's use of alcohol, drugs, or cigarettes during pregnancy.
Correct Answer: B
Rationale: Previous hospitalization reactions help anticipate and address fears, aiding in care planning.
The parents of a child with Wilms tumor ask the nurse why surgery is necessary before a biopsy is performed. Which information should the nurse provide?
- A. Biopsy may rupture the encapsulated tumor and cause the cancer cells to spread.
- B. Metal clips are surgically applied at the tumor site for exact marking for radiation.
- C. Surgery is necessary to stage the tumor and determine metastasis to other sites.
- D. The surgery provides a visualization of other pathology and dysfunction of the kidney.
Correct Answer: A
Rationale: Biopsy risks rupturing the encapsulated Wilms tumor, potentially spreading cancer cells, making surgery the preferred initial approach.
A 3-year-old boy in a daycare facility scratches his head frequently, and the nurse confirms the presence of head lice. The nurse washes the child's hair with permethrin shampoo and calls his parents. Which instruction should the nurse provide to the parents about treatment for head lice?
- A. Take the child to a hair salon for a shampoo and a shorter haircut.
- B. Dispose of the child's brushes, combs, and other hair accessories.
- C. Rewash the child's hair following a 24-hour isolation period.
- D. Wash the child's bed linens and clothing in hot soapy water.
Correct Answer: D
Rationale: Washing bed linens and clothing in hot soapy water kills lice and prevents reinfestation.
The nurse is assessing a 2-week-old male infant in a community health clinic and notes that his sclera appear slightly yellow. Additionally, urine in his diaper appears tea-colored. This child should receive follow-up assessment for what condition?
- A. Intussusception.
- B. Biliary atresia.
- C. Hirschsprung's disease.
- D. Huntington's disease.
Correct Answer: B
Rationale: Jaundice and tea-colored urine suggest biliary atresia, requiring urgent follow-up to prevent liver damage.