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A 1-year-old child with respiratory syncytial virus (RSV) is admitted to the pediatric unit. The child presents with a fever, rhinorrhea, frequent coughing, and sneezing. What additional finding should alert the nurse that the child is in acute respiratory distress?
- A. Diaphragmatic respirations.
- B. A resting respiratory rate of 35 breaths/min.
- C. Bilateral bronchial breath sounds.
- D. Flaring of the nares.
Correct Answer: D
Rationale: Nasal flaring indicates increased breathing effort, a sign of acute respiratory distress in RSV.
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The nurse is giving an intramuscular injection of an antibiotic to a 16-month-old toddler with pneumonia. The toddler does not have any known allergies and has been walking without assistance for one month. Which technique should the nurse select for administration?
- A. Divide the gluteal area into quarters and give IM into the upper outer quadrant.
- B. Administer the injection into the middle of the lateral aspect of the thigh.
- C. Use a needle length of 1/2 inch (1.25 cm) to avoid deep tissue damage.
- D. Give in the arm, one to 2 inches (2.5 to 5.0 cm) below the acromion process.
Correct Answer: B
Rationale: The vastus lateralis in the thigh is the preferred IM site for toddlers, ensuring safe delivery.
The nurse is monitoring a child with hydrocephalus who received a ventriculoperitoneal (VP) shunt yesterday. Which assessment finding indicates to the nurse that the shunt is functioning normally?
- A. The child has grown in height since the previous shunt placement
- B. The child reports no evidence of continuous headaches
- C. An intracranial pressure (ICP) monitoring probe is in place
- D. The child is afebrile with normal vital signs postoperatively.
Correct Answer: B
Rationale: Absence of continuous headaches indicates the shunt is relieving brain pressure effectively.
A 10-year-old boy has been seen frequently by the school nurse over the past three weeks after school begins in the fall. He reports headaches, stomach aches, and difficulty sleeping. Which intervention should the nurse implement?
- A. Compare the child's vital signs over the past three weeks.
- B. Counsel the parents to pay more attention to the child.
- C. Ask the boy to describe a typical day at school.
- D. Conduct a complete neurological assessment.
Correct Answer: C
Rationale: Asking the boy to describe a typical day at school helps identify potential stressors or psychosocial factors contributing to his non-specific symptoms.
The parents of a newborn with hypospadias are anxious about the timing of the surgical correction. What information should the nurse share with them?
- A. Surgery should be performed within one month to prevent bladder infections.
- B. Postponing the repair until the child reaches school age can alleviate fears of castration.
- C. The repair should be completed before the child is toilet-trained.
- D. The urethral repair should be carried out after the child reaches sexual maturity.
Correct Answer: C
Rationale: Repair before toilet training supports normal urinary function and reduces psychological impact.
A 9-week-old infant is scheduled for a cleft lip repair. What information is most important for the nurse to convey to the surgeon before transporting the infant to the surgical suite?
- A. Urine specific gravity is 1.011
- B. White blood cell count of 10,000/mm³
- C. Weight gain of 2 pounds (0.91 kg) since birth
- D. Red blood cell count of 2.3 x 10²/L
Correct Answer: D
Rationale: A low red blood cell count indicates anemia, a surgical risk requiring preoperative attention.