Nokea
A mother brings her 2-month-old to the well-baby clinic. She states that when she kisses her baby, the infant's skin tastes salty. The nurse should prepare the mother for what standard diagnostic test to screen for cystic fibrosis (CF)?
- A. Sweat-chloride test.
- B. Faecal-fat test.
- C. Pulmonary-function test.
- D. Potassium chloride test.
Correct Answer: A
Rationale: Salty-tasting skin is a hallmark of cystic fibrosis, and the sweat-chloride test is the standard diagnostic test.
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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.
The nurse is caring for a 5-week-old infant presenting with a history of projectile vomiting after feedings. Which additional finding should the nurse expect to assess?
- A. Rebound tenderness in the left lower abdominal quadrant.
- B. Stool that consists of mucus and blood.
- C. Olive-size mass in the epigastric area.
- D. Frequent burping accompanied by poor feeding.
Correct Answer: C
Rationale: An olive-size mass in the epigastric area is characteristic of pyloric stenosis, associated with projectile vomiting.
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 parent of an infant asks when the baby's first immunization for measles, mumps, and rubella (MMR) should be given. Which age should the nurse provide the parent?
- A. 6 months.
- B. 12 months.
- C. 24 months.
- D. 2 months.
Correct Answer: B
Rationale: The CDC recommends the first MMR dose at 12-15 months of age.
The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?
- A. Has doubled birth weight.
- B. Plays 'peek-a-boo.'
- C. Demonstrates startle reflex.
- D. Turns head to locate sound.
Correct Answer: C
Rationale: The startle reflex typically disappears by 3-4 months; its presence at 6 months may indicate a developmental or neurological issue.