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An 8-month-old child who starts to cry when his parents leave
A nurse is caring for an 8-month-old child who starts to cry when his parents leave. The nurse should make which of the following statements to the parents?
- A. At this age you should expect your child to be upset when you leave.
- B. Your child needs to rest.
- C. will notify the provider of his behavior.
- D. Your child is responding to an overstimulating environment.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: At 8 months old, infants develop separation anxiety, causing distress when parents leave. Acknowledging this is crucial for parents to understand normal child development. Choice B is irrelevant as the child's emotional needs should be addressed, not just physical rest. Choice C is unnecessary unless the behavior persists or causes concern. Choice D is incorrect as the child's crying is likely due to separation anxiety, not overstimulation.
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A preschool age child undergoing endotracheal suctioning
A charge nurse is observing a newly licensed nurse who is performing endotracheal suctioning for a preschool age child. Which of the following actions by the newly licensed nurse requires the charge nurse to intervene?
- A. Applying suction for 20 seconds
- B. Introducing the catheter without suction
- C. Rotating the catheter between the thumb and forefinger while suctioning
- D. Allowing the child to rest for 30 to 60 seconds between suctioning passes
Correct Answer: B
Rationale: The correct answer is B: Introducing the catheter without suction. When performing endotracheal suctioning, it is crucial to apply suction while introducing the catheter to effectively remove secretions. Introducing the catheter without suction can result in ineffective suctioning and potential harm to the child.
A: Applying suction for 20 seconds is within the recommended time frame for suctioning.
C: Rotating the catheter while suctioning helps to ensure thorough removal of secretions.
D: Allowing the child to rest between suctioning passes is important to prevent hypoxia and maintain oxygenation.
In summary, choice B is incorrect because it goes against the fundamental principle of effective suctioning, while choices A, C, and D are all appropriate actions during endotracheal suctioning for a preschool-age child.
A toddler who is scheduled to have a lumbar puncture
A nurse is caring for a toddler who is scheduled to have a lumbar puncture. Which of the following actions should the nurse take?
- A. Restrain the toddler for 1 hr after the procedure.
- B. Swaddle the toddler in a warm blanket.
- C. Ask another nurse to assist with holding the toddler in a prone position.
- D. Place the toddler in a side-lying knee-chest position
Correct Answer: D
Rationale: The correct answer is D: Place the toddler in a side-lying knee-chest position. This position helps to open up the spaces between the vertebrae, making it easier for the healthcare provider to perform the lumbar puncture. Restraint is not recommended as it can cause distress and increase the risk of complications. Swaddling in a warm blanket may not provide the necessary positioning for the procedure. Asking another nurse to assist with holding the toddler in a prone position may not be as effective in achieving the optimal positioning needed for a lumbar puncture.
An 8-year-old child who has sickle cell anemia and is recovering from a vaso-occlusive crisis
A nurse is caring for an 8-year-old child who has sickle cell anemia and is recovering from a vaso-occlusive crisis. Which of the following precautions should the nurse include in the discharge teaching?
- A. Drink eight glass of fluid daily.
- B. Maintain an updated hemophilus influence type b immunisation
- C. Avoid playground activities at school
- D. Assume postural drainage positions every 6 hrs
Correct Answer: A
Rationale: The correct answer is A: Drink eight glasses of fluid daily. This is crucial for children with sickle cell anemia to prevent dehydration, which can trigger vaso-occlusive crises. Adequate hydration helps maintain blood flow and prevent sickling of red blood cells. Maintaining an updated hemophilus influenzae type b immunization (choice B) is important for preventing infections but is not directly related to vaso-occlusive crises. Avoiding playground activities at school (choice C) is unnecessary as long as the child is careful and stays hydrated. Assuming postural drainage positions every 6 hours (choice D) is not relevant for sickle cell anemia management.
A child who is postoperative following a tonsillectomy
A nurse is collecting data from a child who is postoperative following a tonsillectomy. Which of the following is a clinical manifestation of a hemorrhage?
- A. Drooling
- B. Continuous swallowing
- C. Poor fluid intake
- D. Increased pain
Correct Answer: B
Rationale: The correct answer is B: Continuous swallowing. This is a clinical manifestation of hemorrhage post-tonsillectomy as the child may be swallowing blood. Drooling (A) is more indicative of airway obstruction. Poor fluid intake (C) is a sign of dehydration. Increased pain (D) can be expected postoperatively but is not specific to hemorrhage.
A toddler who has laryngotracheobronchitis
A nurse is caring for a toddler who has laryngotracheobronchitis. For which of the following findings should the nurse monitor to detect airway obstruction?
- A. Decreased stridor
- B. Increased restlessness
- C. Decreased heart rate
- D. Decreased temperature
Correct Answer: B
Rationale: The correct answer is B: Increased restlessness. Restlessness is a common sign of airway obstruction in toddlers with laryngotracheobronchitis. As the airway becomes more obstructed, the toddler may feel increasingly anxious and agitated, leading to increased restlessness. Monitoring for this sign is crucial as it indicates worsening respiratory distress and the need for prompt intervention.
Decreased stridor (choice A) is not indicative of airway obstruction in this condition, as stridor is a high-pitched sound heard on inspiration and can be present in both mild and severe cases of laryngotracheobronchitis. Decreased heart rate (choice C) and decreased temperature (choice D) are not typically associated with airway obstruction and are less relevant in this context.