Nokea
A nurse on the pediatric unit is observing the developmental skills of several 2-year-old children in the playroom. Which child should the nurse continue to evaluate?
- A. Cannot stand on one foot
- B. Builds a tower of 7 blocks
- C. Uses echolalia when speaking
- D. Colors outside the lines of a picture
Correct Answer: C
Rationale: The correct answer is C. Using echolalia, which is the repetition of words or phrases, is not typical for a 2-year-old child and may indicate the need for further evaluation. Choices A, B, and D are all within the expected developmental skills for a 2-year-old. While most 2-year-olds may not be able to stand on one foot, it is not a cause for concern at this age. Building a tower of 7 blocks and coloring outside the lines of a picture are both appropriate for a 2-year-old's developmental skills.
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A child with a diagnosis of acute glomerulonephritis is admitted to the hospital. What is the priority nursing intervention?
- A. Monitoring for hypertension
- B. Providing pain relief
- C. Restricting fluid intake
- D. Encouraging fluid intake
Correct Answer: A
Rationale: The correct answer is monitoring for hypertension. Acute glomerulonephritis involves inflammation of the kidney's glomeruli, potentially leading to impaired kidney function and elevated blood pressure. Monitoring for hypertension is crucial as it is a common complication of this condition. Providing pain relief (choice B) may be necessary for comfort but is not the priority. While fluid restriction (choice C) is important in some kidney conditions, in acute glomerulonephritis, maintaining adequate hydration to support kidney function is typically recommended. Encouraging fluid intake (choice D) may exacerbate fluid overload, making it an inappropriate intervention in this scenario.
What should be used to feed an infant born with a unilateral cleft lip and palate?
- A. Plastic spoon
- B. Cross-cut nipple
- C. Parenteral infusion
- D. Rubber-tipped syringe
Correct Answer: B
Rationale: A cross-cut nipple is the most appropriate choice for feeding an infant with a unilateral cleft lip and palate. Using a cross-cut nipple helps regulate the flow of milk, making feeding easier for the infant and reducing the risk of aspiration. Plastic spoons, parenteral infusion, and rubber-tipped syringes are not recommended for feeding infants with cleft lip and palate as they can pose risks such as choking, aspiration, or inadequate milk intake. It is essential to choose a feeding method that minimizes these risks and ensures proper nutrition for the infant.
A newborn is admitted to the neonatal intensive care unit (NICU) with choanal atresia. Which part of the infant's body should the nurse assess?
- A. Rectum
- B. Nasopharynx
- C. Intestinal tract
- D. Laryngopharynx
Correct Answer: B
Rationale: Choanal atresia is a congenital condition that presents with a blockage in the nasal passages at the junction of the nasal cavity and the nasopharynx. To assess and confirm the diagnosis of choanal atresia, the nurse should focus on assessing the nasopharynx. Choices A, C, and D are incorrect as choanal atresia specifically involves a blockage in the nasal passages, not the rectum, intestinal tract, or laryngopharynx. By assessing the nasopharynx, the severity of the obstruction can be determined, aiding in planning appropriate interventions for the newborn.
When caring for an alert 4-year-old child with a mild airway obstruction, respiratory distress, a strong cough, and normal skin color, what should be included?
- A. Back blows, abdominal thrusts, transport
- B. Oxygen, avoiding agitation, transport
- C. Assisting ventilations, back blows, transport
- D. Chest thrusts, finger sweeps, transport
Correct Answer: B
Rationale: The correct approach for a child with a mild airway obstruction, respiratory distress, and normal skin color includes providing oxygen to support breathing, avoiding agitation that could worsen the situation, and arranging for transport to a healthcare facility. Option A is incorrect because abdominal thrusts are not recommended in a mild airway obstruction scenario, and back blows are typically used for choking. Option C is incorrect because assisting ventilations may not be necessary in a child with a strong cough and normal skin color. Option D is incorrect because chest thrusts are not recommended for a mild airway obstruction, and finger sweeps are used for foreign body airway obstructions.
A 4-year-old child is admitted to the hospital with a diagnosis of epiglottitis. What is the priority nursing intervention?
- A. Administer antibiotics
- B. Provide humidified oxygen
- C. Keep the child NPO
- D. Position the child upright
Correct Answer: C
Rationale: The priority nursing intervention for a 4-year-old child admitted with epiglottitis is to keep the child NPO (nothing by mouth). This is crucial to prevent further airway compromise due to the inflamed epiglottis. Administering antibiotics may be necessary but is not the priority at this moment. Providing humidified oxygen can support oxygenation but does not address the immediate risk of airway obstruction. Positioning the child upright may help with breathing but does not address the risk of aspiration. Keeping the child NPO is essential to maintain a patent airway and prevent complications associated with epiglottitis.