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The nurse is caring for a toddler with acute laryngotracheobronchitis. Which assessment finding would indicate the child is experiencing increased respiratory obstruction?
- A. Restlessness
- B. Tachycardia
- C. Brassy cough
- D. Expiratory wheezing
Correct Answer: A
Rationale: Restlessness is a primary sign of increased respiratory obstruction.
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The nurse is caring for a 4-year-old child diagnosed with H. influenzae type B. Which signs and symptoms exhibited by the child would alert the nurse to suspect epiglottitis? (Select all that apply.)
- A. Harsh cough
- B. Restlessness
- C. Edematous epiglottis
- D. Child insists on lying down
- E. Drooling
Correct Answer: B,C,E
Rationale: The child with epiglottitis insists on sitting up, leans forward with the mouth open, and drools saliva because of the difficulty in swallowing.
The asthmatic child who has been taking theophylline complains of stomachache and tachycardia and is sweating profusely. What does the nurse recognize as the cause of these symptoms?
- A. Severe asthma attack
- B. Allergic response to theophylline
- C. Onset of bronchitis
- D. Drug toxicity
Correct Answer: D
Rationale: The symptoms described are the signs of theophylline toxicity.
The nurse is planning to teach parents about preventing sudden infant death syndrome (SIDS). What significant information would the nurse include?
- A. Wrapping the infant snugly for rest periods
- B. Positioning the infant prone for sleep
- C. Sitting the infant up in an infant seat
- D. Placing infants on their backs or sides for sleep
Correct Answer: D
Rationale: The American Academy of Pediatrics recommends that all healthy infants be placed in the supine or side-lying position on a firm mattress to prevent SIDS.
How would the nurse advise a mother to clear the nostrils when her infant has a cold?
- A. Clear the nasal passages after the infant has a feeding.
- B. Use over-the-counter nose drops to clear passages.
- C. Remove nasal secretions with a bulb syringe.
- D. Instill saline nose drops after clearing away secretions.
Correct Answer: C
Rationale: The nasal passages can be cleared by instilling a few drops of saline into the nose and then suctioning the secretions with a bulb syringe.
The first child of a couple is being treated for bronchopulmonary dysplasia (BPD). They ask how to prevent this from happening with the child they are currently expecting. What will the nurse explain as the best way to prevent BPD?
- A. Maternal intake of folic acid
- B. Exercise
- C. Prevention of preterm birth
- D. Provision of oxygen therapy to the newborn
Correct Answer: C
Rationale: The prevention of preterm birth is the best way to prevent BPD, as it is associated with prematurity and prolonged ventilation.