Nokea
Which of the following techniques represents the most appropriate method of opening the airway of an infant with no suspected neck injury?
- A. lift up the chin and hyperextend the neck
- B. tilt the head back without hyperextending the neck
- C. gently lift the chin while maintaining slight flexion of the neck
- D. perform the technique as you would for an older child or adult
Correct Answer: B
Rationale: The correct technique for opening the airway of an infant with no suspected neck injury is to tilt the head back without hyperextending the neck. This method helps to keep the airway open without risking injury to the infant's delicate neck structures. Choice A, lifting up the chin and hyperextending the neck, can potentially harm the infant's neck. Choice C, gently lifting the chin while maintaining slight flexion of the neck, is not as effective as tilting the head back. Choice D is incorrect as infants require a different approach compared to older children or adults due to their anatomical differences.
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The parents of a 6-week-old infant who was born without an immune system ask a nurse why their baby is still so healthy. How should the nurse reply?
- A. Exposure to pathogens during this time can be limited.
- B. Some antibodies are produced by the infant's colonic bacteria.
- C. Antibodies are passively received from the mother through the placenta and breast milk.
- D. Fewer antibodies are produced by the fetal thymus during the eighth and ninth months of gestation.
Correct Answer: C
Rationale: The correct answer is C. Infants receive passive immunity through antibodies from the mother during pregnancy and breastfeeding, which protect them initially. Choice A is incorrect because a 6-week-old infant born without an immune system would not be able to limit exposure to pathogens effectively. Choice B is incorrect as antibodies produced by colonic bacteria are not a significant source of immunity in infants. Choice D is incorrect as the fetal thymus primarily plays a role in T cell development rather than antibody production during gestation.
A child is diagnosed with atopic dermatitis. Which laboratory test would the nurse expect the child to undergo to provide additional evidence for this condition?
- A. Erythrocyte sedimentation rate
- B. Potassium hydroxide prep
- C. Wound culture
- D. Serum immunoglobulin E (IgE) level
Correct Answer: D
Rationale: The correct answer is D: Serum immunoglobulin E (IgE) level. An elevated serum IgE level is commonly associated with atopic dermatitis, reflecting an allergic response. Choice A, erythrocyte sedimentation rate, is a nonspecific test for inflammation and not specific to atopic dermatitis. Choice B, potassium hydroxide prep, is used to diagnose fungal infections like tinea versicolor, not atopic dermatitis. Choice C, wound culture, is not typically indicated for the diagnosis of atopic dermatitis as it is a chronic inflammatory skin condition rather than an infectious process.
A child with a diagnosis of leukemia is admitted to the hospital with a fever. What is the priority nursing intervention?
- A. Administering antibiotics
- B. Administering antipyretics
- C. Providing nutritional support
- D. Monitoring for signs of infection
Correct Answer: D
Rationale: The priority nursing intervention for a child with leukemia admitted to the hospital with a fever is to monitor for signs of infection. Children with leukemia are immunocompromised, making them more susceptible to infections. Monitoring for signs of infection helps in early detection and timely intervention, which is crucial in preventing complications. Administering antibiotics (choice A) may be necessary if an infection is suspected or confirmed, but the priority is to assess for signs of infection first. Administering antipyretics (choice B) may help reduce fever, but it does not address the underlying cause, which could be an infection. Providing nutritional support (choice C) is important for overall health but is not the priority when a child with leukemia presents with a fever, as infection needs to be ruled out or managed first.
A child with a diagnosis of gastroenteritis is admitted to the hospital. What is the priority nursing intervention?
- A. Monitoring fluid and electrolyte balance
- B. Encouraging regular exercise
- C. Administering antipyretics
- D. Administering antibiotics
Correct Answer: A
Rationale: The correct answer is monitoring fluid and electrolyte balance. Gastroenteritis is characterized by inflammation of the gastrointestinal tract leading to diarrhea and vomiting, which can result in dehydration and electrolyte imbalances. Therefore, the priority nursing intervention is to monitor and maintain the child's fluid and electrolyte balance to prevent complications. Encouraging regular exercise (Choice B) may not be appropriate initially for a child with gastroenteritis who needs rest and fluid replacement. Administering antipyretics (Choice C) is not the priority unless the child has a fever. Administering antibiotics (Choice D) is not indicated for viral gastroenteritis, which is the most common cause of the condition.
A child with a diagnosis of hemophilia is admitted to the hospital with a bleeding episode. What is the priority nursing intervention?
- A. Administering pain medication
- B. Monitoring for signs of infection
- C. Administering factor VIII
- D. Ensuring a safe environment
Correct Answer: C
Rationale: The priority nursing intervention for a child with hemophilia experiencing a bleeding episode is administering factor VIII. Hemophilia is a genetic disorder characterized by a deficiency in clotting factors, such as factor VIII. Administering factor VIII replacement therapy is crucial to stop or control bleeding in individuals with hemophilia. Options A, B, and D are important aspects of patient care but do not take precedence over addressing the underlying cause of the bleeding in a child with hemophilia, which is the deficiency of factor VIII.