Correct Answer: B

Rationale: Burns on the lips and singed nasal hairs indicate inhalation injury, suggesting the child has inhaled hot gases or smoke. This presentation is common in cases where the respiratory tract is exposed to hot gases or smoke, leading to potential airway compromise.
Choice A, chemical burn, is incorrect because there is no mention of exposure to chemicals, and the symptoms described are more indicative of inhalation injury.
Choice C, electrical burn, is incorrect as there is no evidence of electrical involvement in the scenario provided.
Choice D, hot-water scald, is incorrect because the presence of singed nasal hairs points more towards inhalation injury than a scald from hot water, emphasizing the need to prioritize airway management and respiratory support.

Correct Answer: A

Rationale: The correct answer is giving a pacifier to the newborn. Sucking is a natural reflex and a source of comfort for newborns, especially postoperatively. Offering a pacifier can help meet their developmental needs by providing comfort and a soothing mechanism. Placing a mobile over the crib (choice
B) may provide visual stimulation but does not directly address the newborn's developmental needs for comfort and self-soothing. Providing a soft, cuddly toy (choice
C) may offer some comfort but may not be as effective in meeting the specific developmental need for sucking postoperatively. Warming the newborn's formula before feeding (choice
D) relates more to feeding practices than directly addressing a major developmental need in the postoperative period.

Correct Answer: D

Rationale: The major characteristic of a cardiac malformation associated with left-to-right shunting is increased blood flow to the lungs. This increased flow can lead to pulmonary hypertension and heart failure if left untreated. Elevated hematocrit (
Choice
A) is not a typical characteristic of this condition. Severe growth retardation (
Choice
B) is not directly associated with left-to-right shunting. Clubbing of the fingers and toes (
Choice
C) is more commonly seen in conditions involving chronic hypoxia.

Correct Answer: B

Rationale: Peeling skin on the hands and feet is a characteristic clinical manifestation of Kawasaki disease, known as desquamation. This occurs during the convalescent phase of the illness, typically around 2-3 weeks after the onset of symptoms. While a generalized rash can be present in Kawasaki disease, peeling skin on the hands and feet is a more specific and distinctive feature. High fever is also a common symptom of Kawasaki disease, usually lasting for at least 5 days, while a low-grade fever is not typically associated with this condition.
Therefore, the nurse is more likely to observe peeling skin on the hands and feet in a child suspected of having Kawasaki disease, making option B the correct choice.

Correct Answer: C

Rationale: The correct answer is C. Infants may have difficulty regulating glucose and electrolytes due to their immature endocrine systems. This can lead to issues such as hypoglycemia and electrolyte imbalances.
Choice A is incorrect because endocrine glands actually begin developing early in gestation, not just in the third trimester.
Choice B is incorrect as endocrine glands are not fully functional at birth; they continue to mature and develop after birth.
Choice D is incorrect as a child's endocrine system has a significant impact on growth and development through the secretion of hormones that regulate various processes in the body, but it does not specifically address the difficulty in regulating glucose and electrolytes seen in infants.