A 1-day-old newborn has just expelled a thick, greenish-black stool. The nurse determines that this is the first stool. What should the nurse do next?

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Document the stool in the infant's record. This is the appropriate nursing action because the newborn has passed meconium, which is the first stool typically seen in newborns within the first few days of life. Meconium is thick, greenish-black in color, and is a normal occurrence in newborns. By documenting this event in the infant's record, the nurse ensures accurate and thorough documentation of the newborn's bowel movement pattern. Option B) Assess the infant for an intestinal obstruction is incorrect in this situation because the passage of meconium is an expected and normal occurrence in newborns. There are no signs or symptoms indicating an intestinal obstruction based solely on the passage of meconium. Option C) Sending the stool to the laboratory per protocol is unnecessary for meconium passage as it is a normal physiological process in newborns. There is no clinical indication or benefit to sending meconium to the laboratory in this scenario. Option D) Notifying the practitioner that a tarry stool has been passed is incorrect because meconium is not indicative of a tarry stool. Tarry stool typically refers to dark, sticky stools containing digested blood and is not the same as the first meconium stool passed by newborns. In an educational context, understanding normal newborn assessments and variations such as passing meconium is crucial for pediatric nurses. Documenting findings accurately, recognizing normal vs. abnormal newborn characteristics, and knowing when to intervene are essential skills in providing safe and effective care to newborns.

Correct Answer: C

Rationale: In the context of pediatric respiratory distress, the correct answer is C) Blow a pinwheel. This breathing exercise helps to improve the expiratory phase by encouraging the child to exhale fully and slowly. Blowing a pinwheel requires the child to control their exhalation, promoting improved lung function and airway clearance. It also helps in strengthening respiratory muscles and increasing lung capacity. Option A) Using an incentive spirometer is more suitable for older children or adults as it requires better coordination and understanding of the device, which may be challenging for a 3-year-old with asthma. Option B) Breathing into a paper bag is not recommended for children, especially those with asthma, as it can lead to a build-up of carbon dioxide in the body, causing potential harm. Option D) Taking several deep breaths is a more general exercise and may not specifically target improving the expiratory phase in a child with asthma. In an educational context, it is essential for nurses and healthcare providers to understand age-appropriate interventions for pediatric patients with respiratory distress. Choosing the correct breathing exercises tailored to the child's age and condition is crucial in optimizing respiratory function and managing asthma symptoms effectively. By selecting the appropriate intervention, nurses can help improve the child's respiratory health outcomes and overall well-being.

Correct Answer: B

Rationale: In newborns, cyanosis is a concerning sign of inadequate oxygenation. The correct answer is B) Cyanotic defects. Cyanotic defects are congenital heart defects that result in decreased oxygen levels in the blood, leading to cyanosis. Examples include Tetralogy of Fallot, transposition of the great arteries, and tricuspid atresia. Option A) Acyanotic defects, on the other hand, do not typically present with cyanosis. Acyanotic defects include conditions like atrial septal defects, ventricular septal defects, and patent ductus arteriosus, where oxygenated and deoxygenated blood mix but do not cause cyanosis. Option C) Innocent murmurs are benign heart murmurs often heard in healthy children and do not cause cyanosis. These murmurs are typically soft, systolic, and do not indicate any structural abnormalities in the heart. Option D) Hypertension does not directly cause cyanosis in newborns. Hypertension may result from various factors but is not the primary cause of cyanosis in this patient population. Educationally, understanding the association of cyanosis with cyanotic defects in newborns is crucial for nurses caring for pediatric patients. Recognizing cyanosis early, understanding its potential causes, and promptly initiating appropriate interventions are essential to prevent adverse outcomes in infants with respiratory distress. Nurses play a vital role in assessing, monitoring, and advocating for infants with cyanosis, making this knowledge critical in pediatric nursing practice.

Correct Answer: C

Rationale: In pediatric respiratory distress cases, understanding the etiology of conditions like rheumatic fever is crucial for effective nursing interventions. The correct answer is C) Group A beta-haemolytic streptococcus. This bacterium, specifically the Streptococcus pyogenes strain, is responsible for causing rheumatic fever through an autoimmune response triggered by untreated or inadequately treated streptococcal infections. Option A) Streptococcal pneumonia is caused by Streptococcus pneumoniae, a different bacterium than Group A streptococcus, and is associated with pneumonia and other respiratory infections, not rheumatic fever. Option B) Haemophilus influenza is a bacterium that can cause respiratory infections like pneumonia and bronchitis but is not linked to rheumatic fever. Option D) Staphylococcus aureus is a common cause of skin and soft tissue infections, as well as some respiratory infections, but it is not implicated in the development of rheumatic fever. Educationally, understanding the specific pathogens associated with different diseases is essential for nurses to provide accurate assessments, interventions, and patient education. In the case of rheumatic fever, recognizing the role of Group A streptococcus can help in early identification and treatment, potentially preventing serious complications.

Correct Answer: A

Rationale: Rationale: The correct answer is A) Acute lymphocytic leukemia is associated with a cure rate of more than 80%. This statement is true as acute lymphocytic leukemia (ALL) is the most common type of childhood leukemia and has a high cure rate, with modern treatments achieving cure rates exceeding 80%. Option B) is incorrect as chronic lymphocytic leukemia (CLL) is actually more common in adults than in children. Childhood leukemia most commonly presents as ALL. Option C) is incorrect because leukemia in children often has a rapid onset, with symptoms developing over a short period leading to a relatively quick diagnosis once medical attention is sought. Option D) is incorrect as leukemia is typically diagnosed through abnormal blood counts, such as low red blood cells, low platelets, and high white blood cell counts. A normal complete blood count (CBC) would not be indicative of leukemia. Educationally, understanding the differences between types of leukemia in children is crucial for healthcare providers caring for pediatric patients. Recognizing the characteristics, prognosis, and treatment options for childhood leukemia aids in early detection and appropriate intervention, ultimately improving patient outcomes.