A 3-year-old child is receiving dextrose 5% in water and half-normal saline solution at 100 ml/hour. Which sign or symptom suggests excessive I.V. fluid intake?

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Worsening dyspnea. Excessive IV fluid intake can lead to fluid overload, causing pulmonary congestion and worsening dyspnea due to increased fluid in the lungs. Understanding the signs and symptoms of fluid overload is crucial in pediatric nursing as it can lead to serious complications. Option B) Gastric distension is incorrect because it is more indicative of gastrointestinal issues rather than excessive IV fluid intake. Option C) Nausea and vomiting are nonspecific symptoms and can be caused by various factors, not specifically related to excessive IV fluid intake. Option D) Temperature of 102°F (38.9°C) is more indicative of a fever or infection rather than excessive IV fluid intake. Educationally, it is important for nurses to closely monitor pediatric patients receiving IV fluids, especially at higher rates, to identify signs of fluid overload promptly. Understanding the signs and symptoms of fluid overload and differentiating them from other conditions is essential for providing safe and effective care to pediatric patients with cardiovascular disorders.

Correct Answer: B

Rationale: In pediatric nursing, understanding cardiovascular disorders, such as carditis from rheumatic fever, is crucial for providing effective care. The correct answer is B) Heart muscle and the mitral valve. Rheumatic fever can lead to carditis, which is an inflammation of the heart. In this condition, the heart muscle and the heart valves, especially the mitral valve, are commonly affected. The inflammation can lead to damage and scarring of these structures, impacting the heart's ability to function properly. Option A) Coronary arteries are not typically affected by carditis from rheumatic fever. Coronary arteries supply blood to the heart muscle itself and are not a primary target of the inflammatory process in rheumatic fever. Option C) Aortic and pulmonic valves are less commonly affected in carditis compared to the mitral valve. While these valves can be impacted in some cases, the mitral valve is the most commonly affected valve in rheumatic fever-related carditis. Option D) Contractility of the ventricles is not a specific area affected by carditis. While inflammation of the heart muscle can impact overall heart function, the primary focus in carditis is on the heart muscle and valves rather than the contractility of specific heart chambers. Educationally, understanding the specific areas affected by carditis is essential for nurses caring for pediatric patients with rheumatic fever. Recognizing the signs and symptoms of cardiac involvement, such as murmurs or heart failure, can prompt timely interventions and prevent complications. By grasping the pathophysiology behind carditis, nurses can provide comprehensive care and support to pediatric patients with cardiovascular disorders.

Correct Answer: A

Rationale: In this scenario, the nurse's priority is to administer a nebulizer treatment as ordered (Option A) for the child with a known history of asthma admitted to the hospital with a respiratory infection. This action is the priority because asthma is a chronic condition that can worsen during respiratory infections, leading to potentially life-threatening complications like respiratory distress and hypoxia. Administering the nebulizer treatment helps open the child's airways, reduce bronchoconstriction, and improve breathing, which is crucial in managing asthma exacerbations. Monitoring oxygen saturation levels closely (Option C) is important but providing immediate bronchodilator therapy takes precedence to stabilize the child's condition. Performing chest physiotherapy (Option B) may be beneficial in some cases, but in a child with asthma exacerbation, prompt bronchodilator therapy is more critical. Educating the parents about infection prevention (Option D) is important for overall health but is not the immediate priority when a child with asthma is experiencing respiratory distress. From an educational standpoint, understanding the prioritization of interventions in pediatric nursing is crucial. Nurses need to recognize the urgency of administering specific treatments based on the child's condition to provide timely and effective care. Asthma exacerbations require prompt intervention to prevent respiratory compromise, making the administration of bronchodilators a top priority in this situation.

Correct Answer: C

Rationale: In the context of a pediatric patient post-tonsillectomy, the priority nursing action is to monitor for signs of bleeding, making option C the correct answer. Tonsillectomy is a common surgical procedure in children and carries a risk of post-operative bleeding, which can be life-threatening if not promptly addressed. Monitoring for bleeding is crucial in the immediate post-operative period to ensure early detection and intervention if necessary. Providing pain management (option A) is important for the child's comfort but is not the top priority when assessing a post-tonsillectomy patient. Encouraging fluid intake (option B) and educating the child about proper oral hygiene (option D) are essential aspects of post-operative care but take a back seat to monitoring for bleeding in this scenario. Educationally, understanding the priority nursing actions post-tonsillectomy in pediatric patients is vital for nurses caring for these children. Emphasizing the significance of vigilant monitoring for complications like bleeding can help prevent adverse outcomes and ensure the best possible recovery for the child. This rationale highlights the critical thinking and clinical judgment required in pediatric nursing care.

Correct Answer: C

Rationale: High-density lipoproteins (HDLs) are known as "good cholesterol" because they help transport cholesterol from the tissues back to the liver for processing and excretion, thus reducing the risk of cardiovascular disease. Option C, "They have little cholesterol," is accurate because HDLs are composed primarily of proteins with relatively high amounts of cholesterol, compared to other lipoproteins. Option A, "They have high amounts of triglycerides," is incorrect because HDLs are not known for carrying high amounts of triglycerides. Option B, "They have only small amounts of protein," is incorrect as HDLs are protein-rich particles. Option D, "They aid in steroid production," is incorrect because HDLs are primarily involved in cholesterol transport rather than steroid production. In pediatric nursing education, understanding lipoproteins like HDLs is crucial for managing cardiovascular disorders in children. Teaching students about the role of HDLs in cholesterol metabolism and cardiovascular health can help them make informed clinical decisions to promote pediatric patients' well-being.