A 4-month-old with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has the highest priority?

Correct Answer: A

Rationale: In this scenario, the highest priority nursing intervention for a 4-month-old with meningococcal meningitis is option A: Instituting droplet precautions. This is the correct choice because meningococcal meningitis is a highly contagious infection spread through respiratory droplets. By instituting droplet precautions, the nurse can help prevent the spread of the infection to other patients, visitors, and healthcare workers. This action is crucial in maintaining a safe environment and preventing further transmission of the disease. Option B, administering acetaminophen, though important for managing fever and discomfort, is not the highest priority in this case. Controlling the spread of the infection takes precedence over symptom management. Option C, obtaining history information from the parents, is also important for the overall care of the patient but is not the highest priority at the moment. Immediate actions to prevent the spread of infection are critical before delving into detailed history taking. Option D, orienting the parents to the pediatric unit, is not necessary as the priority lies in the immediate medical needs of the child and preventing the spread of the infection. Educationally, this question emphasizes the importance of prioritizing nursing interventions based on the patient's condition and the potential risks to others. Understanding the significance of infection control measures is vital for nurses caring for pediatric patients with contagious diseases to ensure the safety of everyone in the healthcare setting.

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: A

Rationale: In a newborn infant suspected to have a ventricular septal defect (VSD), the assessment finding that would lead the nurse to suspect this condition is a loud, harsh murmur with a systolic thrill (Option A). This is because a VSD causes abnormal blood flow between the ventricles, resulting in turbulent blood flow and the characteristic murmur and thrill. Option B, cyanosis when crying, is more indicative of a cyanotic heart defect rather than a VSD. VSDs typically present with a systolic murmur rather than cyanosis. Option C, blood pressure higher in the arms than in the legs, is suggestive of coarctation of the aorta, a different cardiovascular disorder, not VSD. Option D, a machinery-like murmur, is associated with patent ductus arteriosus (PDA), not VSD. PDA murmur is continuous, unlike the systolic murmur heard in VSD. Educationally, understanding these assessment findings is crucial for pediatric nurses caring for infants with cardiovascular disorders. Recognizing specific murmurs and associated clinical manifestations aids in early identification, appropriate referral, and timely intervention, ultimately improving outcomes for infants with congenital heart defects.

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.