A female child, age 2, is brought to the emergency department after ingesting an unknown number of aspirin tablets about 30 minutes earlier. On entering the examination room, the child is crying and clinging to the mother. Which data should the nurse obtain first?

Correct Answer: A

Rationale: In this situation, the priority data the nurse should obtain first is the vital signs including heart rate, respiratory rate, and blood pressure of the child. This information will help assess the child's current physiological status and potential effects of ingesting the aspirin. Aspirin overdose in children can lead to serious complications such as metabolic acidosis, respiratory distress, and cardiovascular instability. Monitoring the vital signs will provide crucial information to guide appropriate interventions and determine the severity of the child's condition. Height and weight (option D) are important for routine assessments but not the priority in this urgent situation. Recent exposure to communicable diseases (option B) and number of immunizations received (option C) are not relevant to the immediate management of the child's aspirin ingestion.

Correct Answer: C

Rationale: The primary reason for surgical repair of myelomeningocele is to correct the neurologic defect caused by this type of birth defect. Myelomeningocele is a form of spina bifida where the spinal cord and its covering are exposed through an opening in the spine. Surgical closure of the defect is performed to protect the spinal cord and nerves, prevent further damage, and potentially improve long-term outcomes for the child. While preventing complications like hydrocephalus or infection may be important secondary goals of the treatment, the main objective of surgery for myelomeningocele is to address the underlying neurologic defect itself.

Correct Answer: D

Rationale: Performing neurovascular checks is the priority nursing action immediately after applying a spica cast on Baby Betty. A spica cast is used to immobilize the hips and thighs, which can affect circulation and nerve function in the lower extremities. Neurovascular checks involve assessing the circulation, sensation, and movement of the affected limb to ensure there are no signs of impaired circulation or nerve damage. It is crucial to monitor for any signs of compartment syndrome, such as pain, numbness, tingling, or decreased pulse, which could indicate a vascular compromise. Timely identification of any neurovascular compromise is essential to prevent complications and ensure the baby's safety and well-being.

Correct Answer: D

Rationale: Pyloric stenosis is a condition in infants where there is a tightening of the muscle at the outlet of the stomach, causing obstruction of food passage into the small intestine. One of the hallmark symptoms of pyloric stenosis is projectile vomiting, in which the vomit is forceful and shoots out a significant distance. This distinguishes it from regular regurgitation or spitting up, which are more common in infants for other reasons. Nurse Nancy would likely note this symptom while assessing a child with pyloric stenosis.

Correct Answer: D

Rationale: The Jatene procedure is a surgical technique used to correct Transposition of the Great Arteries (TGA). In this procedure, the great arteries (aorta and pulmonary artery) are switched back to their correct positions. The aorta is connected to the left ventricle, and the pulmonary artery is connected to the right ventricle. This correction allows for oxygen-rich blood to flow from the left side of the heart to the body, and oxygen-poor blood to flow from the right side of the heart to the lungs for oxygenation. The Jatene procedure is preferred over other methods like the Rashkind procedure, Rastelli procedure, or pulmonary artery banding for this specific purpose of correcting the high-pressure circulation seen in TGA.