A mother is breastfeeding her newborn son and is experiencing signs of her breasts feeling tender and full in between infant feedings. She asks if there are any suggestions that you can provide to help alleviate this physical complaint. The ideal nursing response would be to

Correct Answer: B

Rationale: The correct answer is B because the patient may be experiencing signs of engorgement, and placing the infant to feed more frequently may help prevent physical complaints of tenderness due to milk accumulation. Wearing a bra or using ice packs may provide comfort but will not resolve engorgement issues. It is important to address the root cause of the issue, which is milk accumulation.

Correct Answer: B

Rationale: A large infant born after a traumatic birth is at risk for shoulder dystocia, which may result in clavicle fracture or damage to the brachial plexus. Evaluating the flexion of both upper extremities can provide important information about any potential injuries. Gestational age status or growth chart percentile will not provide data about traumatic birth injuries, and while large infants are at risk for hypoglycemia, evaluating blood sugar alone may not address potential physical injuries.

Correct Answer: C

Rationale: The best confirmation of hyperbilirubinemia in an infant is through assessing the infant's bilirubin level. While the direct and indirect Coombs tests and maternal blood type are important in determining ABO incompatibility, the infant's bilirubin level provides the most definitive evidence of hyperbilirubinemia or pathologic jaundice.

Correct Answer: D

Rationale: The correct answer is D) 45%. In a healthy child after birth, the ratio of pulmonary vascular resistance to systemic vascular resistance is approximately 1:1. This means that the pulmonary vascular resistance is equal to systemic vascular resistance. The pulmonary vascular resistance is higher in the fetal circulation to divert blood flow away from the lungs. However, after birth, when the lungs become functional, the pulmonary vascular resistance decreases to match the systemic vascular resistance. Option A) 15% is incorrect because the ratio is not as low as 15% in a healthy child after birth. Option B) 25% is also incorrect as it is not the typical ratio of pulmonary to systemic vascular resistance in this context. Option C) 35% is not accurate as well; the ratio is closer to 1:1 rather than 35%. Understanding the ratios of pulmonary and systemic vascular resistance is crucial in pediatric nursing as it helps in assessing the cardiovascular and respiratory status of a child. This knowledge is essential in managing conditions like congenital heart defects or respiratory distress syndrome in pediatric patients.

Correct Answer: D

Rationale: In pediatric patients with pneumonia, hospital admission is crucial for managing severe cases and preventing complications. The correct answer, option D) vomiting, is not typically an indication for hospital admission in children with pneumonia. Vomiting alone, without other significant symptoms or complications, can often be managed on an outpatient basis. Option A) <6 months age is an indication for hospital admission due to the increased risk of severe illness and complications in infants. Option B) sickle cell anemia is also a risk factor for more severe pneumonia and may necessitate hospitalization for close monitoring and appropriate treatment. Option C) moderate to severe respiratory distress is a critical indication for hospital admission as it signifies significant respiratory compromise and the need for interventions such as supplemental oxygen, respiratory support, and close monitoring of the child's condition. Educationally, understanding the criteria for hospital admission in pediatric pneumonia is vital for nurses and healthcare providers caring for children with respiratory infections. Recognizing the signs and symptoms that warrant hospitalization ensures timely and appropriate management, leading to better outcomes for pediatric patients. It also highlights the importance of individualized care based on a child's specific risk factors and clinical presentation.