A parent brings a toddler, age 19 months, to the clinic for a regular check-up. When palpating the toddler’s fontanels, what should the nurse expects to find?

Correct Answer: C

Rationale: In pediatric nursing, understanding fontanel assessment is crucial as it provides valuable information about an infant's intracranial pressure and brain development. In this case, the correct answer is C) Closed anterior and posterior fontanels for a 19-month-old toddler. The anterior fontanel typically closes around 18 months of age, which is consistent with the child's age in this scenario. The closure of the anterior fontanel indicates proper brain growth and development. The posterior fontanel, located at the back of the head, closes much earlier in infancy. Option A) Closed anterior fontanel and open posterior fontanel is incorrect because the posterior fontanel should be closed by this age. Option B) Open anterior fontanel and closed posterior fontanel is also incorrect as both fontanels should be closed at 19 months. Option D) Open anterior and posterior fontanels is incorrect as both fontanels should be closed in a toddler of 19 months. Understanding fontanel closure timelines is essential in pediatric nursing to monitor normal growth and development, identify abnormalities early, and provide appropriate care and interventions.

Correct Answer: D

Rationale: In pediatric CPR, using the heel of one hand for sternal compressions (Option D) is correct because it allows for appropriate force and depth while minimizing the risk of causing injury to the child. This technique is recommended by the American Heart Association for infants and children. Option A is incorrect because using both hands for compressions is preferred in adult CPR, not pediatric CPR. Option B is incorrect as the recommended compression-to-ventilation ratio for pediatric CPR is 30:2. Option C is incorrect as one-person CPR is standard practice in pediatric resuscitation unless another trained rescuer is available. Educationally, it is crucial for nurses to understand the nuances of pediatric CPR to provide effective and safe care to children in emergency situations. Proper technique ensures optimal outcomes and reduces the risk of complications during resuscitation efforts. Training and practice in pediatric CPR are essential for healthcare providers working with pediatric populations.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Gown, gloves, mask, and eye goggles or eye shield. The primary mode of transmission for severe acute respiratory syndrome (SARS) is through respiratory droplets. Therefore, it is crucial for the nurse to wear comprehensive personal protective equipment to prevent exposure. Option A) Gloves alone are not sufficient to protect against respiratory droplets that could potentially transmit SARS. Option B) Gown and gloves provide some protection, but a mask and eye protection are necessary due to the airborne nature of the virus. Option C) Gown, gloves, and mask offer good protection, but eye protection is also essential to prevent exposure through the mucous membranes of the eyes. Educationally, understanding the appropriate personal protective equipment for different infectious diseases is crucial for healthcare professionals to ensure their safety and the safety of their patients. In pediatric nursing, where children may not always exhibit typical symptoms, it is especially important to take all necessary precautions to prevent the spread of infectious diseases.

Correct Answer: A

Rationale: In this scenario, the correct nursing diagnosis that takes priority is "A) Ineffective airway clearance related to edema." The rationale behind this choice is that with third-degree burns involving the hands, face, and chest, there is a high risk of edema (swelling) in the upper airway, which can compromise the child's ability to breathe effectively. Maintaining a clear airway is of utmost priority to ensure oxygenation and ventilation, which are essential for life. Option B, "Disturbed body image related to physical appearance," is not the priority nursing diagnosis in this acute situation. While body image is important for psychosocial well-being, it takes a back seat to addressing immediate physiological needs like airway clearance. Option C, "Impaired urinary elimination related to fluid loss," is also not the priority at this moment. While fluid loss is a concern in burn patients, the immediate threat to life posed by compromised airway clearance takes precedence. Option D, "Risk for infection related to epidermal disruption," is a valid concern in burn patients, but in the immediate aftermath of a burn injury, addressing airway patency is more critical to prevent respiratory distress and potential respiratory failure. In an educational context, understanding the prioritization of nursing diagnoses based on the urgency of the patient's needs is crucial in pediatric nursing, especially in emergency situations like severe burn injuries. This question highlights the importance of recognizing and addressing life-threatening complications promptly to ensure positive patient outcomes.

Correct Answer: A

Rationale: In pediatric nursing, understanding congenital heart defects like ventricular septal defects (VSDs) is crucial. A VSD allows blood to shunt left to right, causing increased pulmonary flow and no cyanosis. This is because the higher pressure in the left ventricle pushes oxygenated blood through the defect into the right ventricle and out to the pulmonary circulation. This shunting of blood does not cause cyanosis because oxygen-rich blood is still reaching the systemic circulation. Option B is incorrect because if blood were to shunt right to left, it would bypass the lungs, resulting in decreased pulmonary flow and cyanosis due to poorly oxygenated blood entering the systemic circulation. Option C is incorrect as VSDs typically result in a left-to-right shunt due to the pressure differences between the ventricles. Option D is also incorrect because a VSD does not directly affect the pressure in the left atrium. Educationally, understanding the hemodynamics of VSDs is crucial for nurses caring for pediatric patients with congenital heart defects. Recognizing the impact of VSDs on pulmonary blood flow and oxygenation helps nurses provide appropriate interventions and education to support optimal outcomes for these patients.