A pediatric client is admitted to the emergency department with a traumatic brain injury (TBI) that caused a loss of consciousness. The last set of vital signs showed heart rate 48, blood pressure (BP) 148/74 mmHg, respiratory rate 28 and irregular. What does the nurse suspect based on these data?

Correct Answer: B

Rationale: The vital signs of bradycardia, hypertension, and irregular respirations indicate increased intracranial pressure. Bradycardia (heart rate of 48), hypertension (blood pressure of 148/74 mmHg), and irregular respirations are typical signs of increased intracranial pressure in a pediatric client with a traumatic brain injury and loss of consciousness.

Correct Answer: A

Rationale: Rationale: The correct answer is A) Suppress rejection. Cyclosporine is an immunosuppressant medication commonly prescribed to organ transplant recipients to prevent rejection. In the context of a kidney transplant, cyclosporine works by suppressing the body's immune response, particularly T-cell activity, to prevent the immune system from attacking and rejecting the transplanted kidney. This is crucial for the long-term success of the transplant and to ensure the child's body accepts the new organ. Option B) Decrease pain is incorrect because cyclosporine is not a pain medication. Its primary function is to prevent organ rejection by suppressing the immune response. Option C) Improve circulation is incorrect as cyclosporine does not directly impact circulation. Its main action is on the immune system to prevent rejection of the transplanted organ. Option D) Boost immunity is incorrect because cyclosporine actually suppresses the immune system. In the context of organ transplantation, boosting immunity would be counterproductive as it could lead to rejection of the transplanted organ. In a pediatric nursing context, understanding the rationale behind medications like cyclosporine is crucial for providing safe and effective care to pediatric patients, especially those who have undergone organ transplantation. Educating parents about the purpose of such medications can help them better understand the treatment plan and actively participate in their child's care, which ultimately contributes to better outcomes and adherence to the prescribed regimen.

Correct Answer: C

Rationale: In caring for a neonate born with bladder exstrophy, the priority nursing intervention is to cover the defect with sterile plastic wrap (Option C). This is crucial to prevent infection and maintain a sterile environment for the exposed bladder tissue. By covering the defect, the nurse helps protect the vulnerable area from contamination and potential complications. Option A, measuring intake and output, while important in overall neonatal care, is not the priority in this situation. Inserting a Foley catheter (Option B) or palpating the bladder mass (Option D) can potentially cause harm or increase the risk of infection due to the exposed nature of the bladder exstrophy. Educationally, understanding the priority interventions in caring for neonates with specific conditions like bladder exstrophy is essential for pediatric nurses. It ensures they can provide safe and effective care, prioritizing actions that address immediate risks to the newborn's health and well-being. This case highlights the importance of infection prevention and sterile technique in neonatal nursing care.

Correct Answer: D

Rationale: The correct answer is D) "I will administer this medication with meals." Prednisone is a corticosteroid that can cause gastrointestinal irritation, so administering it with meals helps to minimize stomach upset and irritation. By taking prednisone with food, the medication is better tolerated and absorbed, reducing the risk of gastrointestinal side effects. Option A) "I will administer this medication between meals" is incorrect because taking prednisone on an empty stomach can increase the risk of gastrointestinal irritation and side effects. Option B) "I will administer this medication at bedtime" is incorrect because prednisone should be taken with meals to reduce stomach upset, rather than before bedtime when the stomach is empty. Option C) "I will administer this medication one hour before meals" is incorrect because prednisone should be taken with meals to help prevent gastrointestinal irritation, not before meals. In pediatric nursing, it is crucial to educate caregivers on the proper administration of medications to ensure optimal therapeutic effects and minimize adverse reactions. Teaching them the importance of giving prednisone with meals can help promote medication adherence and improve the child's overall treatment outcomes.

Correct Answer: A

Rationale: The correct answer is A) Placing the newborn on a radiant warmer. In the case of a newborn with an omphalocele defect, it is crucial to maintain the infant's body temperature due to the exposed abdominal organs. Placing the newborn on a radiant warmer helps to prevent hypothermia and promote thermoregulation, which is essential for the infant's overall well-being and recovery. Option B) Placing the newborn in an open crib is incorrect because it does not address the specific need for thermal regulation in a newborn with an omphalocele defect. Exposing the infant to an open environment without adequate warmth can lead to complications. Option C) Preparing the newborn for phototherapy is also incorrect as phototherapy is used to treat conditions like jaundice, which is not directly related to an omphalocele defect. Option D) Preparing the newborn for bottle-feeding is inappropriate at this point as the priority for a newborn with an omphalocele defect is to ensure proper temperature maintenance and medical management before considering feeding options. In a pediatric nursing context, understanding the specialized care needs of infants with congenital defects is crucial for providing safe and effective nursing care. This question highlights the importance of prioritizing immediate physiological needs, such as thermoregulation, in infants with specific medical conditions like an omphalocele defect.