A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is being breastfed. The nurse provides which most appropriate instructions to the mother?

Correct Answer: C

Rationale: The correct answer is C) Continue to breastfeed every 2-4 hours. In the context of a newborn infant with hyperbilirubinemia, breastfeeding helps promote the passage of meconium, which aids in the elimination of excess bilirubin from the body. Continuing to breastfeed frequently ensures that the baby receives adequate nutrition and hydration, which is essential for managing hyperbilirubinemia. Option A is incorrect because switching to bottle feeding for 2 weeks can disrupt the establishment of breastfeeding and may not be necessary for managing hyperbilirubinemia in a breastfed infant. Option B is also incorrect as stopping breastfeeding and switching to bottle-feeding permanently is not recommended unless there are specific medical reasons to do so. Option D is incorrect because feeding the newborn infant less frequently can lead to inadequate intake of milk and may exacerbate the hyperbilirubinemia. It is crucial to maintain regular feeding intervals to support the baby's overall health and well-being. Educationally, understanding the importance of breastfeeding in managing hyperbilirubinemia is essential for healthcare professionals working with newborns and their families. Providing accurate information and support to mothers regarding breastfeeding can help optimize infant health outcomes and strengthen the mother-infant bond.

Correct Answer: B

Rationale: In the context of a child diagnosed with epiglottitis, the correct answer is B) leaning forward with the chin thrust out and drooling. This posture, known as the "tripod position," indicates that the child is trying to maintain an open airway by extending the neck and thrusting the chin forward. This position helps prevent further airway obstruction, as the epiglottis is inflamed and can block airflow. Drooling is also a common sign due to difficulty swallowing. Option A) exhibiting nasal flaring and tachycardia is a common sign of respiratory distress, but in epiglottitis, the child is more likely to have a muffled voice and avoid moving air. Option C) having a low-grade fever and complaining of a sore throat are common symptoms of epiglottitis but do not directly indicate airway obstruction. Option D) leaning backward, supporting themselves with the hands and arms is incorrect as it does not suggest efforts to maintain an open airway. Educationally, understanding these distinct clinical manifestations is crucial for nurses caring for pediatric patients with respiratory disorders. Recognizing the subtle signs of airway compromise in children, such as the tripod position in epiglottitis, can lead to prompt interventions and potentially life-saving actions in an emergency setting.

Correct Answer: B

Rationale: The correct answer is option B) has diminished breath sounds, no cough, and has a protruding tongue with drooling. In a 15-month-old child, the presence of diminished breath sounds along with drooling and a protruding tongue raises concerns for a potential airway obstruction, such as a foreign body aspiration. This is a critical situation that requires immediate intervention to ensure the child's airway remains patent. Option A) describes a child with signs of respiratory distress but not an immediate life-threatening condition like airway obstruction. Option C) presents symptoms of a respiratory infection which, though concerning, do not indicate an acute emergency. Option D) describes a child with wheezing and feeding difficulties, suggestive of possible asthma or bronchiolitis, but these symptoms are not as immediately life-threatening as airway obstruction. In an educational context, understanding these different presentations is crucial for nurses caring for pediatric patients, as prompt recognition and appropriate intervention can significantly impact patient outcomes, especially in respiratory emergencies. Nurses must be able to differentiate between urgent situations requiring immediate action and those that can be managed with less urgency.

Correct Answer: C

Rationale: The correct answer is C) autosomal-recessive trait passed on by both parents who are carriers and that each child has a 25% chance of having CF. Cystic Fibrosis (CF) is a genetic disorder caused by inheriting two faulty CFTR genes, one from each parent. In an autosomal-recessive inheritance pattern, both parents are carriers of the faulty gene but do not exhibit symptoms of the disease themselves. When two carriers have a child, there is a 25% chance the child will inherit two faulty genes and have CF, a 50% chance the child will be a carrier like the parents, and a 25% chance the child will inherit two normal genes. Option A) is incorrect because CF is not an autosomal-dominant trait and is not passed on exclusively from the child's mother. Option B) is also incorrect as CF is not passed on exclusively by the child's father. It is essential for nurses and healthcare professionals working with families affected by genetic disorders like CF to have a clear understanding of inheritance patterns to provide accurate information and support. This knowledge enables them to educate families about the risks and probabilities associated with genetic conditions, empowering them to make informed decisions about family planning and healthcare management.

Correct Answer: D

Rationale: The correct answer is D) Tetralogy of Fallot because it is a congenital heart defect characterized by four specific heart abnormalities that result in mixing of oxygenated and deoxygenated blood in the heart. This mixing leads to deoxygenated blood being pumped out to the body, causing cyanosis. A) Aortic stenosis is incorrect because it involves narrowing of the aortic valve, which may lead to decreased cardiac output but does not cause cyanosis. B) Coarctation of the aorta is incorrect as it is a narrowing of the aorta that restricts blood flow to the lower part of the body, but it does not result in cyanosis. C) Patent ductus arteriosus is incorrect because it is a condition where a blood vessel called the ductus arteriosus fails to close after birth, causing abnormal blood flow between the aorta and pulmonary artery. While it can lead to other complications, it does not typically cause cyanosis. Understanding these distinctions is vital in pediatric nursing care as it helps in accurate assessment, diagnosis, and management of respiratory and cardiac disorders in children. Recognizing the specific symptoms and implications of each condition can guide nursing interventions and improve patient outcomes.