An 18-month-old child presents with fever, nasal flaring, intercostal retractions, and a respiratory rate of 50 bpm. What is the most appropriate nursing diagnosis?

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Question 1 of 5

An 18-month-old child presents with fever, nasal flaring, intercostal retractions, and a respiratory rate of 50 bpm. What is the most appropriate nursing diagnosis?

Correct Answer: B

Rationale: In this case, the child is showing signs of respiratory distress, such as nasal flaring, intercostal retractions, and an increased respiratory rate. These are indicative of an ineffective breathing pattern. The child's compromised respiratory function requires immediate attention and intervention, making 'Ineffective breathing pattern' the most appropriate nursing diagnosis. Choices A, C, and D do not address the respiratory distress the child is experiencing and are not the priority in this situation.

Question 2 of 5

Which of the following is NOT a function of hormones?

Correct Answer: A

Rationale: Hormones play various roles in the body, such as promoting growth and beauty, maintaining body temperature, and fighting infections. However, producing new offspring is not a direct function of hormones. Reproduction is primarily regulated by other factors like the reproductive system. Choice B is incorrect because hormones can indeed influence growth but not specifically 'beauty.' Choice C is incorrect as hormones can help regulate body temperature indirectly. Choice D is incorrect as hormones like cytokines can be involved in the body's immune response to fight infections.

Question 3 of 5

When using the Ballard gestational assessment tool on a newborn, which of the following tests should be performed after the first hour of birth, allowing the newborn to recover from the stress of birth?

Correct Answer: A

Rationale: The correct answer is Arm recoil. Arm recoil is slower in healthy but fatigued newborns after birth, making it best elicited after the first hour of birth when the baby has had time to recover from the stress of birth. This assessment helps evaluate neuromuscular maturity in newborns and is more accurate when performed after the initial recovery period. The other choices, Square window sign, Scarf sign, and Popliteal angle, are not specifically assessed using the Ballard gestational assessment tool and do not relate to the recovery period after birth.

Question 4 of 5

Before drying off the newborn after birth, which assessment finding should the healthcare professional document to ensure an accurate gestational rating on the Ballard gestational assessment tool?

Correct Answer: A

Rationale: To ensure an accurate gestational rating on the Ballard gestational assessment tool, healthcare professionals should document the amount and area of vernix coverage before drying the newborn. Drying the baby after birth could disturb the vernix, potentially affecting the gestational age assessment. Assessing and documenting the vernix coverage beforehand enables a more precise evaluation using the Ballard gestational assessment tool. Choices B, C, and D are incorrect as they are not directly related to gestational rating on the Ballard assessment tool.

Question 5 of 5

What characteristic indicates that a mass on a newborn's head is a cephalohematoma?

Correct Answer: A

Rationale: A cephalohematoma typically appears between the first and second days after birth, making choice A the correct answer. It results from blood vessel rupture between a cranial bone and the periosteal membrane. Choices B, C, and D are incorrect because the growth of the mass when the newborn cries, asymmetrical head appearance, or the mass being located on only one side of the head are not specific indicators of a cephalohematoma.

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