An infant presents with lethargy in the newborn nursery on the second day of life. On further examination, vital signs are stable and muscle tone is slightly decreased, with sluggish reflexes noted. Other physical characteristics are noted as being normal. Lab tests reveal a decreased hematocrit and increased blood sugar. The nurse suspects that the infant may be exhibiting signs and symptoms of

Correct Answer: B

Rationale: The signs and symptoms described, such as lethargy, decreased muscle tone and reflexes, decreased hematocrit, hyperglycemia, and acidosis, are consistent with intraventricular hemorrhage (IVH) or periventricular hemorrhage (PIVH). If the infant had respiratory distress syndrome (RDS) or bronchopulmonary dysplasia (BPD), there would be more respiratory symptoms present. If the infant had retinopathy of prematurity (ROP), there would be signs and symptoms related to the eyes.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) croup. Grunting is a symptom commonly associated with croup, a viral infection that causes inflammation and swelling of the upper airway, leading to airway obstruction. The grunting sound is produced when the child exhales against a partially closed glottis, which helps maintain positive pressure in the airway to keep it open. This mechanism is the body's way of compensating for the narrowed airway due to inflammation. Option A) epiglottitis is incorrect because in epiglottitis, the child typically presents with a sore throat, high fever, and difficulty swallowing, rather than the characteristic grunting seen in croup. Option B) hyaline membrane disease is a condition primarily affecting premature infants, characterized by respiratory distress due to immature lung development. Grunting is not a typical finding in this condition. Option C) asthma is a chronic respiratory condition characterized by reversible airway obstruction due to inflammation and bronchoconstriction. While wheezing is a common symptom in asthma, grunting is not a typical feature. Educationally, understanding the specific respiratory symptoms associated with different pediatric conditions is crucial for nurses taking the NCLEX exam and in clinical practice. Recognizing the unique signs and symptoms of croup, such as grunting, barking cough, and stridor, can help nurses provide prompt and appropriate care to pediatric patients with this condition. This knowledge aids in effective assessment, intervention, and communication with healthcare providers to ensure timely management and positive patient outcomes.

Correct Answer: C

Rationale: The correct answer is C) tachypnea. In pediatric patients with pneumonia, tachypnea is the most consistent clinical manifestation. Tachypnea, or rapid breathing, is a hallmark sign of respiratory distress and is often seen in children with pneumonia due to the body's attempt to compensate for decreased oxygen levels. This is a key indicator for healthcare providers to assess and monitor in pediatric patients with suspected pneumonia. Subcostal retractions (option A) and grunting (option B) are also signs of respiratory distress but are not as consistently seen in pneumonia compared to tachypnea. Subcostal retractions are more indicative of increased work of breathing, while grunting is a non-specific sign of respiratory distress commonly seen in newborns. Fever (option D) is a common symptom of pneumonia but is not as specific or consistent as tachypnea in pediatric patients. Fever can be present in various respiratory and non-respiratory conditions, so it is not the most consistent clinical manifestation of pneumonia in this context. Educationally, understanding the key clinical manifestations of pneumonia in pediatric patients is crucial for nurses, especially those preparing for the NCLEX exam. Recognizing tachypnea as a key indicator can help nurses prioritize care, intervene promptly, and provide appropriate treatment to pediatric patients with pneumonia.

Correct Answer: A

Rationale: The correct answer is A) cough and production of copious purulent sputum. Bronchiectasis is a chronic condition characterized by irreversible dilation and scarring of the bronchi due to chronic infection or inflammation. The most common complaint in bronchiectasis patients is a chronic cough that produces large amounts of purulent sputum. This is due to the build-up of mucus in the dilated airways, leading to persistent coughing and sputum production. Option B) fever is less likely to be the most common complaint in bronchiectasis. While fever can occur in bronchiectasis due to underlying infections, it is not typically the predominant symptom. Option C) hemoptysis, or coughing up blood, can occur in bronchiectasis but is less common than cough and sputum production. It is not the most common complaint in these patients. Option D) anorexia is not a typical complaint associated with bronchiectasis. While chronic illness can lead to decreased appetite and weight loss, it is not the primary complaint in patients with this condition. Educational context: Understanding the common complaints in patients with bronchiectasis is essential for nurses caring for pediatric patients with respiratory conditions. Recognizing the hallmark symptoms of bronchiectasis can aid in early identification, appropriate management, and improved outcomes for these patients. Nurses should be vigilant in assessing for cough and sputum production in pediatric patients with suspected bronchiectasis to provide timely interventions and support.

Correct Answer: A

Rationale: In cystic fibrosis (CF), a genetic disorder affecting the respiratory system, inhalation therapies play a crucial role in managing symptoms. The correct answer, A) β-agonists may decrease PaO2, is true because while β-agonists can help dilate airways, they may also cause decreased PaO2 levels in CF patients due to ventilation-perfusion mismatch. Option B) human recombinant DNase improves pulmonary function is correct as DNase helps break down DNA in sputum, reducing viscosity and improving airway clearance. This therapy has shown to be effective in CF management. Option C) N-acetylcysteine is toxic to ciliated epithelium is incorrect. N-acetylcysteine is a mucolytic agent that helps break down mucus in CF patients, aiding in clearance and reducing the risk of infections. Option D) nebulized hypertonic saline improves mucociliary clearance is also true. Hypertonic saline helps hydrate airway surfaces, thinning mucus and promoting clearance, which is beneficial for CF patients. Educationally, understanding the rationale behind each inhalation therapy in CF is vital for nurses to provide effective care. Knowing the mechanisms of action, benefits, and potential side effects of these therapies helps ensure safe and evidence-based practice in pediatric respiratory nursing.