The healthcare provider is assessing abdominal girth for a pediatric client who presents with abdominal distension. Which nursing action is appropriate?

Correct Answer: D

Rationale: In pediatric nursing, assessing abdominal girth is crucial in detecting conditions like ascites, organ enlargement, or obstruction. The correct action is to measure the girth around the largest portion of the abdomen (Option D). This is important as it provides a comprehensive measurement that captures any abnormal distension, helping to monitor changes in the child's condition accurately. Measuring the girth just below the umbilicus (Option A) may not capture the full extent of distension if the swelling is higher up in the abdomen. Measuring just below the sternum (Option B) is too high and may miss lower abdominal distension. Measuring just above the pubic bone (Option C) is too low and may not encompass the entire abdominal area. Educationally, understanding the correct technique for assessing abdominal girth is essential for pediatric nurses to accurately monitor and assess children's abdominal conditions. It ensures proper evaluation and detection of abnormalities, leading to timely interventions and improved patient outcomes.

Correct Answer: A

Rationale: The correct answer is A) Covering the exposed intestines with sterile moist gauze. This is the priority nursing action because the gastroschisis defect involves a hole in the abdominal wall, leading to exposed intestines, which are at risk for infection, dehydration, and heat loss. By covering the intestines with sterile moist gauze, the nurse can protect the organs from infection and prevent fluid loss. Option B) Wrapping the newborn warmly in two or three blankets is incorrect because while maintaining the newborn's body temperature is important, it is secondary to protecting the exposed intestines. Option C) Providing sterile water feeding to maintain hydration during transport is incorrect as neonates with gastroschisis are at risk for fluid and electrolyte imbalances, and providing water feeding without proper surgical correction can lead to complications. Option D) Allowing the parents of the newborn to see their child prior to transport is not the priority action as the immediate focus should be on protecting the exposed intestines to prevent complications. In an educational context, this question highlights the importance of prioritizing interventions based on the immediate needs of the neonate with a surgical emergency like gastroschisis. It emphasizes the critical thinking skills required in pediatric nursing to provide safe and effective care for neonates with complex conditions.

Correct Answer: B

Rationale: Tachycardia is a common early sign of dehydration in infants, especially when presenting with dry mucous membranes and diarrhea. The increased heart rate is the body's compensatory mechanism to maintain cardiac output in response to dehydration. Bradycardia, increased blood pressure, and normal fontanels are not typically associated with early to moderate dehydration in infants.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Uncompensated respiratory acidosis. This is because the child with croup has an increased PCO2 (respiratory component), a decreased pH, and a normal HCO3 (metabolic component) blood gas values. Respiratory acidosis occurs when there is inadequate excretion of carbon dioxide, leading to its buildup in the blood, resulting in a decrease in pH. The normal HCO3 level indicates that there is no compensatory metabolic response to the respiratory acidosis. Option A, Uncompensated metabolic alkalosis, is incorrect because the HCO3 level is normal, ruling out metabolic alkalosis. Option B, Uncompensated metabolic acidosis, is incorrect because the HCO3 level is normal, ruling out metabolic acidosis. Option D, Uncompensated respiratory alkalosis, is incorrect as the child's PCO2 is increased, indicating respiratory acidosis rather than respiratory alkalosis. In an educational context, understanding blood gas values and their interpretation is crucial for pediatric nurses to assess and manage respiratory conditions effectively. Recognizing the acid-base balance disturbances aids in providing appropriate interventions and collaborating with healthcare providers for optimal patient care.

Correct Answer: B

Rationale: In this scenario, the correct answer is option B, 86 mL/hr. The healthcare provider's formula combines maintenance and replacement fluid requirements. For maintenance, it is 1000 mL for the first 10 kg of body weight and 50 mL for every additional kg over 10. For replacement, it is the percentage of lost body weight (7% in this case) multiplied by 10 per kg of body weight. Option A (88 mL/hr) is incorrect as it does not consider both maintenance and replacement fluid needs accurately. Option C (81 mL/hr) and Option D (83 mL/hr) are also incorrect because they do not account for the total fluid requirements based on the child's weight and the percentage of weight lost. Educationally, understanding fluid balance calculations in pediatric nursing is crucial for providing safe and effective care to children, especially when managing conditions like dehydration. Nurses need to accurately calculate and administer IV fluids to prevent complications associated with fluid imbalances. This question reinforces the importance of precise calculations in pediatric nursing practice to ensure optimal patient outcomes.