The nurse, caring for a patient whose labor is being augmented with oxytocin, recognizes that the oxytocin should be discontinued immediately if there is evidence of:

Correct Answer: B

Rationale: In this scenario, the correct answer is option B: a fetal heart rate (FHR) of 180 with absence of variability. This is a critical indicator of fetal distress. Oxytocin, a medication used to augment labor, can lead to uterine hyperstimulation, which in turn can compromise fetal oxygenation. A FHR of 180 with absence of variability suggests fetal distress due to reduced oxygen supply. Discontinuing oxytocin in this situation is crucial to prevent further harm to the fetus. Option A, uterine contractions occurring every 8 to 10 minutes, is a normal pattern of contractions during labor and not necessarily indicative of fetal distress requiring immediate discontinuation of oxytocin. Option C, the patient needing to void, is not directly related to fetal distress or the need to discontinue oxytocin. It is important for the patient's comfort and to prevent bladder distention, but it does not warrant immediate cessation of oxytocin. Option D, rupture of the patient's amniotic membranes, is also not an immediate indication to discontinue oxytocin. While rupture of membranes requires monitoring for signs of infection and changes in labor progression, it does not directly signal fetal distress necessitating immediate cessation of oxytocin. In an educational context, understanding the signs of fetal distress during labor and the implications of oxytocin administration is crucial for nurses caring for laboring patients. Recognizing these signs promptly and taking appropriate actions, such as discontinuing oxytocin, can help prevent adverse outcomes for both the mother and the baby.

Correct Answer: A

Rationale: In pediatric respiratory distress scenarios, administering the inactivated flu vaccine to individuals with the highest risk of complications is crucial. The correct answer is option A, the healthy 8-month-old who attends day care. This choice aligns with the priority to protect vulnerable populations, such as infants, who have underdeveloped immune systems and are more susceptible to severe flu-related complications. Option B, the 8-year-old with a history of Guillain Barre Syndrome (GBS), is not the highest priority for the flu vaccine in this context. While individuals with a history of GBS should consult with their healthcare provider before vaccination, the immediate priority is to protect infants like the 8-month-old. Option C, the 7-year-old who attends public school, and option D, the 17-year-old living in a college dormitory, are also not the highest priority for the inactivated flu vaccine in this scenario. While these individuals may benefit from vaccination to prevent the spread of flu in communal settings, the 8-month-old has a higher risk of severe complications. Educationally, understanding the rationale behind prioritizing certain populations for vaccination is vital in pediatric nursing practice. It emphasizes the importance of evidence-based decision-making and targeted interventions to protect those most at risk in respiratory distress situations. Prioritizing vaccinations based on risk factors is a key aspect of providing safe and effective care to pediatric patients.

Correct Answer: C

Rationale: In the context of pediatric respiratory distress, the correct answer is C) Blow a pinwheel. This breathing exercise helps to improve the expiratory phase by encouraging the child to exhale fully and slowly. Blowing a pinwheel requires the child to control their exhalation, promoting improved lung function and airway clearance. It also helps in strengthening respiratory muscles and increasing lung capacity. Option A) Using an incentive spirometer is more suitable for older children or adults as it requires better coordination and understanding of the device, which may be challenging for a 3-year-old with asthma. Option B) Breathing into a paper bag is not recommended for children, especially those with asthma, as it can lead to a build-up of carbon dioxide in the body, causing potential harm. Option D) Taking several deep breaths is a more general exercise and may not specifically target improving the expiratory phase in a child with asthma. In an educational context, it is essential for nurses and healthcare providers to understand age-appropriate interventions for pediatric patients with respiratory distress. Choosing the correct breathing exercises tailored to the child's age and condition is crucial in optimizing respiratory function and managing asthma symptoms effectively. By selecting the appropriate intervention, nurses can help improve the child's respiratory health outcomes and overall well-being.

Correct Answer: B

Rationale: In newborns, cyanosis is a concerning sign of inadequate oxygenation. The correct answer is B) Cyanotic defects. Cyanotic defects are congenital heart defects that result in decreased oxygen levels in the blood, leading to cyanosis. Examples include Tetralogy of Fallot, transposition of the great arteries, and tricuspid atresia. Option A) Acyanotic defects, on the other hand, do not typically present with cyanosis. Acyanotic defects include conditions like atrial septal defects, ventricular septal defects, and patent ductus arteriosus, where oxygenated and deoxygenated blood mix but do not cause cyanosis. Option C) Innocent murmurs are benign heart murmurs often heard in healthy children and do not cause cyanosis. These murmurs are typically soft, systolic, and do not indicate any structural abnormalities in the heart. Option D) Hypertension does not directly cause cyanosis in newborns. Hypertension may result from various factors but is not the primary cause of cyanosis in this patient population. Educationally, understanding the association of cyanosis with cyanotic defects in newborns is crucial for nurses caring for pediatric patients. Recognizing cyanosis early, understanding its potential causes, and promptly initiating appropriate interventions are essential to prevent adverse outcomes in infants with respiratory distress. Nurses play a vital role in assessing, monitoring, and advocating for infants with cyanosis, making this knowledge critical in pediatric nursing practice.

Correct Answer: C

Rationale: In pediatric respiratory distress cases, understanding the etiology of conditions like rheumatic fever is crucial for effective nursing interventions. The correct answer is C) Group A beta-haemolytic streptococcus. This bacterium, specifically the Streptococcus pyogenes strain, is responsible for causing rheumatic fever through an autoimmune response triggered by untreated or inadequately treated streptococcal infections. Option A) Streptococcal pneumonia is caused by Streptococcus pneumoniae, a different bacterium than Group A streptococcus, and is associated with pneumonia and other respiratory infections, not rheumatic fever. Option B) Haemophilus influenza is a bacterium that can cause respiratory infections like pneumonia and bronchitis but is not linked to rheumatic fever. Option D) Staphylococcus aureus is a common cause of skin and soft tissue infections, as well as some respiratory infections, but it is not implicated in the development of rheumatic fever. Educationally, understanding the specific pathogens associated with different diseases is essential for nurses to provide accurate assessments, interventions, and patient education. In the case of rheumatic fever, recognizing the role of Group A streptococcus can help in early identification and treatment, potentially preventing serious complications.