The nurse notices that a 10-month-old infant being seen in the clinic is wearing expensive clothing.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Discuss with the parents the importance of appropriate clothing for infants. This option is the most appropriate response because it focuses on the importance of appropriate clothing for infants rather than making assumptions about the family's financial situation or offering unsolicited advice. Option A) Question the parents about their financial situation is invasive and could lead to unnecessary embarrassment or discomfort for the parents. It is not the nurse's role to pry into personal financial matters unless related to the child's health and safety. Option B) Ask the parents if they receive assistance for clothing also assumes financial need without any evidence. It may come across as judgmental and could strain the nurse-parent relationship. Option C) Advise the parents on budget-friendly clothing options could be perceived as condescending or presumptuous. It is essential to approach discussions about clothing with sensitivity and respect for the parents' choices and circumstances. In an educational context, it is crucial for nursing students to understand the importance of cultural sensitivity, professionalism, and non-judgmental communication when interacting with families. Discussing the significance of appropriate clothing for infants can be a way to educate parents on factors like safety, comfort, and developmental needs without making assumptions or passing judgment. It promotes a collaborative and respectful approach to addressing parenting concerns.

Correct Answer: B

Rationale: The correct answer is B) amphetamine. The presentation described aligns with amphetamine toxicity symptoms, including delusions, paranoia, tachycardia, hypertension, hyperpyrexia, diaphoresis, piloerection, mydriasis, hyperreflexia, seizures, hypotension, and dysrhythmia. Understanding the effects of amphetamines is crucial in pediatric nursing as they are increasingly misused by adolescents for various reasons, leading to potentially life-threatening situations. Option A) antidepressant agents typically do not cause the array of symptoms described. Barbiturates (C) usually present with respiratory depression, hypotension, and CNS depression, not the hyperstimulation seen in the case. Benzodiazepines (D) would manifest with CNS depression, sedation, and respiratory depression, contrasting the symptoms presented. Educationally, this question reinforces the importance of recognizing drug toxicity in adolescents, highlighting the need for vigilance in assessment and the critical role of pediatric nurses in identifying and managing such cases promptly to prevent adverse outcomes. Understanding these distinctions is vital for providing safe and effective care to pediatric patients.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) heart failure. Rapid and deep breathing without other signs of respiratory distress is known as Kussmaul breathing and is often seen in conditions like diabetic ketoacidosis (option A) and renal tubular acidosis (option B) due to metabolic acidosis. Additionally, CNS stimulants (option D) can also lead to increased respiratory rate. Heart failure, however, typically presents with respiratory distress due to pulmonary congestion and edema, leading to symptoms such as shortness of breath, crackles in the lungs, and possibly cyanosis. Therefore, in a case of rapid and deep breathing without these typical signs of respiratory distress, heart failure is less likely to be the cause. In an educational context, understanding the differentiating signs and symptoms of various pediatric conditions is crucial for accurate clinical assessment and intervention. By recognizing the unique presentations of different pathologies, healthcare providers can make timely and appropriate decisions in the care of pediatric patients. This knowledge helps in providing safe and effective care tailored to the specific needs of each child.

Correct Answer: C

Rationale: In pediatric nursing, understanding the timeline of brain damage post-drowning is crucial for providing effective care. The correct answer is C) 30 minutes. After a drowning incident, brain damage can begin to occur as early as 4-6 minutes after the brain is deprived of oxygen. By the 30-minute mark, significant brain damage can already manifest, highlighting the critical importance of timely intervention and resuscitation efforts. Option A) 5 minutes is too early for significant brain damage to occur, though immediate action is still necessary to prevent complications. Option B) 15 minutes is also within the window where brain damage can start, but it may not capture the full extent of potential damage that can occur by 30 minutes. Option D) 60 minutes is too long, as significant brain damage would likely have already occurred by this time, emphasizing the need for rapid response and intervention. Educationally, this question underscores the urgency of recognizing and responding to drowning incidents promptly. It reinforces the importance of quick assessment, initiation of appropriate interventions, and the critical role of pediatric nurses in managing such emergencies to prevent irreversible brain damage in pediatric patients. By understanding this timeline, nurses can be better prepared to act decisively in these high-stakes situations.

Correct Answer: B

Rationale: In pediatric nursing, understanding the indications for intubation in neonates is crucial for providing optimal care. The correct answer is option B) inadequate oxygen saturation despite supplemental oxygen. This is the primary indication for intubation in a neonate as it signifies that despite providing additional oxygen, the infant is still not able to maintain adequate oxygen levels, which can be life-threatening. Option A) a respiratory rate of 40-50 breaths per minute is within the normal range for a neonate and does not necessarily indicate the need for intubation. Option C) stable blood pressure is important but not a direct indication for intubation. Option D) good respiratory effort is a positive sign and does not warrant immediate intubation. Educationally, it is important to understand that neonates have unique physiological needs and can deteriorate rapidly. Intubation is a critical intervention to ensure adequate oxygenation and ventilation in neonates who are unable to maintain appropriate oxygen levels despite other measures. Nurses caring for neonates must be vigilant in recognizing signs of respiratory distress and the need for interventions such as intubation to prevent further complications.