What procedure is most appropriate for the assessment of an abdominal circumference related to a bowel obstruction?

Correct Answer: B

Rationale: The correct answer is B) Marking the point of measurement with a pen. This is the most appropriate procedure for assessing an abdominal circumference related to a bowel obstruction because marking the point of measurement with a pen ensures consistency in measuring the same location each time, allowing for accurate monitoring of changes in abdominal girth. In the context of a bowel obstruction, changes in abdominal circumference can indicate worsening or improvement of the condition, making precise measurements crucial for effective patient care. Option A) Measuring the abdomen after feedings is incorrect because abdominal measurements should ideally be taken before meals to minimize variations due to food intake. Option C) Measuring the circumference at the symphysis pubis is incorrect as it is not the standard location for assessing abdominal circumference related to a bowel obstruction. The point of measurement should be consistent and reproducible, typically around the umbilicus. Option D) Using a new tape measure with each assessment to ensure accuracy is unnecessary as long as the same tape measure is used consistently and the point of measurement is marked accurately. Replacing the tape measure for each assessment may not significantly impact measurement accuracy if the technique is standardized and reliable. In an educational context, understanding the correct procedure for assessing abdominal circumference in conditions like bowel obstruction is essential for nurses caring for pediatric patients. Accurate measurements can provide valuable information about a child's condition, guide treatment decisions, and help in monitoring progress or identifying complications. Nurses must be proficient in proper measurement techniques to deliver high-quality care and ensure patient safety.

Correct Answer: C

Rationale: The correct answer is C) Prevent abdominal distention. In the context of a child post-surgery for Hirschsprung disease, which is a condition affecting the large intestine, the NG tube serves to decompress the gastrointestinal system and prevent abdominal distention. Hirschsprung disease results in the inability of the colon to push stool toward the rectum, leading to a build-up of stool in the intestines. Option A) Prevent the spread of infection is incorrect as the primary purpose of an NG tube in this scenario is not related to infection control. Option B) Monitor electrolyte balance is also not the primary purpose of an NG tube in this specific situation. While electrolyte balance may be monitored in children with NG tubes for other reasons, it is not the main purpose post-surgery for Hirschsprung disease. Option D) Maintain accurate records of output is not the primary purpose of the NG tube in this case. While output may be measured and recorded, the main goal of the NG tube here is to prevent abdominal distention by removing gas and fluids from the gastrointestinal tract. Educationally, understanding the rationale behind the use of an NG tube in specific conditions like Hirschsprung disease is crucial for providing safe and effective care to pediatric patients. Nurses need to be knowledgeable about the purposes of different interventions to ensure optimal outcomes for their patients.

Correct Answer: C

Rationale: The correct measure that should be included in the plan of care for an infant after a cleft lip repair is to position the infant supine. Placing the infant in a supine position helps protect the surgical site from injury and promotes proper healing. Choice A, 'Position prone,' is incorrect as placing the infant prone can put pressure on the surgical site and hinder healing. Choice B, 'Provide fluids from a cup,' is not directly related to the surgical care of a cleft lip repair. Choice D, 'Avoid elbow restraints,' is not specific to the postoperative care of a cleft lip repair.

Correct Answer: C

Rationale: The correct answer is C: 'Barking cough and inspiratory stridor.' Classic signs of laryngotracheobronchitis (LTB) include a barking cough, often described as a seal-like cough, and inspiratory stridor, which is a high-pitched sound heard during inspiration. These symptoms occur due to inflammation and narrowing of the upper airway. Choices A, B, and D are incorrect as they do not align with the typical assessment findings of LTB. Cyanosis and dyspnea (Choice A) may occur in severe cases but are not specific to LTB. Productive cough and high fever (Choice B) are more indicative of lower respiratory tract infections. Pale laryngeal and dyspnea (Choice D) are not characteristic findings of LTB.

Correct Answer: A

Rationale: The correct answer is A. RSV is typically diagnosed by swabbing the nose and testing the secretions. This method helps confirm the presence of the respiratory syncytial virus. Choice B is incorrect because while symptoms are important in diagnosis, specific tests like swabbing for RSV do exist. Choice C is incorrect as sending a viral culture to an outside lab is not the primary method for diagnosing RSV. Choice D is a duplicate of choice B and is incorrect for the same reasons.