ATI RN
Pediatric Respiratory Distress Nursing Interventions Questions
Question 1 of 5
When assessing a child with a cleft palate, the nurse is aware that the child is at risk for more frequent episodes of otitis media due to which of the following?
Correct Answer: B
Rationale: In pediatric respiratory distress nursing interventions, understanding the relationship between cleft palate and otitis media is crucial. The correct answer is B) Ineffective functioning of the Eustachian tubes. Children with cleft palate often have structural abnormalities that impact the Eustachian tubes, leading to poor drainage and ventilation of the middle ear. This dysfunction creates a conducive environment for bacterial growth, increasing the risk of otitis media. Option A) Lowered resistance from malnutrition is incorrect as malnutrition may weaken the immune system but is not directly related to the development of otitis media in children with cleft palate. Option C) Plugging of the Eustachian tubes with food particles is incorrect as while feeding may temporarily block the Eustachian tubes, it is not a significant factor contributing to the increased risk of otitis media in these children. Option D) Associated congenital defects of the middle ear is incorrect as this is a broad statement that does not specifically address the mechanism through which cleft palate predisposes to otitis media. Educationally, nurses need to grasp the anatomical and physiological implications of cleft palate on otitis media development to provide comprehensive care for these vulnerable pediatric patients. Recognizing the impact of Eustachian tube dysfunction can guide nurses in implementing preventive measures and early interventions to manage otitis media effectively in children with cleft palate.
Question 2 of 5
Which of the following assessment findings would lead the nurse to suspect Down syndrome in an infant?
Correct Answer: B
Rationale: In pediatric nursing, recognizing clinical manifestations associated with genetic conditions like Down syndrome is crucial for early detection and intervention. The correct answer is B) Transverse palmar crease. Infants with Down syndrome often present with this physical characteristic, known as the "simian crease," which is a single crease across the palm instead of the typical three creases. This finding is a significant indicator of Down syndrome and should prompt further evaluation and genetic testing. Option A) Small tongue is not typically associated with Down syndrome. However, infants with Down syndrome may have a protruding tongue due to hypotonia, not a small one. Option C) Large nose is a vague characteristic and not specific to Down syndrome. While some individuals with Down syndrome may have a slightly larger nose, it is not a definitive diagnostic feature. Option D) Restricted joint movement is not a common finding in infants with Down syndrome. Instead, joint laxity and hyperflexibility are more commonly observed due to ligamentous laxity associated with the condition. Educationally, understanding these subtle physical cues can aid nurses in identifying potential genetic conditions early, allowing for timely interventions and support for the infant and their family. It is essential for nurses to be familiar with a wide range of assessment findings associated with various conditions to provide holistic and individualized care to pediatric patients.
Question 3 of 5
Which of the following should the nurse do first after noting that a child with Hirschsprung disease has a fever and watery explosive diarrhea?
Correct Answer: A
Rationale: The correct answer is A) Notify the physician immediately. When a child with Hirschsprung disease presents with a fever and watery explosive diarrhea, it can be indicative of an enterocolitis, a serious complication requiring prompt medical attention. Notifying the physician first is crucial as they need to assess the child's condition, possibly order diagnostic tests, and initiate appropriate treatment promptly. Delay in seeking medical intervention can lead to worsening of symptoms and potential life-threatening complications. Administering antidiarrheal medications (option B) is contraindicated in this situation as it can mask symptoms and potentially worsen the underlying condition by delaying appropriate treatment. Monitoring the child every 30 minutes (option C) is important, but it should not take precedence over notifying the physician, especially in a critical situation like this. Doing nothing and assuming it is characteristic of Hirschsprung disease (option D) is dangerous as fever and explosive watery diarrhea are not typical symptoms of this condition and could indicate a serious complication that needs immediate attention. In an educational context, this question highlights the importance of recognizing and responding to potentially serious complications in pediatric patients with chronic conditions. It emphasizes the critical role of nurses in prompt assessment, communication with healthcare providers, and advocating for the best interests of the child.
Question 4 of 5
The nurse notes a swelling on the neonate's scalp that crosses the suture line. The nurse documents this condition as...
Correct Answer: B
Rationale: The correct answer is B) Caput succedaneum. In a neonate, a swelling on the scalp that crosses the suture line is most likely to be a caput succedaneum. This condition is characterized by localized soft tissue edema that is present over the presenting part of the fetus at birth. It usually resolves on its own without intervention. A) Cephalic hematoma is a collection of blood between the skull and periosteum. It does not cross suture lines and is typically caused by trauma during delivery. C) Hemorrhagic edema refers to localized swelling with blood accumulation. This term is not commonly used in neonatal care for this specific presentation. D) Perinatal caput is not a recognized term in neonatal care. It does not describe the specific condition of swelling on the scalp that crosses the suture line. Educational context: Understanding the differences between these terms is crucial for nurses caring for neonates. Correctly identifying and documenting such findings can aid in appropriate treatment and monitoring of neonatal conditions. Proper documentation ensures clear communication among the healthcare team and accurate medical records for future reference.
Question 5 of 5
When discussing a seven-month-old infant's motor skill development, the nurse should explain that by age seven months, an infant most likely will be able to...
Correct Answer: D
Rationale: In discussing a seven-month-old infant's motor skill development, it is crucial for nurses to have a strong understanding of typical developmental milestones. At seven months, infants are typically able to sit alone using their hands for support, making option D the correct answer. This milestone is known as the "tripod sit" where infants can balance themselves briefly while using their hands for additional support. Option A, walking with support, is not developmentally appropriate for a seven-month-old infant as walking typically begins around 12-15 months. Option B, eating with a spoon, involves more advanced fine motor skills that infants typically develop around 12-18 months. Option C, standing while holding onto furniture, known as cruising, is a skill that emerges around 9-12 months. Understanding these milestones is crucial for nurses working with pediatric patients as it allows them to assess development appropriately, provide anticipatory guidance to parents, and identify potential developmental delays early on. By comprehensively understanding infant motor skill development, nurses can offer holistic care to promote optimal growth and development in pediatric patients.