Which assessment would lead the nurse to suspect that a newborn infant has a ventricular septal defect?

Correct Answer: A

Rationale: In a newborn infant suspected to have a ventricular septal defect (VSD), the assessment finding that would lead the nurse to suspect this condition is a loud, harsh murmur with a systolic thrill (Option A). This is because a VSD causes abnormal blood flow between the ventricles, resulting in turbulent blood flow and the characteristic murmur and thrill. Option B, cyanosis when crying, is more indicative of a cyanotic heart defect rather than a VSD. VSDs typically present with a systolic murmur rather than cyanosis. Option C, blood pressure higher in the arms than in the legs, is suggestive of coarctation of the aorta, a different cardiovascular disorder, not VSD. Option D, a machinery-like murmur, is associated with patent ductus arteriosus (PDA), not VSD. PDA murmur is continuous, unlike the systolic murmur heard in VSD. Educationally, understanding these assessment findings is crucial for pediatric nurses caring for infants with cardiovascular disorders. Recognizing specific murmurs and associated clinical manifestations aids in early identification, appropriate referral, and timely intervention, ultimately improving outcomes for infants with congenital heart defects.

Correct Answer: A

Rationale: In this scenario, the nurse's priority is to administer a nebulizer treatment as ordered (Option A) for the child with a known history of asthma admitted to the hospital with a respiratory infection. This action is the priority because asthma is a chronic condition that can worsen during respiratory infections, leading to potentially life-threatening complications like respiratory distress and hypoxia. Administering the nebulizer treatment helps open the child's airways, reduce bronchoconstriction, and improve breathing, which is crucial in managing asthma exacerbations. Monitoring oxygen saturation levels closely (Option C) is important but providing immediate bronchodilator therapy takes precedence to stabilize the child's condition. Performing chest physiotherapy (Option B) may be beneficial in some cases, but in a child with asthma exacerbation, prompt bronchodilator therapy is more critical. Educating the parents about infection prevention (Option D) is important for overall health but is not the immediate priority when a child with asthma is experiencing respiratory distress. From an educational standpoint, understanding the prioritization of interventions in pediatric nursing is crucial. Nurses need to recognize the urgency of administering specific treatments based on the child's condition to provide timely and effective care. Asthma exacerbations require prompt intervention to prevent respiratory compromise, making the administration of bronchodilators a top priority in this situation.

Correct Answer: C

Rationale: In the context of a pediatric patient post-tonsillectomy, the priority nursing action is to monitor for signs of bleeding, making option C the correct answer. Tonsillectomy is a common surgical procedure in children and carries a risk of post-operative bleeding, which can be life-threatening if not promptly addressed. Monitoring for bleeding is crucial in the immediate post-operative period to ensure early detection and intervention if necessary. Providing pain management (option A) is important for the child's comfort but is not the top priority when assessing a post-tonsillectomy patient. Encouraging fluid intake (option B) and educating the child about proper oral hygiene (option D) are essential aspects of post-operative care but take a back seat to monitoring for bleeding in this scenario. Educationally, understanding the priority nursing actions post-tonsillectomy in pediatric patients is vital for nurses caring for these children. Emphasizing the significance of vigilant monitoring for complications like bleeding can help prevent adverse outcomes and ensure the best possible recovery for the child. This rationale highlights the critical thinking and clinical judgment required in pediatric nursing care.

Correct Answer: C

Rationale: High-density lipoproteins (HDLs) are known as "good cholesterol" because they help transport cholesterol from the tissues back to the liver for processing and excretion, thus reducing the risk of cardiovascular disease. Option C, "They have little cholesterol," is accurate because HDLs are composed primarily of proteins with relatively high amounts of cholesterol, compared to other lipoproteins. Option A, "They have high amounts of triglycerides," is incorrect because HDLs are not known for carrying high amounts of triglycerides. Option B, "They have only small amounts of protein," is incorrect as HDLs are protein-rich particles. Option D, "They aid in steroid production," is incorrect because HDLs are primarily involved in cholesterol transport rather than steroid production. In pediatric nursing education, understanding lipoproteins like HDLs is crucial for managing cardiovascular disorders in children. Teaching students about the role of HDLs in cholesterol metabolism and cardiovascular health can help them make informed clinical decisions to promote pediatric patients' well-being.

Correct Answer: D

Rationale: In the tetralogy of Fallot, the four structural heart anomalies are: 1) Hypertrophied right ventricle: This is not part of the tetralogy of Fallot. It is a result of increased workload on the right ventricle due to the other defects present. 2) Patent ductus arteriosus: This is a separate congenital heart defect involving the persistence of a fetal blood vessel connecting the aorta and pulmonary artery, not a component of tetralogy of Fallot. 3) Ventral septal defect: While a ventricular septal defect is one of the components of tetralogy of Fallot, a ventral septal defect is not specific to this condition. 4) Narrowing of pulmonary artery: This is correct as one of the four defects in tetralogy of Fallot. It leads to reduced blood flow to the lungs, causing cyanosis. Educational context: Understanding the specific structural anomalies in tetralogy of Fallot is crucial for nurses caring for pediatric patients with this condition. Recognizing these anomalies helps in providing appropriate care, monitoring for complications, and educating patients and families about the condition. It also highlights the importance of early detection and intervention in managing congenital heart defects.