ATI RN
Pediatric Respiratory Distress Nursing Interventions Questions
Question 1 of 5
Which child diagnosed with pneumonia would benefit most from hospitalization?
Correct Answer: C
Rationale: In the context of pediatric respiratory distress due to pneumonia, the 15-year-old with vomiting for 3 days and a fever of 38.5°C (101.3°F) would benefit most from hospitalization. This choice is correct because persistent vomiting can lead to dehydration, which can worsen respiratory distress. Additionally, the combination of vomiting and fever indicates a more severe illness that may require closer monitoring and intravenous fluid administration in a hospital setting. Option A is incorrect because while cough, coarse breath sounds, and poor sleep are concerning symptoms, they do not indicate the same level of acuity as dehydration from persistent vomiting. Option B, a 14-year-old with fever, rapid breathing, and decreased appetite, is also concerning but does not present with the added complication of persistent vomiting. Option D, a 16-year-old with cough, chills, fever, and wheezing, may have a viral respiratory infection rather than pneumonia, which typically presents with crackles rather than wheezing. In an educational context, it is important for nurses to understand the nuances of pediatric respiratory distress presentations to make appropriate clinical decisions regarding hospitalization. Recognizing the need for hospitalization based on specific symptoms can help prevent complications and improve outcomes in pediatric patients with pneumonia.
Question 2 of 5
What is an early sign of respiratory distress in a 2-month-old?
Correct Answer: B
Rationale: In pediatric respiratory distress, tachypnea is an early sign in a 2-month-old. Tachypnea refers to rapid breathing, which can indicate the body's attempt to compensate for inadequate oxygenation. In infants, tachypnea is often a prominent sign of respiratory distress due to their smaller airways and increased metabolic demands. Option A, breathing shallowly, is a common misconception. While shallow breathing can be a sign of distress, rapid breathing (tachypnea) is more indicative of early respiratory distress in infants. Option C, tachycardia, is a common response to respiratory distress as the body tries to increase oxygen delivery. However, tachycardia typically occurs after tachypnea in the progression of respiratory distress. Option D, bradycardia, is not typically an early sign of respiratory distress in infants. Bradycardia may occur in severe cases of respiratory distress when oxygen levels are critically low. Educationally, understanding these early signs of pediatric respiratory distress is crucial for nurses caring for infants. Recognizing these signs promptly can lead to early intervention, preventing further deterioration and optimizing patient outcomes. Nurses need to be vigilant in assessing respiratory status in infants to provide timely and appropriate interventions.
Question 3 of 5
After the birth of a newborn, which action would the nurse do first to assist in thermoregulation?
Correct Answer: B
Rationale: In the context of pediatric respiratory distress nursing interventions, the correct action to assist in thermoregulation after the birth of a newborn is to dry the newborn thoroughly (Option B) first. This is because drying the newborn helps to remove amniotic fluid and promote evaporative heat loss, preventing hypothermia which is crucial for stabilizing the newborn's temperature. Checking the newborn's temperature (Option A) may seem important, but it should come after drying the newborn. Putting a hat on the newborn's head (Option C) or wrapping the newborn in a blanket (Option D) can be effective interventions to maintain warmth, but they should follow the step of drying the newborn thoroughly. Educationally, it is important for nurses to understand the sequence of actions in assisting newborns with thermoregulation to prevent complications such as hypothermia. By prioritizing drying the newborn first, nurses can establish a foundation for maintaining the newborn's body temperature within the normal range, promoting a smooth transition to extrauterine life, and reducing the risk of respiratory distress.
Question 4 of 5
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.
Question 5 of 5
A 1-day-old newborn has just expelled a thick, greenish-black stool. The nurse determines that this is the first stool. What should the nurse do next?
Correct Answer: A
Rationale: In this scenario, the correct answer is A) Document the stool in the infant's record. This is the appropriate nursing action because the newborn has passed meconium, which is the first stool typically seen in newborns within the first few days of life. Meconium is thick, greenish-black in color, and is a normal occurrence in newborns. By documenting this event in the infant's record, the nurse ensures accurate and thorough documentation of the newborn's bowel movement pattern. Option B) Assess the infant for an intestinal obstruction is incorrect in this situation because the passage of meconium is an expected and normal occurrence in newborns. There are no signs or symptoms indicating an intestinal obstruction based solely on the passage of meconium. Option C) Sending the stool to the laboratory per protocol is unnecessary for meconium passage as it is a normal physiological process in newborns. There is no clinical indication or benefit to sending meconium to the laboratory in this scenario. Option D) Notifying the practitioner that a tarry stool has been passed is incorrect because meconium is not indicative of a tarry stool. Tarry stool typically refers to dark, sticky stools containing digested blood and is not the same as the first meconium stool passed by newborns. In an educational context, understanding normal newborn assessments and variations such as passing meconium is crucial for pediatric nurses. Documenting findings accurately, recognizing normal vs. abnormal newborn characteristics, and knowing when to intervene are essential skills in providing safe and effective care to newborns.