Which of the following should the nurse expect to note as a frequent complication for a child with congenital heart disease?

Correct Answer: A

Rationale: In pediatric patients with congenital heart disease, susceptibility to respiratory infections is a frequent complication. This is due to the altered anatomy and physiology of the heart, which can lead to inefficient oxygenation and ventilation, making these children more prone to respiratory infections. Therefore, option A is the correct answer. Option B, bleeding tendencies, is less likely to be a frequent complication in children with congenital heart disease unless they are on anticoagulant therapy or have a co-existing bleeding disorder. Option C, frequent vomiting and diarrhea, is not typically associated with congenital heart disease itself but may occur as a result of other conditions or treatments. Option D, seizure disorder, is not a common complication of congenital heart disease unless there are complications such as hypoxia or brain injury. Educationally, understanding the common complications of congenital heart disease in pediatric patients is crucial for nurses caring for these children. Recognizing these complications helps nurses provide appropriate care, monitor for potential issues, and intervene promptly to prevent further complications. It also highlights the importance of a holistic approach to care, considering both cardiac and respiratory health in these vulnerable patients.

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.

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.

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.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Pulling toys, which is typical for an 18-month-old baby. At this age, children are developing their fine and gross motor skills. Pulling toys helps in improving their muscle strength and coordination. It also fosters their curiosity and exploration abilities. Option A) Copying a circle involves more advanced fine motor skills and is typically seen in older children, around 3-4 years old. Option C) Playing with other children is a social interaction skill that starts developing more prominently after 2 years of age. Option D) Building a tower of eight blocks requires more refined hand-eye coordination and spatial awareness, skills that are usually acquired around 2-3 years of age. Educationally, understanding age-appropriate developmental milestones is crucial for healthcare providers, especially nurses working with pediatric patients. Recognizing what tasks are typical for different age groups guides the assessment of a child's growth and development, aiding in early identification of any potential delays or issues that may require further evaluation or intervention. This knowledge also informs the planning and implementation of appropriate nursing interventions to support the child's overall well-being and development.