Which of the following would the nurse do first for a 3-year-old boy who arrives in the emergency room with a temperature of 105°F, inspiratory stridor, and restlessness, who is leaning forward and drooling?

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Notify the physician immediately and prepare for intubation. This is the priority action because the child is exhibiting signs of epiglottitis, a potentially life-threatening condition that requires urgent intervention to secure the airway and ensure adequate oxygenation. Inspiratory stridor, high fever, drooling, and the classic tripod position of leaning forward are indicative of significant airway obstruction. Option A is incorrect because auscultating the lungs and placing the child in a mist tent would delay crucial interventions for airway management. Option B is incorrect as having the child lie down and encouraging fluids could worsen the airway compromise. Option C is incorrect as examining the throat and performing a throat culture can also delay necessary interventions for airway protection. From an educational standpoint, it's crucial for nurses to recognize the emergent signs and symptoms of conditions like epiglottitis in pediatric patients. Prompt identification and appropriate actions can be life-saving in such critical situations. Understanding the priority of airway management and swift communication with the healthcare team are fundamental principles in pediatric respiratory nursing.

Correct Answer: C

Rationale: In the assessment of a child for possible intussusception, the least likely option to provide valuable information is C) Family history. Intussusception is a medical emergency where one part of the intestine slides into another, causing obstruction. Family history is not a significant contributing factor to intussusception as it is not a condition that is known to have a strong genetic component. A) Stool inspection is important as it can reveal signs of blood in the stool which may indicate intestinal bleeding associated with intussusception. B) Pain pattern is crucial as children with intussusception often present with severe abdominal pain that comes in waves. D) Abdominal palpation is also essential as it can help detect a sausage-shaped mass in the abdomen, a classic sign of intussusception. In an educational context, it is important for pediatric nurses to understand the key clinical manifestations and assessment findings associated with intussusception to facilitate early detection and intervention. By prioritizing critical assessment techniques such as abdominal palpation and pain pattern recognition, nurses can promptly identify and initiate appropriate care for children at risk of intussusception.

Correct Answer: B

Rationale: In pediatric nursing, understanding normal growth and development patterns is crucial for assessing a child's health. In this scenario, the correct answer is B) 2 centimeters larger than the chest. This is because it is typical for a neonate's head circumference to be slightly larger than their chest circumference at birth. The head is usually larger to accommodate the rapidly growing brain and skull development in infants. This discrepancy in size is a normal physiological variation and helps healthcare providers monitor proper growth and identify any abnormalities early on. Option A) The same size as the chest is incorrect as it does not align with the expected anatomical differences between head and chest circumferences in neonates. Option C) 2 centimeters smaller than the chest is inaccurate as it contradicts the typical pattern of head growth being larger than the chest in newborns. Option D) 4 centimeters larger than the chest is also incorrect as it overestimates the typical difference in size between the head and chest circumferences of a neonate. Understanding these normal growth parameters is essential for pediatric nurses to provide accurate assessments, detect deviations from expected growth patterns, and intervene promptly to ensure optimal health outcomes for infants.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Turning the head from side to side. At one month old, infants are expected to demonstrate the ability to turn their head from side to side. This developmental milestone is crucial as it indicates proper neck muscle strength and control, which is essential for feeding and visual exploration. Infants who cannot turn their heads adequately may display signs of developmental delay or muscle weakness. Option A) Smiling and laughing out loud is more commonly seen around 2-3 months of age, as it requires more cognitive and social development. Option B) Rolling from back to side typically occurs around 4-5 months of age, when infants have gained more strength and coordination. Option C) Holding a rattle briefly is a skill that emerges around 3-4 months of age, as it requires the development of better hand-eye coordination and grasp reflex. Educationally, understanding these developmental milestones is vital for nurses working with pediatric patients. By recognizing the expected achievements at various ages, nurses can assess and monitor infants' growth and development effectively. This knowledge enables early identification of any delays or abnormalities, leading to timely interventions and appropriate support for the child and their family.

Correct Answer: D

Rationale: In pediatric respiratory nursing, understanding child development milestones is crucial for assessing a child's overall health. In this scenario, the correct answer is D) Using blunt scissors. At the age of 3, a child should be developing fine motor skills, hand-eye coordination, and the ability to use simple tools like blunt scissors. Option A) Riding a bicycle requires a higher level of gross motor skills and coordination, typically achieved around ages 5-6. Option B) Tying shoelaces involves complex fine motor skills and hand dexterity, usually mastered around ages 5-7. Option C) Stringing large beads also requires more advanced fine motor skills and hand-eye coordination, usually seen in children around ages 4-5. Educationally, understanding these developmental milestones helps nurses assess a child's growth and development accurately. By knowing what skills are expected at different ages, nurses can identify potential delays or issues early on and provide appropriate interventions or referrals. It also helps in educating parents about their child's development and what to expect as their child grows.