Question 1

A two-year-old male child arrived in the emergency department with complaints of sore throat, difficulty swallowing, and suspected diagnosis of acute epiglottitis. Which of the following interventions should not be included in the child's immediate care and assessment?

Accepted Answer

Throat culture could cause agitation and potentially worsen the airway obstruction in a child with acute epiglottitis. Treatment of epiglottitis should be focused on securing the airway, administering antibiotics, and providing supportive care. Immediate assessment of vital signs, medical history, and assessment of breath sounds are crucial in the child's care.

Question 2

A two-month-old infant is a direct admission to the pediatric unit with a diagnosis of ALTE (apparent life-threatening event). The physician is to see the infant to write medical orders. The nurse completes the nursing history and performs an assessment and finds no abnormal findings. While waiting on the physician, which activity can the nurse perform independently?

Accepted Answer

Placing the child on an apnea monitor is an independent nursing action that can be taken to monitor the infant's breathing pattern and detect apnea, which is relevant for a patient with a history of an apparent life-threatening event (ALTE).

Question 3

A newborn who is 24 hours old is suspected of having cystic fibrosis. As the child is being prepared for transfer to a pediatric hospital, the mother asks the nurse what symptoms made the physician suspect cystic fibrosis. The nurse would reply that the clinical manifestation of cystic fibrosis that is seen first is:

Accepted Answer

The clinical manifestation of cystic fibrosis that is seen first is meconium ileus, which is a blockage in the intestine caused by abnormally thick meconium (the earliest stool of a newborn). This is often the first sign of cystic fibrosis in infants. Rectal prolapse, constipation, and steatorrheic stools can also be seen in cystic fibrosis, but they usually occur later in life.

Question 4

A child is on rifampin (Rimactane) for treatment of tuberculosis. The parents call the clinic and report that the child's urine is orange. The nurse should advise the parents to:

Accepted Answer

Rifampin can turn urine and other bodily fluids orange or red. This is a harmless side effect of the medication and does not require any intervention unless accompanied by other symptoms. Therefore, the nurse should advise the parents to expect orange-colored urine while the child is on rifampin.

Question 5

An infant was born at 34 weeks' gestation and is being treated in the NICU for apnea of prematurity. The infant is in an isolette with an apnea monitor and intravenous fluids. The apnea monitor sounds, and the nurse checks the infant to find the infant is not breathing. The initial intervention by the nurse would be to:

Accepted Answer

Stroking the infant's back is a gentle stimulation method often effective in prompting premature infants to resume breathing when they experience apnea of prematurity. This is a less invasive first step before escalating to more intensive interventions.

Question 6

After a routine vaginal delivery, the infant transitions with the mother in the recovery room without difficulty. Prior to being discharged from the recovery room, it is noted that the infant's respiratory rate is 102 and the lungs are clear to auscultation. Based on these findings, an appropriate transfer for this infant would be to:

Accepted Answer

The infant's elevated respiratory rate (normal is 40-60 breaths per minute for a newborn) suggests potential respiratory distress or an underlying issue, warranting closer observation and care in the NICU (Neonatal Intensive Care Unit), rather than routine postnatal care.

Question 7

The nurse stops at the scene of an accident and finds a child conscious but with a sucking wound of the chest. The immediate action by the nurse would be to:

Accepted Answer

The immediate action by the nurse would be to cover the wound with an air occlusive dressing to prevent air from entering the pleural cavity and causing a tension pneumothorax. Trendelenburg position is not indicated for this condition, and rescue breathing and cardiac resuscitation would not address the child's specific injury.

Question 8

The nurse is teaching the parents of a patient who is newly diagnosed with cystic fibrosis how to administer the pancreatic enzymes. The nurse will advise the parents to administer the enzymes:

Accepted Answer

Pancreatic enzymes should be administered with meals and snacks to aid in digestion and absorption of nutrients.

Question 9

A toddler has had recurrent respiratory infections. The mother of the child expresses concern that her infant seems to be at increased risk for complications from respiratory infections in comparison with her older children. The best response from the nurse would be:

Accepted Answer

Younger children have smaller airways, which makes them more easily occluded during respiratory infections. This puts them at increased risk for complications such as pneumonia or bronchiolitis.

Question 10

Which nursing diagnosis would be most appropriate for an infant with acute bronchiolitis due to respiratory syncytial virus (RSV)?

Accepted Answer

Infants with acute bronchiolitis due to RSV often experience increased effort with breathing, resulting in decreased energy and activity intolerance. Ineffective tissue perfusion, acute pain, and decreased cardiac output are not necessarily key concerns in this situation.

Question 11

A premature infant develops acute respiratory distress syndrome (ARDS). How will the nurse position the baby?

Accepted Answer

The answer of A premature infant develops acute respiratory distress...

Question 12

The family rushes a four-month-old infant to the hospital after finding the infant not breathing. The child is diagnosed as a victim of sudden infant death syndrome. Supportive care for this family would include:

Accepted Answer

Allowing parents to hold, touch, and rock the deceased infant can provide them with comfort and support during this difficult time. It allows them to grieve and develop emotional connections with their child. The other options are not appropriate as sheltering parents from their grief can prolong the grieving process, an autopsy is important to determine the cause of death, and interviewing parents can be intrusive and traumatic.

Question 13

The nurse is evaluating the parent's understanding of teaching related to environmental control for their child's asthma management. Which statement by the parents indicates that they understand the teaching?

Accepted Answer

Option D indicates that the parents understand the importance of removing allergens from their child's environment by replacing carpet with tile, which will make cleaning easier and decrease the amount of dust and other allergens that accumulate. Options A, B, and C all indicate a lack of understanding of environmental control measures for asthma management. Keeping a pet in the child's room can exacerbate asthma symptoms, not dusting plants regularly can increase the amount of allergens in the air, and using a fireplace can release smoke and other irritants into the air, all of which can trigger asthma symptoms.

Quiz 47: The Child With Alterations in Respiratory Function