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A nurse in an emergency department is caring for an infant.

Exhibits

The nurse on the pediatric unit is reviewing the infant's medical record immediately after receiving report from the emergency department nurse. Which of the following information requires immediate follow-up? Select all that apply.

Intake and output

Heart rate

Respiratory rate

Bowel sounds

Mucous membranes

Weight

Retractions

Lung sounds

Temperature

Oxygen saturation

Answer and Explanation

Correct Answer : A,B,C,G,H,I,J

A.   Intake and output: The infant has not fed in 8 hours and has only had 1 wet diaper during this time, which is concerning for dehydration or inadequate intake. The decreased output requires immediate follow-up to prevent further dehydration and assess fluid needs.
B.   Heart rate: The heart rate of 180/min is elevated for an infant, potentially indicating dehydration, fever, or respiratory distress. Tachycardia can also signify compensation for hypoxia.
C.   Respiratory rate: A respiratory rate of 60/min is elevated for an infant and indicates respiratory distress, compounded by retractions and diminished lung sounds in the right lobes.
D.   Bowel sounds: Active bowel sounds in all four quadrants are a normal finding and do not indicate an acute issue.
E.   Mucous membranes: While dry mucous membranes confirm dehydration, they are not the highest priority compared to respiratory distress or oxygen saturation.
F.   Weight: Weight loss from 9 lb to 8 lb 8 oz is concerning for chronic dehydration or inadequate nutrition, but it does not require immediate action compared to acute respiratory and oxygenation issues.
G.   Retractions: Moderate substernal and intercostal retractions are indicative of respiratory distress. This requires immediate follow-up to assess the severity of the distress and initiate appropriate interventions, such as supplemental oxygen or further evaluation.
H.   Lung sounds: Diminished lung sounds in the right lobes and occasional coarse crackles are concerning for a respiratory infection or condition such as pneumonia or bronchiolitis. Immediate follow-up is required to assess the cause and severity of the respiratory findings.
I.   Temperature: The infant has a fever, which is concerning, especially with poor feeding and lethargy. Fever in an infant can indicate a serious infection (e.g., sepsis, urinary tract infection, or pneumonia) that requires immediate medical attention and further investigation.
J.   Oxygen saturation: An oxygen saturation of 92% is low for an infant, indicating hypoxia, likely due to respiratory compromise. Immediate intervention (e.g., oxygen therapy) is necessary to prevent further deterioration.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. "I will ensure that my child takes a 1-hour nap each day." Prolonged inactivity, like frequent naps, may increase joint stiffness. Physical activity should be encouraged to maintain joint mobility.
B. "I will give my child prednisone as needed for pain." Prednisone is not typically used as needed for pain. NSAIDs are the first-line treatment for inflammation and pain in JIA.
C. "I will apply cool compresses to my child's painful joints during exacerbations." Warm compresses, not cool, are typically more effective in relieving joint stiffness in JIA.
D. "I will have my child wear splints during the night." Wearing splints at night helps maintain joint position and prevent contractures.

A. 6 months B. 10 months C. 18 months D. 24 months

Correct Answer is C

Explanation

A. 6 months: At this age, infants typically coo and babble but do not form words.
B. 10 months: Infants might say "mama" or "dada," but their vocabulary is usually less than 10 words.
C. 18 months: By 18 months, most children have a vocabulary of approximately 10–20 words.
D. 24 months: By 24 months, children typically have a vocabulary of about 50 words or more and begin forming two-word phrases.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing discharge teaching to the parent of a school-age child who has juvenile idiopathic arthritis (JIA). The nurse should identify that which of the following responses by the parent indicates an understanding of the teaching?

Correct Answer is D

Explanation

A nurse is teaching a group of new parents about expected language development. The nurse should include that a child should begin to speak 10 or more words at about which of the following ages?

Correct Answer is C

Explanation

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