ATI B MN 580/MN 580 PEDIATRICS MATERNAL
Midterm/FINAL EXAM ACTUAL EXAM NEWEST
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1.
The mother of a 3-week-old tells the nurse she is residing in a homeless shelter and
is concerned about his mild cough, poor appetite, low-grade fever, weight loss, and
fussiness over the last 2 weeks. Which nursing intervention would be the nurse's
highest priority?
1. Weigh the baby to have an accurate weight using standard precautions.
2. Reassure the mother that the baby may only have a cold, which can last a few
weeks.
3. Immediately initiate droplet face-mask precautions, and isolate the infant.
4. Take a rectal temperature while completing the assessment using standard
precautions. - Answer ✓✓Answer:
3. Immediately initiate droplet face-mask precautions, and isolate the infant.
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Rationale:
1. Weighing the child would be important but
not the priority when concerned about an
infectious cause. Initiating droplet precau-
tions to prevent infecting others would be a
priority, then weighing the infant.
2. The symptoms are not suggestive of a cold
but something more serious. Infants do not
usually lose weight, nor are they irritable
with a simple cold.
3.
Children with tuberculosis may have a
history of living in a crowded home or
could be homeless. Other symptoms
may include a cough, cold symptoms,
low-grade fever, irritability, poor
appetite, and exposure to a person
with tuberculosis. Initiation of droplet
precautions and isolation of the infant
would be warranted in this situation.
4. Taking the infant's temperature is important, but initiating droplet precautions
would be the priority.
TEST-TAKING HINT:
The test taker should be
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highly suspicious of tuberculosis given the family and patient history. Health-care personnel
need to be vigilant to contain and prevent further spread of communicable
diseases. This child could have meningitis, which would also require isolation and
respiratory precautions.
2.
Which would be the priority nursing intervention for a newly admitted child with Kawasaki
disease?
1. Continuous cardiovascular and oxygen-saturation monitoring.
2. Vital signs every 4 hours until stable.
3. Strict intake and output monitoring hourly.
4. Begin aspirin therapy after fever has resolved. - Answer ✓✓Answer:
1. Continuous cardiovascular and oxygen-saturation monitoring.
Rationale:
1. Cardiovascular manifestations of
Kawasaki disease are the major complications in pediatric patients. Continuous cardiac
monitoring is required to alert
the nurse of any cardiovascular complications. Decreased oxygen saturation
and respiratory changes have been
shown to be early indicators of potential complications.
2. Vital signs would be taken every 1 to
2 hours until stable on a new admission
with Kawasaki disease.
3. Strict intake and output is very important,
but because the major complications with
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Kawasaki disease are cardiovascular, contin-
uous cardiac monitoring is the priority.
4. High-dose aspirin therapy is begun and
continued until the child has been afebrile
for 48 to 72 hours; then the child is placed
on low-dose therapy.
TEST-TAKING HINT:
The test taker should
understand that cardiovascular manifesta-
tions of Kawasaki disease are the major
complications in pediatric patients.
3.
Which clinical assessment of a neonate with bacterial meningitis would warrant
immediate intervention?
1. Irritability.
2. Rectal temperature of 100.6°F (38.1°C).
3. Quieter than usual.
4. Respiratory rate of 24 breaths per minute. - Answer ✓✓Answer:
4. Respiratory rate of 24 breaths per minute.
4.
An 18-month-old is discharged from the hospital after having a febrile seizure
secondary to exanthem subitum (roseola). On discharge, the mother asks the nurse if
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