A 4-year-old child with a history of cystic fibrosis (CF) presents to the clinic for a routine follow-up. The parents report that the child has had an increase in productive cough, wheezing, and shortness of breath over the past few days. Upon examination, the child has clubbed fingers, and chest auscultation reveals decreased breath sounds. Given these findings, which of the following interventions should the nurse prioritize to manage the child's condition and prevent further respiratory complications?

Increasing the child's intake of high-fat foods to address malnutrition

Administering inhaled corticosteroids to reduce airway inflammation

Initiating chest physiotherapy (CPT) to promote airway clearance and reduce mucus build-up

Encouraging increased fluid intake to help with hydration and thin mucus

Answer and Explanation

The Correct Answer is C

A. Nutrition is important in CF because malabsorption is common, but addressing malnutrition is not the immediate priority when the child is experiencing respiratory compromise. Nutritional interventions are secondary to airway management.

B. Inhaled corticosteroids can help reduce chronic airway inflammation, but they do not remove existing mucus or immediately improve airflow. They are part of long-term management rather than urgent treatment during an exacerbation.

C. CPT is the cornerstone of CF management, particularly during exacerbations. Techniques such as percussion, postural drainage, and vibration help mobilize thick mucus, improve airway clearance, enhance oxygenation, and reduce the risk of infection and further lung damage. Immediate airway clearance is critical for symptom relief and prevention of respiratory complications.

D. Adequate hydration can support mucus thinning but is not sufficient alone to manage an acute pulmonary exacerbation. It is adjunctive, supporting other interventions like CPT and medications.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. The first action when a child shows behavioral signs of pain, such as being quiet, withdrawn, or refusing to play, is to assess pain accurately using a tool suited to the child’s age and developmental level. For a 6-year-old, tools like the Faces Pain Scale–Revised (FPS-R) or Oucher Pain Scale are appropriate. Accurate assessment is essential to guide appropriate pain management interventions and ensure the child’s comfort.

B. Vital signs may not always reflect pain, especially in children. Behavioral and psychological cues are often more sensitive indicators of pain than vital signs in pediatric patients. Assuming the child is fine could lead to undertreatment of pain.

C. While offering food or drink may provide comfort, it does not address the underlying pain. Without assessment, the nurse cannot determine if the child’s withdrawal is due to pain or another cause. This is not the first or priority action.

D. Relying on self-report alone may delay pain recognition and treatment, particularly if the child is quiet, withdrawn, or fearful. Children often do not verbalize pain immediately, so proactive assessment is crucial.

A. Erb's palsy B. Facial nerve injury C. Cephalohematoma D. Caput succedaneum

Correct Answer is A

Explanation

A. The combination of weak arm movement, absent Moro reflex, and intact grasp reflex directly points to an upper brachial plexus injury, consistent with Erb’s palsy. Immediate management includes supportive care, gentle range-of-motion exercises, and referral to a pediatric neurologist or physical therapist. Early intervention improves functional outcomes and reduces long-term disability.

B. Caput succedaneum is diffuse edema of the scalp caused by pressure during delivery, often crossing suture lines. It is benign, self-limiting, and does not affect limb movement or reflexes. The infant’s motor deficits are not explained by caput succedaneum.

C. Cephalohematoma is a localized subperiosteal blood collection, typically limited by suture lines. It presents as a firm scalp swelling, sometimes with jaundice as a complication. Cephalohematoma does not cause limb weakness or absent reflexes, so it is inconsistent with the findings in this case.

D. Facial nerve injury during birth, often due to traction or forceps application on the face, manifests as facial asymmetry, inability to close the eyelid, drooping of the mouth, or absent nasolabial fold. It does not affect arm movement or the Moro reflex, so it cannot account for the infant’s symptoms.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 6-year-old child in the pediatric ward has had a minor laceration sutured on the forearm. Vital signs are within normal limits but the child is quiet. withdrawn, and refuses to play. The nurse suspects pain. What action should the nurse take FIRST?

Correct Answer is A

Explanation

A newborn is delivered vaginally after a prolonged second stage of labor with the use of forceps. Upon assessment, the nurse notes weak movement of the left arm, absent Moro reflex on that side, and intact grasp reflex. Which birth injury should the nurse suspect?

Correct Answer is A

Explanation

A 13-year-old with juvenile arthritis has been experiencing persistent joint pain for the past 4 months. Which statement BEST defines this type of pain?

The nurse is performing an assessment on a pregnant patient with a diagnosis of severe preeclampsia. The nurse reviews the assessment findings and determines that which finding is most closely associated with a complication of this diagnosis?

A pregnant client completes the 1-hour glucose tolerance test (GTT) at 26 weeks' gestation. The nurse explains that if the blood glucose result is above ____ to ____mg/dL. It is considered a positive screening and the client will need a 3-hour oral glucose tolerance test.

A 5-year-old child is scheduled for a vaccination. The nurse wants the child to self-report pain. The child can understand pictures but has difficulty with numbers. Which pain assessment tool is MOST appropriate?

A nurse is teaching a parent about normal infant growth and development. Which statement by the parent indicates they can apply developmental principles correctly to their own child?

A nurse is assessing a 3-year-old child's response to a new daycare environment. The child initially clings to the parent, cries, and takes several minutes to warm up to other children and new activities. Which statement BEST reflects the child's temperament?

A 12-week pregnant client presents for a routine checkup. She reports no vaginal bleeding or cramping, but her last fetal heartbeat detected on ultrasound is absent. The cervix is closed, and the client feels no fetal movement. Which type of miscarriage does the nurse suspect?

A 12-year-old child with sickle cell disease is admitted with a vaso-occlusive crisis. The child rates pain as 10/10 but refuses IV opioids due to fear of needles. Which intervention should the nurse implement FIRST?