A nurse is assessing a toddler. Which of the following findings should the nurse identify as an indication of potential child maltreatment?
Superficial scrapes on the toddler's lower legs
Circular burns on the soles of the toddler's feet
Irregular area of blue pigmentation over the toddler's sacrum
Single bruise on the toddler's forearm
The Correct Answer is B
A. Superficial scrapes on the toddler's lower legs: These are common in toddlers due to normal play and exploration.
B. Circular burns on the soles of the toddler's feet: Circular burns, especially in unusual areas like the soles, are a hallmark sign of intentional injury and potential abuse.
C. Irregular area of blue pigmentation over the sacrum: This is likely a Mongolian spot, a benign and common finding in children of certain ethnicities.
D. Single bruise on the toddler's forearm: This is not necessarily indicative of abuse, as toddlers frequently sustain minor injuries from routine activities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Protective environment: This is for immunocompromised clients, not infectious diseases like pertussis.
B. Airborne: Airborne precautions are used for diseases like tuberculosis, measles, or varicella, which spread through smaller airborne particles.
C. Contact: Contact precautions are for diseases transmitted via direct contact, such as MRSA or C. difficile, and are not appropriate for pertussis.
D. Droplet. Pertussis is transmitted through respiratory droplets, so droplet precautions (e.g., wearing a surgical mask and maintaining distance) are essential to prevent the spread.
Correct Answer is []
Explanation
Condition Most Likely Experiencing: Bronchiolitis
The infant's symptoms—fever, cough, nasal congestion, wheezing, nasal flaring, intercostal retractions, and difficulty feeding—are characteristic of bronchiolitis, commonly caused by RSV in infants.
Actions to Take:
- Administer Oxygen via nasal cannula: The infant's low oxygen saturation (88% on room air) and respiratory distress (nasal flaring, retractions) indicate the need for supplemental oxygen to ensure adequate oxygenation and reduce respiratory distress.
- Suction nares with a bulb aspirator: Suctioning the infant’s nasal passages helps clear mucus and improve breathing. Infants with RSV often have significant nasal congestion that can impair feeding and breathing, so clearing the airways is crucial for respiratory management.
Parameters to Monitor:
- Oxygen saturation via continuous pulse oximetry: Monitoring oxygen saturation provides critical information on the infant’s respiratory status and helps assess the effectiveness of oxygen therapy.
- Respiratory effort and breath sounds: The infant is showing signs of increased respiratory effort (e.g., nasal flaring, intercostal retractions) and abnormal breath sounds (e.g., wheezes). Monitoring these parameters helps assess the severity of respiratory distress and guides further interventions.
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