A nurse is assisting with the care of a preschooler who has epiglottitis. Which of the following actions should the nurse take?

Request an x-ray of the neck.

Monitor urine for protein.

Obtain a nasopharyngeal swab

Administer fluconazole.

Answer and Explanation

The Correct Answer is A

A) Request an x-ray of the neck: In cases of suspected epiglottitis, a lateral neck x-ray can help confirm the diagnosis by showing the classic "thumbprint sign," which indicates swelling of the epiglottis. This is a critical diagnostic step, but it should only be performed in a controlled setting where the child’s airway can be monitored closely. The priority is to avoid any procedures that may cause irritation or further compromise the airway.

B) Monitor urine for protein: Monitoring urine for protein is not relevant to the management of epiglottitis. This condition is related to inflammation and obstruction of the upper airway, and the focus should be on respiratory management rather than renal function.

C) Obtain a nasopharyngeal swab: While obtaining a nasopharyngeal swab can help identify the organism causing an infection (often bacterial), it is not the immediate priority in a child with suspected epiglottitis. The child’s airway is the most critical concern, and diagnostic interventions that could potentially cause further distress or obstruction (such as swabbing) should be avoided until airway management is stable.

D) Administer fluconazole: Fluconazole is an antifungal medication, and its use is not appropriate for epiglottitis. Epiglottitis is most often caused by a bacterial infection, particularly Haemophilus influenzae type b (Hib), which requires antibiotic therapy, not antifungals.

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Correct Answer is C

Explanation

A) Wait 1 min between suctioning attempts: The nurse should wait 20 to 30 seconds between suctioning attempts, not a full minute. Waiting too long between attempts can cause the patient unnecessary distress. The goal is to allow for oxygenation and recovery of the airway in between suctioning attempts.

B) Apply intermittent suction for 30 seconds: Suctioning should be limited to 10 to 15 seconds at a time to prevent hypoxia and damage to the mucous membranes. Applying suction for 30 seconds could lead to complications such as hypoxia, mucosal trauma, and increased risk of infection.

C) Insert the catheter 10 cm (4 in.): This is the correct technique. For an adult client, the catheter should be inserted 10 cm (4 inches) into the airway. Inserting the catheter too far can cause trauma to the airway, while inserting it too shallow may not effectively clear secretions.

D) Apply suction while inserting the catheter: Suction should not be applied while inserting the catheter. Suctioning should only be applied while withdrawing the catheter, not while inserting it, to prevent mucosal trauma and to ensure effective clearance of secretions. Suctioning during insertion could damage the airway and increase discomfort for the client.

A. Rigid abdomen B. Bright red vaginal bleeding C. Persistent uterine contractions D. Increased fetal movement

Correct Answer is B

Explanation

A) Rigid abdomen: A rigid abdomen is more commonly associated with conditions like placental abruption or uterine rupture, where there is significant internal bleeding and trauma to the uterine wall. It is not a typical finding in placenta previa, where bleeding is typically present without uterine rigidity.

B) Bright red vaginal bleeding: Bright red vaginal bleeding is the most characteristic finding in placenta previa. The condition occurs when the placenta is abnormally located in the lower part of the uterus, covering or being near the cervix. This leads to painless, bright red vaginal bleeding, which is often seen in the second or third trimester. The bleeding results from the placenta's location as the uterus expands.

C) Persistent uterine contractions: Persistent uterine contractions are more often associated with preterm labor or placental abruption, not placenta previa. While contractions can occur in placenta previa, they are not the primary or most expected symptom. The hallmark of placenta previa is bleeding, rather than contractions.

D) Increased fetal movement: Fetal movement is not typically altered by placenta previa. In some cases, the location of the placenta may affect the feeling of fetal movement, especially if the placenta is anterior, but increased fetal movement is not a specific finding associated with placenta previa. The focus should be on bleeding and uterine stability.

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A nurse is assisting with the care of a preschooler who has epiglottitis. Which of the following actions should the nurse take?

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