A pediatric nurse is caring for a child whose parents are going through a divorce. Which of the following is the priority action for the nurse to take to support the child during this time?

Reassure the child that their parents divorce is not their fault.

Encourage the child to express their feelings and concerns.

Provide education on age-appropriate coping strategies for children who are experiencing divorce.

Collaborate with both parents to ensure a consistent routine for the child.

Answer and Explanation

The Correct Answer is A

A. Reassure the child that their parents' divorce is not their fault: Children often internalize blame during parental separation. Addressing this misconception first is the priority because it directly impacts the child’s emotional well-being and sense of security, which forms the foundation for other supportive interventions.

B. Encourage the child to express their feelings and concerns: Encouraging expression of feelings is important, but reassurance that the child is not at fault should come first to reduce guilt and anxiety before further emotional processing.

C. Provide education on age-appropriate coping strategies for children who are experiencing divorce: Teaching coping strategies is beneficial but secondary to establishing the child’s sense of safety and understanding of the situation.

D. Collaborate with both parents to ensure a consistent routine for the child: Maintaining routines supports stability, yet it does not immediately address the child’s potential self-blame, which is the most urgent concern for emotional support.

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Correct Answer is B

Explanation

A. Loose stool: Infant botulism more commonly presents with constipation due to decreased gastrointestinal motility from neuromuscular blockade. Botulinum toxin inhibits acetylcholine release, reducing smooth muscle activity in the gut. Loose stools are not a typical early manifestation.

B. Difficulty breastfeeding: Botulinum toxin causes flaccid paralysis by blocking acetylcholine at the neuromuscular junction, leading to weak suck and poor feeding. Difficulty breastfeeding is often one of the earliest signs in infants. This reflects bulbar muscle involvement and generalized hypotonia.

C. Crying for long periods of time: Infant botulism is associated with a weak or diminished cry rather than excessive crying. Neuromuscular weakness limits vocal cord strength and respiratory effort. Prolonged crying is more suggestive of pain or discomfort from other causes.

D. Spasms involving the whole body: Botulism produces flaccid paralysis, not spasticity or muscle spasms. Increased muscle tone and generalized spasms are more consistent with conditions such as tetanus or seizure activity. This finding does not align with the toxin’s mechanism of action.

A. Spinal nerve fibers exposed in a lesion B. The patient has ineffective airway clearance related to weak respiratory muscles. C. Frequent seizures, impacting daily function D. The patient is immunocompromised.

Correct Answer is B

Explanation

A. Spinal nerve fibers exposed in a lesion: Exposed spinal nerve tissue is characteristic of neural tube defects such as myelomeningocele, not spinal muscular atrophy. SMA is a genetic neuromuscular disorder affecting motor neurons without structural spinal lesions.

B. The patient has ineffective airway clearance related to weak respiratory muscles: Spinal Muscular Atrophy Type I (Werdnig–Hoffmann disease) causes profound hypotonia and progressive weakness, including the intercostal and bulbar muscles. Respiratory muscle weakness leads to poor cough effort and ineffective airway clearance, making this a hallmark clinical concern.

C. Frequent seizures, impacting daily function: Seizures are not a typical manifestation of SMA Type I, as the disorder primarily affects lower motor neurons and does not directly involve cortical brain function.

D. The patient is immunocompromised: Immunodeficiency is not a defining feature of SMA. While recurrent infections may occur secondary to poor airway clearance, the immune system itself is not intrinsically impaired.

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A pediatric nurse is caring for a child whose parents are going through a divorce. Which of the following is the priority action for the nurse to take to support the child during this time?

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