During a follow-up clinic visit, a mother tells the nurse that her 5-month-old son who had surgical correction for tetralogy of Fallot (TOF) has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held and his growth is in the expected range. Which intervention should the nurse implement?

Evaluate infant for failure to thrive (FTT).

Auscultate heart and lungs while infant is held.

Stimulate the infant to cry to produce cyanosis.

Obtain a 12-lead electrocardiogram.

Answer and Explanation

The Correct Answer is B

A. Evaluating the infant for failure to thrive (FTT) is not the most appropriate initial intervention in this case. FTT is a long-term growth issue, and the immediate concern is the infant's current symptoms and cardiac status.

B. Auscultate heart and lungs while the infant is held.

Tetralogy of Fallot (TOF) is a congenital heart defect that includes four specific cardiac abnormalities, and it often requires surgical correction in infancy. When an infant with a history of TOF surgery presents with symptoms such as rapid breathing, feeding difficulties, and fatigue, it may raise concerns about potential cardiac issues or complications.

The most appropriate initial intervention is to auscultate the infant's heart and lungs while the infant is held to assess for any abnormal heart sounds or signs of respiratory distress. Auscultation can provide important information about the infant's cardiac and respiratory status. This assessment will help determine if there are any immediate concerns related to the infant's cardiac condition.

C. Stimulating the infant to cry to produce cyanosis is not a recommended or appropriate intervention. Cyanosis is a sign of inadequate oxygenation and should not be induced in a child.

D. Obtaining a 12-lead electrocardiogram may be indicated if there are significant concerns about the infant's cardiac status, but auscultation should be performed first to assess the immediate condition. An electrocardiogram is a diagnostic tool and would be ordered as a follow-up assessment if needed.

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Correct Answer is C

Explanation

A. Chickenpox is caused by the varicella-zoster virus and is not directly related to the development of acute rheumatic fever.

B. Mumps is caused by the mumps virus and is not directly related to the development of acute rheumatic fever.

C. Sore throat.

Acute rheumatic fever (ARF) is an inflammatory condition that can occur after an untreated or inadequately treated streptococcal throat infection, such as streptococcal pharyngitis (strep throat). It is caused by group A Streptococcus bacteria.

In ARF, the body's immune response to the streptococcal infection can lead to inflammation and damage to various parts of the body, including the heart, joints, skin, and central nervous system. One of the major criteria for diagnosing ARF is a history of a sore throat. Therefore, the most significant recent occurrence for the health history in this case would be a sore throat (option C).

D. Influenza is caused by the influenza virus and is not directly related to the development of acute rheumatic fever.

A. Fever 101.0° F (38.3° C) B. Difficulty swallowing secretions. C. Barking cough, worse at night. D. Cries often when nursing.

Correct Answer is B

Explanation

When advising a new mother in caring for a child with croup, the symptom that should be a priority concern to the telephone triage nurse is B.

Explanation:

A. A fever of 101.0°F (38.3°C) is a common symptom in many childhood illnesses, including croup, but it is not the primary concern when difficulty swallowing secretions is present.

B Difficulty swallowing secretions.

Croup is characterized by a barking cough and may also be associated with stridor (noisy breathing), hoarseness, and difficulty swallowing secretions. While all the symptoms mentioned can be concerning, difficulty swallowing secretions is a priority concern because it can potentially lead to respiratory distress if not managed appropriately. Thick secretions can cause airway obstruction, and prompt assessment and intervention are needed to ensure the child's airway remains clear and that the child is able to breathe effectively.

C. A barking cough, worse at night, is a classic symptom of croup and should be addressed, but difficulty swallowing secretions can have a more direct impact on the child's airway.

D. Crying often when nursing may be related to the discomfort caused by croup, but it is not as immediately concerning as difficulty swallowing secretions.

While the barking cough, hoarseness, and other croup symptoms should also be addressed, the priority is ensuring that the child is able to manage secretions effectively without respiratory distress. The telephone triage nurse should provide guidance to the mother on how to help the child manage these secretions and when to seek medical attention if the situation worsens.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant?

Correct Answer is C

Explanation

When advising a new mother in caring for a child with croup, which symptom should be a priority concern to the telephone triage nurse?

Correct Answer is B

Explanation

The nurse is providing nutrition education to the parents of an infant with failure to thrive (FTT). Which statement made by the parent should the nurse recognize as an appropriate understanding of interventions?

A 10-year-old boy has been seen frequently by the school nurse over the past three weeks after school begins in the fall. He reports headaches, stomach aches, and difficulty sleeping. Which intervention should the nurse implement?

An 8-year-old girl with precocious sexual development is being treated medically with injections of luteinizing hormone-releasing hormone (LHRH) to regulate the pituitary gland. Which statement by the parents indicates that they understand the treatment?

The nurse is assessing the growth and development of a 3-year-old child. Which speech and language skills should the nurse identify as normal developmental milestones for this child?

The mother of an 11-year-old boy who has juvenile idiopathic arthritis tells the nurse, "I really don't want my son to become dependent on pain medication, so I only allow him to take it when he is really hurting." Which information is most important for the nurse to provide this mother?

A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?