Phase 3:

A 10-week-old is brought to the emergency department with three days of rhinorrhea, congestion, and cough. He is presenting with mild intercostal retractions, congested cough, HR: 178, RR: 65 breaths/min, his capillary refill is >4 seconds, O2 Sat: 92% on RA, T- 99.2 F, wheezing is heard bilaterally, & mother feels the infant needs help breathing. Unable to stay latched to breast. Restless and has head bobbing. Mother at bedside.

After implementing the appropriate nursing interventions, the nurse assesses the infant. For each assessment finding listed, place the finding in the appropriate category based on whether the nursing and collaborative intervention was effective (helped to meet expected outcome), ineffective (did not help to meet expected outcomes), or unrelated (not related to the expected outcome)

A three-year-old, is admitted to the pediatric medical unit with acute kawasaki disease. What signs and symptoms are you most likely to note as you do your intake assessment?

What nursing action is appropriate to take when an infant with a congenital heart defect has increased respiratory rate, is sweating, and is not feeding well?

Children with a history of Respiratory syncytial virus (RSV) infection are at an increase risk of developing asthma later in life.

Phase 2:

A 10-week-old is brought to the emergency department with three days of rhinorrhea, congestion, and cough. He is presenting with mild intercostal retractions, congested cough, HR: 178, RR: 65 breaths/min, his capillary refill is >4 seconds, O2 Sat: 92% on RA, T- 99.2 F, wheezing is heard bilaterally, & mother feels the infant needs help breathing. Unable to stay latched to breast. Restless and has head bobbing. Mother at bedside.

Place each nursing action for the infant’s care during hospitalization into one of the 3 categories: indicated (appropriate or necessary), contraindicated (could be harmful), or non-essential (makes no difference or not necessary)

The nurse encourages the mother of a toddler with acute laryngotracheobronchitis (LTB) to stay at the bedside as much as possible. What is the nurse’s primary rationale for this action?

Phase 1

A 5 year old is brought to her pediatrician for an annual routine checkup. Her grandparents, who are also the legal guardians, are with her. The child has not seen her pediatrician in a year. The child recently had a visit to the urgent care center and was treated for strep throat. The grandparents are concerned about the child’s weight gain. They state no matter how much she eats she cannot gain weight and is hungry all of the time. 

Phase 2

The primary care office does not have a glucometer available, so the provider orders a urinalysis dip stick test. The urinalysis shows a glucose of over 500mg/dl with blood, leukocytes, and ketones.  The results are shared with the grandparents along with the potential diagnosis and complications. The child’s grandparents are visibly upset and start asking the nurse questions about their grandchild.

Below are several responses the nurse can make to the child’s grandparents. Drag and drop the nurse’s responses to the child’s grandparents to either ‘therapeutic” or “nontherapeutic” based on how you would best categorize the responses.

The primary problem in cystic fibrosis is the production of thin, watery mucus that helps clear airways.

Phase 3:

A 10-week-old is brought to the emergency department with three days of rhinorrhea, congestion, and cough. He is presenting with mild intercostal retractions, congested cough, HR: 178, RR: 65 breaths/min, his capillary refill is >4 seconds, O2 Sat: 92% on RA, T- 99.2 F, wheezing is heard bilaterally, & mother feels the infant needs help breathing. Unable to stay latched to breast. Restless and has head bobbing. Mother at bedside.

After implementing the appropriate nursing interventions, the nurse assesses the infant. For each assessment finding listed, place the finding in the appropriate category based on whether the nursing and collaborative intervention was effective (helped to meet expected outcome), ineffective (did not help to meet expected outcomes), or unrelated (not related to the expected outcome)

Phase 1

A 10-week-old is brought to the emergency department with three days of rhinorrhea, congestion, and cough. He is presenting with mild intercostal retractions, congested cough, HR: 178, RR: 65 breaths/min, his capillary refill is >4 seconds, O2 Sat: 92% on RA, T- 99.2 F, wheezing is heard bilaterally, & mother feels the infant needs help breathing. Unable to stay latched to breast. Restless and has head bobbing. Mother at bedside.

Choose the most likely options for the information missing from the statements below by choosing from the corresponding list. 

Based on the infant’s assessment data, the nurse determines that the infant’s abnormal vital sign findings are most likely due to

Cystic fibrosis (CF) is suspected in a toddler. Which test is essential in establishing this diagnosis?