The nurse is collecting data on a 4-month-old child brought to the clinic by the caregiver. The nurse observes the child’s mouth and notes a white coating that looks like milk curds. Which of the following questions would be most important for the nurse to ask the caregiver?
“Are you breastfeeding or bottle feeding your baby?”
“Did you have a vaginal delivery with this baby?”
“Has your child been treated for any type of infection recently?”
“Does everyone in your house wash their hands often?”
The Correct Answer is C
Choice A reason: Breastfeeding or bottle feeding does not directly relate to a white coating resembling milk curds, which suggests oral thrush. Recent infections or antibiotic use are more relevant to thrush’s etiology, making this less critical and incorrect for the most important question to ask the caregiver.
Choice B reason: Vaginal delivery may increase thrush risk from maternal candida, but it is less immediate than recent infections or antibiotics, which directly predispose to oral thrush. This question is less relevant, making it incorrect compared to assessing recent infection history for the coating’s cause.
Choice C reason: A white coating resembling milk curds suggests oral thrush, often linked to recent antibiotic use or infections disrupting oral flora. Asking about recent infections identifies potential causes, aligning with pediatric infectious disease protocols, making it the most important question for assessing the child’s condition.
Choice D reason: Handwashing is relevant for infection prevention but does not directly address the cause of a white coating like thrush. Recent infections or antibiotics are more pertinent to the etiology, making this less critical and incorrect for the primary question to investigate the oral finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A cool mist humidifier may help croup but is inadequate for a child with a barking cough, fever, and cyanosis (blue around the mouth), indicating severe respiratory distress. Immediate ER evaluation is critical, making this insufficient and incorrect for the urgent symptoms described in the scenario.
Choice B reason: A barking cough, fever, and cyanosis suggest severe croup or airway obstruction, requiring urgent medical evaluation. Bringing the child to the ER immediately ensures timely intervention for potential respiratory compromise, aligning with pediatric emergency protocols, making it the correct recommendation for the caregiver.
Choice C reason: Cold air exposure may temporarily relieve croup but is unsafe for a cyanotic child with fever, indicating severe distress. Immediate ER care is needed to address potential airway issues, making this risky and incorrect for managing the child’s critical symptoms in this urgent situation.
Choice D reason: Steam may help mild croup but delays care for a child with cyanosis, signaling severe respiratory compromise. Immediate ER evaluation is essential to prevent deterioration, making this inadequate and incorrect compared to the urgent need for professional assessment in the emergency department.
Correct Answer is C
Explanation
Choice A reason: Removing equipment reduces clutter but is less urgent than preventing falls, especially post-procedure when a child may be disoriented. Ensuring side rails and a low bed prioritizes safety, making this secondary and incorrect for the most immediate action in pediatric post-procedure care.
Choice B reason: Handling contaminated linens follows infection control but is not the immediate safety concern post-procedure. Preventing falls with side rails and a low bed is critical, making this less urgent and incorrect compared to the priority of ensuring the child’s physical safety after the procedure.
Choice C reason: Assessing side rails up and bed lowered prevents falls, the most immediate safety risk post-procedure when a child may be sedated or unsteady. This aligns with pediatric safety protocols, making it the correct statement for the most urgent action in post-procedure interventions.
Choice D reason: Documentation is essential but not immediate compared to fall prevention, which protects the child post-procedure. Side rails and bed positioning take precedence, making this subsequent and incorrect for the most urgent safety action required after a pediatric procedure in the hospital.
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