RN

1. The nurse is caring for an infant after a cleft lip repair. Which of these measures should be included in the plan of care?

• A. Position prone
• B. Provide fluids from a cup
• C. Position supine
• D. Avoid elbow restraints

Correct Answer: C

Rationale: The correct measure that should be included in the plan of care for an infant after a cleft lip repair is to position the infant supine. Placing the infant in a supine position helps protect the surgical site from injury and promotes proper healing. Choice A, 'Position prone,' is incorrect as placing the infant prone can put pressure on the surgical site and hinder healing. Choice B, 'Provide fluids from a cup,' is not directly related to the surgical care of a cleft lip repair. Choice D, 'Avoid elbow restraints,' is not specific to the postoperative care of a cleft lip repair.

2. A 14-month-old child is admitted to the hospital with laryngotracheobronchitis (LTB). Which assessment findings should the nurse expect?

• A. Cyanosis and dyspnea
• B. Productive cough and high fever
• C. Barking cough and inspiratory stridor
• D. Pale laryngeal and dyspnea

Correct Answer: C

Rationale: The correct answer is C: 'Barking cough and inspiratory stridor.' Classic signs of laryngotracheobronchitis (LTB) include a barking cough, often described as a seal-like cough, and inspiratory stridor, which is a high-pitched sound heard during inspiration. These symptoms occur due to inflammation and narrowing of the upper airway. Choices A, B, and D are incorrect as they do not align with the typical assessment findings of LTB. Cyanosis and dyspnea (Choice A) may occur in severe cases but are not specific to LTB. Productive cough and high fever (Choice B) are more indicative of lower respiratory tract infections. Pale laryngeal and dyspnea (Choice D) are not characteristic findings of LTB.

3. The physician tells the parents of a 2-year-old that the child probably has RSV. The parents ask how the diagnosis will be confirmed. How should the nurse respond?

• A. We will swab your child's nose and send the secretions for testing.
• B. There is no specific test for RSV. The diagnosis is based on symptoms.
• C. We will send a viral culture to an outside lab for testing.
• D. There is no specific test for RSV. The diagnosis is based on symptoms.

Correct Answer: A

Rationale: The correct answer is A. RSV is typically diagnosed by swabbing the nose and testing the secretions. This method helps confirm the presence of the respiratory syncytial virus. Choice B is incorrect because while symptoms are important in diagnosis, specific tests like swabbing for RSV do exist. Choice C is incorrect as sending a viral culture to an outside lab is not the primary method for diagnosing RSV. Choice D is a duplicate of choice B and is incorrect for the same reasons.

4. What should the nurse include in the discharge instructions for the parents of an infant diagnosed with acute otitis media?

• A. Keep the baby in an elevated position during sleep
• B. Administer an antibiotic
• C. Place the baby to sleep with a bottle
• D. Administer acetaminophen (Tylenol) to relieve discomfort

Correct Answer: D

Rationale: Acetaminophen (Tylenol) is recommended to help relieve the discomfort associated with acute otitis media, such as pain and fever. Elevating the baby's head during sleep can also help with drainage and relieve pressure, making choice A incorrect. Administering an antibiotic may be necessary for bacterial otitis media but is not usually the first-line treatment for acute otitis media, so choice B is incorrect. Placing the baby to sleep with a bottle can increase the risk of ear infections due to the pooling of milk around the Eustachian tube, so choice C is incorrect.

5. A preschool-age boy presents to the outpatient clinic for a sore throat. In the child’s mind, which is the most likely cause for the sore throat?

• A. Being exposed to a classmate with strep throat
• B. Not eating the right foods
• C. Not taking daily vitamins
• D. Yelling at sibling for being annoying

Correct Answer: D

Rationale: The correct answer is D. Preschool-age children often attribute illness to their actions, like yelling at a sibling or not following instructions. They may not understand medical causes such as exposure to infections like strep throat (choice A), dietary factors (choice B), or vitamin deficiencies (choice C). It is common for young children to connect symptoms to recent behaviors or events within their limited understanding.