a 6 month old infant is admitted with a diagnosis of respiratory syncytial virus rsv what should the nurse include in the care plan
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Nursing Elites

HESI LPN

Pediatrics HESI 2023

1. What should the nurse include in the care plan for a 6-month-old infant admitted with a diagnosis of respiratory syncytial virus (RSV)?

Correct answer: D

Rationale: Elevating the head of the bed is crucial in the care plan for an infant with RSV as it helps improve breathing by facilitating better airflow and drainage of secretions. This position can also enhance comfort and reduce respiratory distress. Providing small, frequent feedings (Choice A) is generally beneficial for infants but is not specific to managing RSV. Administering antibiotics (Choice B) is not indicated for RSV as it is caused by a virus, and antibiotics are ineffective against viral infections. Maintaining strict isolation (Choice C) is important to prevent the spread of contagious infections but is not a direct intervention for improving the infant's respiratory status in RSV.

2. During a nap, a 3-year-old hospitalized child wets the bed. How should the nurse respond?

Correct answer: C

Rationale: When a 3-year-old hospitalized child wets the bed during a nap, the nurse should respond by changing the child’s clothes without discussing the incident. This approach helps to maintain the child's dignity, avoid embarrassment, and reduce anxiety related to bedwetting. Asking the child to help with remaking the bed (Choice A) may not be appropriate as it could cause unnecessary distress. Putting clean sheets on the bed over a rubber sheet (Choice B) addresses the aftermath but does not directly address the child's needs. Explaining that children should call the nurse when they need to go to the bathroom (Choice D) may not be effective in this immediate situation of bedwetting during a nap.

3. When explaining the occurrence of febrile seizures to a parents' class, what information should the nurse include?

Correct answer: A

Rationale: The correct answer is A: 'They may occur in minor illnesses.' Febrile seizures can occur even in minor illnesses, particularly in young children, and are often triggered by a rapid increase in body temperature. Choice B is incorrect because the cause of febrile seizures is not always readily identified. Choice C is incorrect as febrile seizures commonly occur in children between the ages of 6 months to 5 years, which includes the toddler years. Choice D is incorrect as febrile seizures are slightly more common in males than females.

4. The nurse is assessing a family to determine if they have access to adequate health care. Which statement accurately describes how certain families are affected by common barriers to health care?

Correct answer: B

Rationale: Choice B is the correct answer because it accurately states that White, non-Hispanic children are more likely to be in very good or excellent health compared to African American and Hispanic children. This reflects a disparity in health outcomes among different racial groups. Choices A, C, and D are incorrect. Choice A is unrelated to the impact of common barriers to health care on families. Choice C talks about overweight children but does not address access to health care. Choice D discusses the impact of the overall health care plan on working families but does not specifically address the disparity in health status among different racial groups.

5. While performing a visual inspection of a 30-year-old woman in active labor, you can see the umbilical cord at the vaginal opening. After providing high concentration oxygen, what should you do next?

Correct answer: B

Rationale: In the scenario described, the priority is to relieve pressure from the umbilical cord protruding from the vaginal opening by gently pushing it back inside using your gloved fingers. This action helps prevent cord compression, maintains blood flow to the fetus, and ensures fetal oxygenation. Massaging the uterus (Choice A) is not appropriate in this situation as it can potentially worsen the cord compression. Placing the mother on her left side and providing rapid transport (Choice C) can be considered after relieving the pressure on the cord. Elevating the mother's lower extremities and providing immediate transport (Choice D) is not the correct approach when dealing with a visible umbilical cord; instead, the focus should be on relieving pressure from the cord to prevent fetal compromise.

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