Pediatric Primary Care for the Advanced Practice Nurse (D119)

Correct Answer A. Coolness of the client’s left forearm, pitting edema at the insertion site

Explanation

Infiltration occurs when IV fluid leaks into the surrounding tissue instead of staying within the vein. Coolness and pitting edema at the insertion site are classic signs of infiltration. The fluid causes swelling and discomfort, leading to a change in temperature at the site, with the area becoming cooler than the rest of the skin. This is due to the body’s response to the non-vesicant fluid leaking into the tissues.

Why other options are wrong

B. Erythema along the path of the vein

Erythema (redness) along the path of the vein usually indicates phlebitis, which is inflammation of the vein, not infiltration. Infiltration typically does not cause redness along the vein but rather swelling and coolness around the insertion site.

C. Bruising around the insertion site

Bruising around the insertion site can occur from trauma to the vein or surrounding tissues, but it is not a specific sign of infiltration. Bruising is more commonly associated with venipuncture or accidental injury rather than the leakage of fluid into the tissue.

D. Pitting edema in the client’s ankles

Pitting edema in the ankles is a sign of fluid retention and can indicate systemic issues such as heart failure or kidney problems. This is unrelated to infiltration at the IV site, which would typically cause localized swelling around the insertion site rather than generalized edema.

Correct Answer A. Sudden infant death syndrome

Explanation

Sudden Infant Death Syndrome (SIDS) is the leading cause of death in infants during the first year of life. It is defined as the sudden, unexplained death of a healthy baby, often during sleep. The cause is still not fully understood, but certain risk factors like sleeping on the stomach or exposure to smoke can contribute.

Why other options are wrong

B. Unintentional injuries

Unintentional injuries are also a significant concern for infants, particularly during accidents involving falls or suffocation. However, they are not the leading cause of death for this age group, with SIDS being more prevalent.

C. Congenital anomalies

Congenital anomalies, such as birth defects, are a cause of infant mortality, but they rank behind SIDS. Many congenital anomalies are diagnosed early, and with proper care, survival rates have improved, reducing their impact as the leading cause of death.

D. Preterm birth

Preterm birth can result in complications that lead to infant death, but it is not the primary cause. Advances in neonatal care have improved survival rates for preterm infants, making this less common than SIDS in the first year of life.

Correct Answer A. Greek yogurt with fruit

Explanation

Greek yogurt is an excellent source of protein, especially for a vegetarian diet. Since the client consumes dairy, Greek yogurt is an ideal choice to meet their protein needs. Adding fruit provides additional nutrients, making it a balanced and healthful snack.

Why other options are wrong

B. Hummus with pita bread

Although hummus is a good source of protein, it is primarily plant-based, and the client dislikes nuts. This may limit the amount of protein that can be obtained from this option, especially if they avoid other legumes. The pita bread itself is not a high-protein food.

C. Cheese and crackers

Cheese does provide some protein, but crackers do not contribute significantly to the protein content of the snack. This option may not provide enough protein compared to Greek yogurt, which is richer in protein per serving.

D. Vegetable sticks with ranch dip

While vegetable sticks are healthy, they do not provide a significant source of protein. Ranch dip typically contains minimal protein, making this a poor choice for meeting the client's protein needs.

Correct Answer B. 0.5mL

Explanation

To calculate the volume to administer, divide the ordered dose by the concentration of the medication.

0.4mg (ordered dose) ÷ 0.8mg/mL (concentration) = 0.5mL.

Thus, the nurse should administer 0.5mL of atropine sulfate.

Why other options are wrong

A. 0.25mL

This is incorrect because it represents half of the required dose, and thus would result in an underdose. The correct dose is 0.5mL.

C. 1.0mL

This is incorrect because 1.0mL would exceed the ordered dose of 0.4mg. The correct dose is only 0.5mL.

D. 1.25mL

This is also incorrect because it is far too much for the 0.4mg order, and would deliver an excess of the medication.

Correct Answer D. 390 mL

Explanation

To calculate the total fluid intake, the nurse must account for the following:

Medication: 15 mL

Formula: 4 oz = 120 mL (since 1 oz = 30 mL)

Water: 3 oz = 90 mL

IV fluids: 30 mL/hr x 12 hours = 360 mL

Adding all these amounts together gives:

15 mL + 120 mL + 90 mL + 360 mL = 390 mL

Therefore, the total fluid intake for the infant is 390 mL.

Why other options are wrong

A. 360 mL

This value is only the amount of IV fluids the infant received. It does not include the other fluids from medication, formula, and water. The total fluid intake includes all these sources.

B. 450 mL

This value is too high because it overestimates the total fluid intake. It likely includes a miscalculation in converting the formula and water from ounces to milliliters.

C. 480 mL

This option also overestimates the total fluid intake, possibly due to an error in the conversion of ounces or miscalculating the IV fluids. The correct total is 390 mL.

Correct Answer A. It's common for teenagers to need extra sleep during their growth spurts.

Explanation

It is typical for teenagers to need more sleep due to the physical and mental demands of growth, development, and hormonal changes. Teenagers often experience a shift in their sleep cycle, requiring more sleep on weekends and during breaks to recover from the cumulative effects of sleep deprivation during the school week. The nurse should reassure the parent that this is a normal pattern and not necessarily indicative of a health problem.

Why other options are wrong

B. Teenagers should ideally limit their sleep to 8 hours per night.

While 8 hours of sleep is the recommended amount for adults, teenagers generally require more sleep. It’s not unusual for teenagers to need between 8 to 10 hours on a regular basis, and they may need even more during periods of growth and development.

C. Sleeping this much could indicate a potential health issue.

While excessive sleep can sometimes be linked to health issues such as depression or sleep disorders, this is not typically the case for a 15-year-old who sleeps more on weekends and during breaks. The most likely explanation is normal developmental changes, so further assessment would be needed only if there are additional concerning symptoms.

D. Many teenagers have irregular sleep patterns due to their busy schedules.

While irregular sleep patterns are common, the focus should be on the teenager's need for extra rest during growth periods, rather than just attributing it to a busy schedule. This answer does not fully address the developmental reason behind the child's sleep habits.

Correct Answer C. Assess the client for allergies to penicillin

Explanation

Before administering any antibiotic, especially one from the penicillin family, it is crucial to assess the patient for allergies to penicillin. This is a standard precaution to prevent an allergic reaction, which can be severe. In this case, the correct intervention is to assess for a penicillin allergy prior to administration.

Why other options are wrong

A. Draw up 10 ml of ampicillin and administer

The concentration of ampicillin is 125 mg/5 mL, which means each 5 mL contains 125 mg of ampicillin. For a 125 mg dose, only 5 mL is needed, not 10 mL. Drawing up 10 mL would double the intended dose.

B. Administer the medications at 1000, 1400, 1800, and 2200

This is a correct approach for administering the drug every 6 hours, but the timing of the doses is not the most relevant intervention in this scenario. It is more critical to first ensure that the child is not allergic to penicillin and that the correct dose is being administered.

D. Question the physician about the order because it's more than the recommended dosage

The dose of ampicillin in the order is appropriate for the child’s weight, based on the drug label recommendation (25 mg to 50 mg/kg/day). The child weighs 10 kg, so the total daily dose should be between 250 mg (10 kg x 25 mg) and 500 mg (10 kg x 50 mg). The order is within this range, so questioning the physician about the dosage is not necessary.

Correct Answer C. Between the umbilicus and the xiphoid process

Explanation

The correct location for performing abdominal thrusts (also known as the Heimlich maneuver) in a child is between the umbilicus and the xiphoid process. This area is where the diaphragm is located, and applying pressure here will effectively help expel the object causing the choking. The thrusts should be quick and inward, aimed at creating enough force to expel the object from the airway.

Why other options are wrong

A. Above the xiphoid process

Applying pressure above the xiphoid process may cause injury to the sternum or ribs, and it is not the recommended area for performing abdominal thrusts. The force should be directed lower, between the umbilicus and the xiphoid process.

B. Between the xiphoid process and the rib cage

This location is too high for effective abdominal thrusts. The thrusts need to be applied lower in the abdomen, between the umbilicus and the xiphoid process, for optimal results and safety.

D. Below the umbilicus

Positioning hands below the umbilicus is incorrect for abdominal thrusts in a child. The thrusts should be applied between the umbilicus and the xiphoid process to create the proper pressure on the diaphragm to expel the choking object.

Correct Answer A. Uses a regular kitchen spoon to measure the medication

Explanation

A regular kitchen spoon is not an accurate tool for measuring medication. The parent should use a medicine syringe or dropper that is specifically designed for administering precise doses. This ensures the correct dosage is given, as kitchen spoons are not standardized for measuring liquid medications.

Why other options are wrong

B. Holds the infant in a sitting position during administration

Holding the infant in a sitting position is the correct approach. It helps prevent choking and ensures the infant can swallow the medication safely. It also reduces the risk of aspiration.

C. Administers the medication slowly to avoid choking

Administering the medication slowly is an appropriate action to reduce the risk of choking. It gives the infant time to swallow the medication properly and prevents gagging or aspiration.

D. Ensures the infant is calm before giving the medication

Ensuring the infant is calm is an important part of the process, as it reduces stress and makes it easier to administer the medication. A calm state helps the infant swallow the medication without resistance or distress.