Question Set B: Next-Generation Items on the Sick Child
The scaffolds drawn empty: a matrix grid with hairline rules, a bowtie skeleton of a center hexagon flanked by two pairs of rectangles, and a trend frame of three stacked timed data blocks.
ITEM 1 · MATRIX. A neonate is admitted two hours after birth with an open myelomeningocele over the lumbar spine. The sac is intact and uncovered. For each nursing action, indicate whether it is indicated, non-essential, or contraindicated.
| Nursing action | Indicated | Non-essential | Contraindicated |
|---|---|---|---|
| A. Position the neonate prone | ☐ | ☐ | ☐ |
| B. Cover the sac with sterile gauze moistened with sterile normal saline | ☐ | ☐ | ☐ |
| C. Use latex-free gloves and supplies for all care | ☐ | ☐ | ☐ |
| D. Measure head circumference daily | ☐ | ☐ | ☐ |
| E. Place the neonate supine on a padded surface and apply a dry sterile dressing | ☐ | ☐ | ☐ |
| F. Apply a warm blanket directly over the sac to prevent heat loss | ☐ | ☐ | ☐ |
Rationale. A, B, C, and D are indicated. Prone positioning keeps pressure and stool off the sac; moist sterile saline gauze prevents the exposed neural tissue from drying; latex precautions begin at birth because repeated exposure produces latex allergy in this population; daily head circumference detects developing hydrocephalus. E is contraindicated on both counts: supine positioning compresses the sac and a dry dressing adheres to and tears neural tissue on removal. F is contraindicated because direct pressure and dry material damage the sac. The strongest distractor, a dry dressing, would be correct on a closed, healed surgical incision at about one week after repair.
ITEM 2 · TREND. A 9-month-old is brought to the emergency department. Review the three data sets and select the correct interpretation.
| 1400 | 1700 | 2000 | |
|---|---|---|---|
| Behavior | Episodes of sudden crying with knees drawn to chest, then plays normally between episodes | Episodes closer together, lethargic between them | Quiet, less responsive |
| Abdomen | Soft, mild tenderness | Sausage-shaped mass palpated in the right upper quadrant | Distended |
| Stool | None | Stool with blood and mucus, currant-jelly appearance | One normal brown stool passed after imaging |
| Heart rate | 132 | 158 | 164 |
Which action does the nurse take?
- Document the normal brown stool as evidence of resolution and continue observation
- Report the passage of the normal brown stool to the provider immediately
- Offer clear oral fluids because the obstruction has cleared
- Prepare the child for discharge with return precautions
Rationale. Answer 2. A normal brown stool after imaging suggests the telescoped bowel may have reduced, which changes the plan and must be reported, not filed as improvement. The heart rate is still climbing and the child is less responsive, so nothing here supports discharge. Answer 1 would be correct only in a child with no obstruction findings at all, where a normal stool is simply a normal stool.
ITEM 3 · BOWTIE. An 18-month-old is brought in after a two-minute generalized seizure at home. Temperature 103.4 °F, now alert and clinging to the caregiver, neurologic examination normal, no neck stiffness, no rash. Complete the diagram by selecting the condition the child is most likely experiencing, two actions to take, and two parameters to monitor.
Condition, select 1: bacterial meningitis · febrile seizure · epilepsy · head injury · hypoglycemia Actions to take, select 2: position the child side-lying and protect the head during any further event · insert a padded tongue blade during seizure activity · restrain the extremities · identify and treat the source of the fever · initiate seizure precautions with immediate long-term anticonvulsant teaching Parameters to monitor, select 2: temperature trend · level of consciousness and neurologic status · urine specific gravity · abdominal girth
Rationale. A brief generalized seizure with a rapid fever rise in a child between six months and five years who returns to baseline neurologically describes a simple febrile seizure. Side-lying protects the airway and nothing goes in the mouth. Temperature and neurologic status are the parameters that distinguish a simple febrile seizure from meningitis. Long-term anticonvulsant teaching would be correct in a child with a diagnosed seizure disorder and repeated afebrile seizures, typically school age and older.
ITEM 4 · DROP-DOWN. Complete the paragraph by selecting one term for each blank.
At the two-week well visit, the nurse screens a female infant for developmental dysplasia of the hip using the [1: forward bend test / Ortolani and Barlow maneuvers / straight leg raise], and considers the finding significant when there is [2: a palpable clunk with limited hip abduction and unequal knee height / equal thigh creases / full painless range of motion]. Treatment in the young infant is a harness, and the caregiver is taught [3: to loosen the straps at bedtime / never to adjust the straps and to check the skin daily / to remove the harness for four hours each day]. At a middle-school sports physical, the nurse screens a 13-year-old for scoliosis using the [4: Ortolani maneuver / Adams forward bend test / Galeazzi sign], looking for [5: a rib hump with uneven shoulders and waistline / a positive clunk / limb length equal within one inch].
Rationale. Keys: Ortolani and Barlow maneuvers; a palpable clunk with limited abduction and unequal knee height; never to adjust the straps and to check the skin daily; Adams forward bend test; a rib hump with uneven shoulders and waistline. The screening maneuver is chosen by age. The Ortolani and Barlow maneuvers are reliable only in the young infant and are abandoned as the hip stabilizes; the forward bend test belongs to the pre-adolescent and adolescent growth spurt, roughly 10 to 14 years.
ITEM 5 · SELECT ALL THAT APPLY. A 4-month-old is brought to the clinic. Which findings require the nurse to report suspected maltreatment?
- A bruise on the left ear
- Bruising over both shins
- A sharply demarcated burn on both feet with a clean line at the ankles and no splash marks
- A caregiver history that changed twice during the visit
- A small bruise on the forehead
- Bruising across the upper back and posterior rib line
Rationale. Answers 1, 3, 4, and 6. Bruising of the ear, torso, or neck, and any bruising in a 4-month-old who cannot yet cruise, is concerning. A stocking-pattern burn with no splash marks indicates forced immersion. A history that changes is itself a red flag. Shin bruising and a forehead bruise are ordinary in an ambulatory child and would be unremarkable at about 12 months and older, but this infant is not mobile. Report reasonable suspicion; do not investigate and do not confront.
Margin notenext-generation items want the action, not the label.
Takeawaythese items reward naming the next action, and the next action is chosen by age as often as by diagnosis. → BOOK 13 · P9