HESI Pediatrics Quizlet

Correct Answer: B

Rationale: The correct answer is B: systolic blood pressure. In young children, systolic blood pressure is the least reliable parameter for assessing perfusion status. Factors such as anxiety, crying, and fear can significantly affect blood pressure measurements, leading to inaccuracies. Distal capillary refill, skin color and temperature, and presence of peripheral pulses are more reliable indicators of perfusion status in pediatric patients. Distal capillary refill assesses peripheral perfusion, skin color, and temperature reflect tissue perfusion, and the presence of peripheral pulses indicates blood flow to the extremities. Therefore, when evaluating a 2-year-old child with possible shock, focusing on parameters other than systolic blood pressure is crucial for an accurate assessment of perfusion status.

Correct Answer: C

Rationale: Positive fibrin split products indicate disseminated intravascular coagulation (DIC), a condition characterized by the widespread formation of blood clots throughout the body. In DIC, clotting factors are consumed, leading to increased fibrin split products. A shortened prothrombin time (Choice A) is not typically seen in DIC as it indicates faster blood clotting, which is not consistent with the pathophysiology of DIC. An increased fibrinogen level (Choice B) is also not a characteristic finding in DIC, as fibrinogen levels may be decreased due to consumption in the formation of clots. Increased platelets (Choice D) are not typically observed in DIC; instead, thrombocytopenia (decreased platelet count) is more common due to their consumption in clot formation.

Correct Answer: C

Rationale: The correct answer is C. Longer periods of sleep than usual can be a sign of illness in infants. When an infant sleeps more than usual, it can indicate that the baby is conserving energy due to an underlying condition. Grunting respirations (choice A) can be a sign of respiratory distress, not just an indication of illness. Excessive perspiration (choice B) can occur due to various reasons and is not a specific major indication of illness. Crying immediately after feedings (choice D) is a common behavior in infants and not necessarily a major indication of illness.

Correct Answer: A

Rationale: The correct answer is to notify the practitioner. The passage of a normal brown stool in a child with intussusception could indicate spontaneous reduction of the intussusception. It is crucial to inform the practitioner immediately so that they can reassess the situation and determine the next steps, which may include adjusting the planned intervention. Measuring abdominal girth (choice B) may be important in assessing for abdominal distension but is not the most immediate action required in this scenario. Auscultating for bowel sounds (choice C) is a routine nursing assessment but does not take precedence over notifying the practitioner in this critical situation. Taking vital signs, including blood pressure (choice D), is also important but notifying the practitioner is more urgent to address the unexpected change in the patient's condition.

Correct Answer: A

Rationale: Preventing shivering is crucial in this situation as it can increase the body temperature and counteract the effects of antipyretic measures aimed at reducing the fever. Shivering generates heat, potentially worsening the fever. Restricting oral fluids (Choice B) is not appropriate as fluid intake is important to prevent dehydration, especially in a child who has been vomiting. Measuring output hourly (Choice C) and taking vital signs hourly (Choice D) are important nursing actions but not as critical as preventing shivering in this scenario. Therefore, the most important nursing action is to prevent shivering to aid in fever reduction and management.