Choice A rationale:

Limiting fluids at bedtime is not a suitable instruction for a child with sickle cell disease. These patients are at risk of dehydration due to increased red blood cell destruction, and limiting fluids can exacerbate this condition, leading to vaso-occlusive crises and pain episodes.

Choice B rationale:

Applying cold compresses to painful areas might provide temporary relief for pain associated with sickle cell disease, but it does not address the overall management of the illness. Encouraging physical activity, on the other hand, is essential as it promotes overall health and can prevent complications like thrombosis.

Choice C rationale:

Encouraging physical activity as tolerated is the correct choice. Regular physical activity helps improve circulation and can reduce the risk of vaso-occlusive crises in patients with sickle cell disease. The nurse should advise the guardians to encourage the child to engage in activities that are appropriate for their age and physical condition, while also being mindful of any signs of fatigue or pain.

Choice D rationale:

Having the child wear a surgical mask to school is not relevant to the management of sickle cell disease. This measure is more appropriate for preventing the spread of contagious diseases and is not a specific intervention for sickle cell disease management.

Choice A rationale:

Discouraging the parents from allowing siblings to view the body can prevent healthy grieving and closure for the siblings. Allowing siblings to view the body, if they wish, can help them understand the reality of the situation and cope with their emotions in a healthy way.

Choice B rationale:

Providing a follow-up phone call 1 week following the infant's death is a good practice, but it is not the most immediate and crucial action in this situation. Acknowledging the family's feelings of guilt and providing emotional support should take precedence.

Choice C rationale:

Avoiding discussing details of the attempt to revive the infant might hinder the family's ability to process the situation. Open communication, including discussing the events leading to the infant's death, can help the family members come to terms with their loss.

Choice D rationale:

Acknowledging the family members' feelings of guilt is the correct choice. Parents and family members often experience guilt after the death of an infant from SIDS, wondering if there was something they could have done differently. The nurse should acknowledge these feelings and provide reassurance, emphasizing that SIDS is not the result of parental actions or negligence.

Choice A rationale:

A sausage-shaped abdominal mass is a classic sign of intussusception, a condition where one segment of the intestine telescopes into another, causing obstruction. This is a medical emergency that requires prompt intervention.

Choice B rationale:

Increased urinary output is not a characteristic finding of intussusception. Instead, the child may present with signs of dehydration due to vomiting, diarrhea, and decreased oral intake caused by the obstruction.

Choice C rationale:

Constipation is a symptom that can be associated with various gastrointestinal disorders but is not specific to intussusception. In intussusception, the child typically experiences severe abdominal pain, vomiting, and the classic sausage-shaped abdominal mass.

Choice D rationale:

A board-like abdomen can occur in conditions such as peritonitis, but it is not a typical finding in intussusception. The presence of a sausage-shaped abdominal mass is the hallmark sign of intussusception.

Choice A rationale:

Moisten the mucosa with lemon glycerin swabs is not recommended because lemon glycerin swabs can be acidic and may irritate the oral ulcers further. It's important to avoid irritating substances in the oral cavity to promote healing.

Choice B rationale:

Cleaning the gums with saline-soaked gauze is a gentle and non-irritating method to maintain oral hygiene for a toddler with oral ulcers. Saline solution helps keep the oral cavity clean and reduces the risk of infection without causing further irritation.

Choice C rationale:

Administering oral viscous lidocaine is not recommended for routine use in managing oral ulcers in children. Lidocaine can be absorbed systemically and lead to toxicity, especially in young children. It should only be used under the guidance of a healthcare provider and in specific circumstances where the benefits outweigh the risks.

Choice D rationale:

Scheduling routine oral care every 8 hours is important, but the method of oral care is equally crucial. Using gentle methods like saline-soaked gauze to clean the gums ensures proper hygiene without causing discomfort to the child.

Choice Arationale:

Lime-flavored ice pop may be too cold and acidic, potentially causing discomfort and irritation to the surgical site. It's best to avoid acidic foods and very cold temperatures during the initial recovery period after tonsillectomy.

Choice B rationale:

Sugar-free cherry gelatin is a suitable choice for a preschooler who is postoperative following a tonsillectomy. Gelatin is soft, easy to swallow, and does not require chewing, reducing the risk of injury to the surgical site. Sugar-free options are preferred to prevent irritation from sugary foods.

Choice Crationale:

Vanilla ice cream may be too cold and could irritate the surgical site following a tonsillectomy. It's important to offer foods that are soft, non-irritating, and at a moderate temperature to prevent discomfort and promote healing.

Choice D rationale:

Chocolate milk may not be the best choice immediately after a tonsillectomy. Dairy products can sometimes coat the throat and cause discomfort, especially if the child is experiencing any residual throat pain or irritation. Additionally, chocolate milk contains sugar, which can also be irritating to the healing surgical site.

Choice A rationale:

Unable to hold a bottle is a developmental milestone expected at around 6 months of age. This is not a concerning finding for a 5-month-old infant.

Choice B rationale:

The grasp reflex is present in infants until about 6 months of age. Its absence is expected at 5 months and is not a cause for concern.

Choice C rationale:

Rolling from back to abdomen is typically achieved by 5 months of age. However, the inability to do so is not necessarily a red flag at this age, as each infant develops at their own pace.

Choice D rationale:

Head lag refers to the infant's head falling backward when pulled to a sitting position, indicating poor head control. This is a significant developmental red flag at 5 months of age and should be reported to the provider. It might indicate possible neuromuscular issues or developmental delays, requiring further evaluation and intervention.

Choice A rationale:

Bradycardia, or a slow heart rate, is a manifestation of digoxin toxicity. Digoxin, a medication commonly prescribed for heart conditions, can cause toxic effects when its levels become too high in the body. Bradycardia is a result of the drug's action on the heart's electrical conduction system and indicates toxicity.

Choice B rationale:

Diaphoresis, or excessive sweating, is not a specific manifestation of digoxin toxicity. While sweating can occur due to various reasons, it is not a characteristic sign of digoxin toxicity.

Choice C rationale:

Jaundice, or yellowing of the skin and eyes, is not a typical manifestation of digoxin toxicity. Jaundice is more commonly associated with liver or bile duct disorders.

Choice D rationale:

Polyuria, or excessive urination, is not a specific sign of digoxin toxicity. Digoxin toxicity primarily affects the heart and its electrical conduction system, leading to symptoms like bradycardia.

Choice A rationale:

Checking oxygen saturation every 4 hours is a monitoring parameter for patients with respiratory issues but is not the priority in a child with acute epiglottitis. Airway management and infection control are more critical in this situation.

Choice B rationale:

Obtaining a throat culture is important to confirm the diagnosis of epiglottitis. However, initiating isolation precautions and ensuring the child's airway is secure take precedence in the immediate care of a child with acute epiglottitis.

Choice C rationale:

Assisting the child into a supine position is contraindicated in acute epiglottitis. This position can further compromise the airway by obstructing it. The child should be allowed to sit in a position of comfort, usually sitting upright and leaning slightly forward.

Choice D rationale:

Initiating droplet isolation precautions is crucial when dealing with a suspected or confirmed case of epiglottitis. Epiglottitis is highly contagious and is transmitted via respiratory droplets. Isolation precautions help prevent the spread of the infection to others.

Choice A rationale:

Providing a high-calorie, low-protein diet is not directly related to the management of osteomyelitis. However, proper nutrition is essential for overall healing and immune function.

Choice B rationale:

Encouraging frequent physical activity to increase bone mass is not appropriate for a child with osteomyelitis. Physical activity can worsen the condition and cause further damage to the affected bone.

Choice C rationale:

Maintaining a patent intravenous catheter is important for administering intravenous antibiotics, which are the mainstay of treatment for osteomyelitis. Ensuring that the catheter is functional and infection-free is crucial for the delivery of appropriate antibiotics to combat the infection.

Choice D rationale:

Initiating contact precautions is not necessary for osteomyelitis. Osteomyelitis is not typically spread through direct contact but results from the spread of bacteria through the bloodstream to the affected bone.

Choice A rationale:

Heart rate is important to monitor but is not specific to the management of cystic fibrosis or the prescribed treatments mentioned in the exhibit. Monitoring heart rate is essential in various clinical situations, but it is not the focus here.

Choice B rationale:

WBC count, or white blood cell count, is a marker of infection or inflammation in the body. While it can be useful in assessing the overall health of a patient, it is not specific to cystic fibrosis or the prescribed treatments mentioned in the exhibit.

Choice C rationale:

HbA1c, or glycated hemoglobin, is a marker used in diabetes management to assess long-term blood sugar control. It is not relevant to cystic fibrosis or the medications prescribed in this case.

Choice D rationale:

Oxygen saturation is a crucial parameter to monitor in a child with cystic fibrosis, especially considering the respiratory complications associated with this condition. Low oxygen saturation levels can indicate respiratory distress, which needs prompt medical attention. Reporting any abnormal oxygen saturation values to the provider ensures timely intervention and appropriate management of the child's respiratory status.

Choice A rationale:

The nurse does not need to report the heart rate as it falls within the normal range for a school-age child, which is typically between 70-100 beats per minute.

Choice B rationale:

The WBC count is 9,600/mm3, which is within the normal range for a school-age child (4,500 to 13,500/mm3) Therefore, this finding does not warrant reporting to the provider.

Choice C rationale:

HbA1c level is 8.5%, indicating poor blood sugar control. However, this finding is related to the child's cystic fibrosis and not an immediate concern. The nurse should address this issue but does not need to urgently report it to the provider.

Choice D rationale:

Oxygen saturation is 95%, which is within the normal range (typically 95-100%) However, for a child with cystic fibrosis who may have respiratory issues, a lower oxygen saturation level might be concerning. Therefore, the nurse should report this finding to the provider for further evaluation and intervention.

Answer is D. Oxygen saturation. The nurse should report the low oxygen saturation of 92% on room air to the provider, as this indicates hypoxemia and respiratory distress in a child with cystic fibrosis. The normal range for oxygen saturation is 95% to 100%¹. Hypoxemia can lead to complications such as pulmonary hypertension, cor pulmonale, and respiratory failure².

A. Heart rate is not the correct answer. The heart rate of 98 beats/min is normal high, but not alarming for a child with cystic fibrosis. The normal range for heart rate in school-age children is 60 to 100 beats/min³. A higher heart rate may be due to fever, infection, dehydration, or anxiety⁴.

B. WBC count is not the correct answer. The WBC count of 10,000/mm3 is within the normal range of 5,000 to 10,000/mm3⁵. A high WBC count may indicate infection or inflammation, which are common in cystic fibrosis⁶.

C. HbA1c is not the correct answer. The HbA1c of 6.5% is borderline for diabetes, but not an urgent finding. The normal range for HbA1c is 4% to 5.6%, and a level of 6.5% or higher indicates diabetes⁷. Cystic fibrosis-related diabetes (CFRD) is a common complication of cystic fibrosis, affecting about 30% of adults with the condition⁸. CFRD requires regular monitoring and treatment with insulin⁹..

Choice A rationale:

Placing a baby on their side to sleep is not recommended due to the risk of sudden infant death syndrome (SIDS) Babies should be placed on their back to sleep to reduce the risk of SIDS. Therefore, this statement indicates a misunderstanding of the teaching and should be corrected by the nurse.

Choice B rationale:

Dressing the baby in lightweight clothing is a correct understanding of SIDS prevention guidelines. Overheating is a risk factor for SIDS, so dressing the baby in lightweight, breathable clothing is recommended to maintain a comfortable body temperature during sleep.

Choice C rationale:

Moving the baby's stuffed animal to the corner of the crib is not a recommended practice. Stuffed animals and soft bedding should be kept out of the baby's sleep area to reduce the risk of suffocation and SIDS. This statement indicates a misunderstanding of the teaching and should be corrected by the nurse.

Choice D rationale:

Having the baby sleep next to the parents in bed increases the risk of accidental suffocation and SIDS. Babies should sleep in their own safe sleep environment, such as a crib or bassinet, to reduce the risk of SIDS. This statement indicates a misunderstanding of the teaching and should be corrected by the nurse.

Choice A rationale:

Maintaining balance when standing with eyes closed is a test of the vestibular system and cerebellar function, not the trigeminal nerve.

Choice B rationale:

Exhibiting a gag reflex when stimulated with a tongue blade is a test of the glossopharyngeal and vagus nerves, not the trigeminal nerve.

Choice C rationale:

The trigeminal nerve is responsible for sensory input from the face and motor functions such as biting and chewing. Symmetrical jaw strength when biting down indicates proper functioning of the trigeminal nerve, making choice C the correct answer.

Choice D rationale:

Correctly identifying specific scents is related to olfactory nerve function, not the trigeminal nerve.

Answer is A. Use a 24-gauge catheter to start the IV.

A 24-gauge catheter is the smallest and most appropriate size for an infant's vein¹. It reduces the risk of infiltration, phlebitis, and thrombosis².

B. Start the IV in the infant's foot. Statement is wrong because starting the IV in the foot can interfere with the infant's mobility and increase the risk of infection³. The preferred sites for IV insertion in infants are the scalp, hand, or arm veins⁴.

C. Change the IV site every 3 days. Statement is wrong because changing the IV site every 3 days is not recommended for infants and children. The IV site should be changed only when clinically indicated, such as signs of infection, infiltration, or phlebitis.

D. Cover the insertion site with an opaque dressing. Statement is wrong because covering the insertion site with an opaque dressing can obscure the visibility of the site and prevent early detection of complications. A transparent dressing is preferred as it allows for continuous assessment of the site.

Choice A rationale:

Administer cool, humidified oxygen via nasal cannula. Infants with heart failure often experience respiratory distress due to inadequate oxygenation. Administering cool, humidified oxygen via nasal cannula helps improve oxygen saturation and alleviate respiratory distress. Humidified oxygen prevents the mucous membranes from drying out, making breathing easier for the infant. Cool oxygen is preferred to reduce the work of breathing and to soothe irritated airways, improving the overall comfort of the infant.

Choice B rationale:

Provide less frequent, higher volume feedings. Infants with heart failure may have difficulty feeding due to fatigue and increased respiratory effort. Providing less frequent, higher volume feedings ensures that the infant receives adequate nutrition without becoming overly fatigued during feeding sessions. It allows the infant to obtain the necessary nutrients without putting excessive stress on their weakened cardiovascular system.

Choice C rationale:

Place the infant in a prone position. Placing the infant in a prone position is not recommended in the care of a child with heart failure. Placing the infant in an upright or semi-upright position is more appropriate as it reduces the workload on the heart and improves respiratory function. Placing the infant flat on their back may cause increased pressure on the diaphragm and worsen respiratory distress.

Choice D rationale:

Repeat a digoxin dosage if the infant vomits within 1 hr of administration. Digoxin is a medication commonly prescribed for heart failure. However, if the infant vomits shortly after receiving a dose, repeating the dose is not advisable. Vomiting may indicate that the medication was not properly absorbed, and administering an additional dose could lead to an overdose. Instead, the nurse should consult the healthcare provider for further instructions and closely monitor the infant's condition.

Choice A rationale:

"The test will measure the amount of chloride in your baby's sweat." Pilocarpine iontophoresis testing is used to diagnose cystic fibrosis by measuring the chloride content in the patient's sweat. Cystic fibrosis patients have elevated chloride levels in their sweat, which is a characteristic feature of the disease. Educating the parents about the purpose of the test helps them understand its significance in diagnosing their baby's condition.

Choice B rationale:

"We will measure the amount of protein in your baby's urine over a 24-hour period." Measuring protein in urine over a 24-hour period is a test for kidney function, not for cystic fibrosis. This statement is unrelated to the pilocarpine iontophoresis testing and may confuse the parents about the purpose of the procedure.

Choice C rationale:

"Your baby will need to fast for 8 hours prior to the test." Fasting is not a requirement for pilocarpine iontophoresis testing. This statement is incorrect and could cause unnecessary stress for the parents and the infant. It is essential to provide accurate information to ensure that the parents are well-prepared for the procedure.

Choice D rationale:

"A nurse will insert an IV prior to the test." Inserting an IV is not a part of the pilocarpine iontophoresis testing procedure. This statement is inaccurate and does not contribute to the parents' understanding of the test. Providing irrelevant information can create confusion and anxiety, which should be avoided during patient education.

Choice A rationale:

"Consume 1,500 to 1,700 calories per day." This statement provides a specific calorie range suitable for most adolescents. It ensures they receive adequate energy to support their growth and daily activities. Adequate caloric intake is essential during adolescence to support proper physical and mental development.

Choice B rationale:

"Decrease your vitamin D intake once you start to menstruate." Menstruation does not affect the need for vitamin D intake. In fact, vitamin D is crucial for bone health, especially during adolescence when bones are still developing. Adolescents, including females, should maintain an appropriate level of vitamin D intake to support bone health and overall well-being.

Choice C rationale:

"Increase the amount of your dietary iron intake." During adolescence, especially for females, iron requirements increase due to menstrual losses. Iron is essential for the production of red blood cells and to prevent anemia. Adolescents, particularly females, should be educated about the importance of including iron-rich foods in their diet to meet their increased nutritional needs.

Choice D rationale:

"Limit your sodium intake to 3,000 milligrams per day." While limiting sodium intake is generally advisable for overall health, this statement does not specifically address the nutritional needs of adolescents. Adolescents need guidance on various aspects of nutrition, but limiting sodium intake should be part of a broader discussion about a balanced diet, rather than a singular focus during this educational session.

Choice A rationale:

Check the toddler's ID band against the medical record. Verifying the toddler's identity through their ID band is a standard and reliable practice in healthcare settings. It ensures that the right medication is administered to the right patient, promoting patient safety and preventing medication errors. Checking the ID band against the medical record is a fundamental step in the medication administration process.

Choice B rationale:

Ask another nurse to confirm the toddler's identity. While collaboration and double-checking are important in healthcare settings, the primary responsibility lies with the nurse administering the medication. Relying solely on another nurse to confirm the toddler's identity could lead to errors. Nurses should follow established protocols, including checking the ID band, to maintain patient safety.

Choice C rationale:

Check the toddler's room number against their ID band. Verifying the room number is not a reliable method of confirming a patient's identity. Room assignments can change, and patients can be moved to different locations within the healthcare facility. Relying on room numbers can lead to confusion and errors in identifying patients.

Choice D rationale:

Ask the parent to confirm the toddler's identity. While involving parents in the care process is important, the primary responsibility for confirming a patient's identity lies with the healthcare provider. Parents can assist by providing information, but the final verification should be done through established healthcare protocols, such as checking the ID band against the medical record.

Choice A rationale:

Assess respiratory status. In a child with a head injury, assessing respiratory status is the top priority. Respiratory distress or compromise could indicate potential brain injury or other serious complications. Ensuring an open airway, adequate breathing, and proper oxygenation is essential for the child's immediate well-being. Any signs of respiratory distress should be promptly addressed to prevent further complications.

Choice B rationale:

Check pupil reactions. Checking pupil reactions is important in assessing neurological function, but it is secondary to assessing respiratory status in this scenario. Respiratory status takes precedence because impaired breathing can lead to hypoxia, which can further compromise neurological function. Once respiratory status is stabilized, assessing neurological signs, including pupil reactions, becomes crucial to evaluate potential brain injury.

Choice C rationale:

Inspect for fluid leaking from the ears. Inspecting for fluid leaking from the ears is important in head injury assessment, specifically for signs of cerebrospinal fluid leakage. However, it is not the first action to take. Assessing respiratory status and ensuring proper oxygenation are immediate

Choice A rationale:

Allowing the child to adjust their bedtime might promote autonomy, but in a hospital setting, routine and familiarity are essential for reducing anxiety in school-age children. Disrupting their home sleep routine may increase stress and hinder the child's ability to rest properly.

Choice B rationale:

Leaving the lights on in the child's room contradicts the principles of creating a sleep-conducive environment. Adequate sleep hygiene involves a dark and quiet room. Leaving lights on could interfere with the child's ability to fall asleep, potentially leading to sleep disturbances and increased anxiety.

Choice C rationale:

Following the child's home sleep routine is the most appropriate intervention. Maintaining consistency with the child's usual bedtime routine provides a sense of familiarity and security, reducing anxiety and promoting better sleep. This approach aligns with the principles of pediatric nursing, ensuring the child's emotional well-being while in the hospital.

Choice D rationale:

Providing the child with video games prior to bedtime is not recommended, especially in a hospital setting. Screen time, especially before sleep, can disrupt sleep patterns due to the blue light emitted by electronic devices. Additionally, video games may stimulate the child, making it harder for them to relax and fall asleep. This choice can exacerbate the child's stress and hinder their ability to achieve adequate sleep.

Choice A rationale:

A blood pressure of 95/56 mm Hg is within the normal range for a 5-year-old child. While assessing vital signs, the nurse should consider the patient's age-specific parameters. In this case, the blood pressure is not indicative of hemorrhage.

Choice B rationale:

Flushing of the face might be a common postoperative finding and is not necessarily indicative of hemorrhage. It can be caused by various factors such as anesthesia or emotional states. Flushing alone is not a reliable sign of hemorrhage and should be assessed in conjunction with other symptoms.

Choice C rationale:

Continuous swallowing, especially with an increased heart rate and signs of restlessness, can be indicative of hemorrhage after a tonsillectomy and adenoidectomy. Frequent swallowing suggests the presence of blood in the mouth or throat, indicating possible bleeding at the surgical site. This finding requires immediate attention and intervention by the nurse.

Choice D rationale:

A heart rate of 54/min is below the normal range for a 5-year-old child, which typically ranges from 70 to 120 beats per minute. While bradycardia can be a concern, the more specific and immediate indication of hemorrhage in this case is continuous swallowing, which signals active bleeding from the surgical site.

Choice A rationale:

Asking the parent if they are willing to take new parenting classes is a closed-ended question that does not encourage open communication or exploration of the parent's coping mechanisms. It does not assess the parent's current strategies or provide an opportunity for them to express their concerns.

Choice B rationale:

Asking the parent what they do when their infant is fussy encourages open dialogue and allows the parent to share their coping mechanisms. It provides insight into the parent's current strategies for managing their infant's fussiness, which can guide the nurse in providing appropriate support and education.

Choice C rationale:

Asking if parenting is overwhelming on a bad day is a general question that may not yield specific information about the parent's coping mechanisms. It does not address the parent's strategies for managing their infant's fussiness or provide a clear understanding of their coping skills.

Choice D rationale:

Asking if parenting causes stress is a closed-ended question that may yield a yes or no response without exploring the parent's coping mechanisms in detail. It does not encourage the parent to elaborate on their experiences or provide specific information about their coping strategies.

Choice A rationale:

Using vague language to describe the procedure can increase anxiety in the child. Children often fear the unknown, and providing clear, age-appropriate information about the procedure can help alleviate their anxiety. Vague language may lead to misconceptions and increased fear.

Choice B rationale:

Choice C rationale:

Explaining the procedure to the child when they are in the playroom is not the most appropriate setting. The playroom may not be a quiet or comfortable environment for the child to focus on the information provided. Additionally, it may not allow the child to ask questions or express concerns privately, which is essential for effective communication.

Choice D rationale:

Demonstrating deep-breathing and counting exercises is an appropriate action to help the child cope with anxiety and fear related to the invasive procedure. Deep-breathing exercises promote relaxation, while counting exercises provide a distraction and a sense of control. Teaching these coping techniques in a calm and supportive manner can significantly enhance the child's ability to manage their anxiety during the procedure.

Choice A rationale:

Preparing the child for a lumbar puncture is the priority action in this situation. Bacterial meningitis is a medical emergency that requires prompt diagnosis and treatment. A lumbar puncture is a crucial diagnostic procedure to assess cerebrospinal fluid for signs of infection. Early identification of bacterial meningitis is essential for initiating appropriate antibiotic therapy and preventing complications.

Choice B rationale:

Dimming the lights in the child's room may help create a more comfortable environment, but it is not the priority action when a child is suspected of having bacterial meningitis. The urgent need for a lumbar puncture takes precedence to confirm the diagnosis and initiate treatment promptly.

Choice C rationale:

Administering an antipyretic to the child can help reduce fever and provide comfort. However, it is not the first action to take in this scenario. The priority is to perform a lumbar puncture to confirm the diagnosis of bacterial meningitis and initiate appropriate treatment. Antipyretics can be administered after the lumbar puncture and as part of the overall treatment plan.

Choice D rationale:

Implementing droplet precautions for the child is essential to prevent the spread of infection, especially if bacterial meningitis is suspected. While this is important, the immediate priority is to confirm the diagnosis through a lumbar puncture. Once the diagnosis is confirmed, appropriate isolation precautions can be implemented to prevent the transmission of the infection to others.

Choice A rationale:

The nurse should position the opening of the urine collection bag over the urethra and the anus. This technique ensures that the urine specimen is collected effectively without contamination from stool. Placing the bag over both the urethra and the anus prevents mixing of urine with feces, ensuring the accuracy of the specimen.

Choice B rationale:

Stretching the perineum taut when applying the bag is not necessary and may cause discomfort to the infant. Placing the bag correctly over the urethra and the anus is sufficient for proper urine collection.

Choice C rationale:

Applying lidocaine gel to the perineum before attaching the bag is not a standard practice for collecting urine specimens from infants. It is unnecessary and may cause skin irritation or allergic reactions.

Choice D rationale:

Placing a snug-fitting diaper over the drainage bag is not recommended as it can compress the bag, leading to backflow of urine or leakage. The urine collection bag should be placed directly on the infant's perineal area without any obstructions for accurate collection.

Choice A rationale:

Lack of sleep is a common trigger that increases the risk of seizures in individuals with a seizure disorder. Sleep deprivation can lower the seizure threshold, making individuals more susceptible to seizures. Educating the guardians about the importance of maintaining a regular sleep schedule for the child can help minimize the risk of seizures.

Choice Brationale:

Decreased temperature is not a common trigger for seizures. In fact, high fever, rather than decreased temperature, is associated with febrile seizures in children. Febrile seizures are triggered by a rapid increase in body temperature.

Choice Crationale:

Exposure to secondhand smoke is a trigger for respiratory issues but is not directly linked to seizures. While it is essential to educate families about the dangers of secondhand smoke, it is not a specific trigger for seizures.

Choice D rationale:

Prolonged headache is not a trigger for seizures. However, it could be a symptom of an underlying neurological issue, and individuals experiencing persistent headaches should seek medical evaluation for proper diagnosis and management.

Choice A rationale:

Varicella (chickenpox) vaccine is typically administered to children at the age of 1 and again at the age of 4. At the age of 12, the child should have already received the varicella vaccine as part of the routine childhood immunization schedule. It is not necessary to administer it again at this age.

Choice B rationale:

Diphtheria, tetanus, and pertussis (DTaP) vaccine is recommended for adolescents as a booster dose to ensure continued immunity against these diseases. Booster doses are necessary because immunity from childhood vaccinations can wane over time. Administering DTaP at the age of 12 helps maintain protection against these serious illnesses.

Choice C rationale:

Hepatitis A vaccine is typically administered to children at the age of 1 and again at least 6 months later. By the age of 12, the child should have completed the hepatitis A vaccination series. There is no need for an additional dose at this age unless the child missed the earlier doses.

Choice D rationale:

Human papillomavirus (HPV) vaccine is recommended for adolescents to prevent HPV-related cancers and diseases. The vaccine is typically administered as a two-dose series for adolescents under the age of 15, with the doses spaced 6 to 12 months apart. It is essential to provide this vaccine to 12-year-old clients to protect them against HPV infections.

Choice A rationale:

Partial thromboplastin time (PTT) measures the time it takes for blood to clot and is used to monitor conditions like bleeding disorders or the effectiveness of anticoagulant therapy. PTT is not specific to rheumatic fever and does not contribute to confirming this diagnosis.

Choice B rationale:

Blood urea nitrogen (BUN) measures the amount of nitrogen in the blood that comes from urea. It is a marker of kidney function and hydration status. BUN levels are not directly related to rheumatic fever and do not play a role in confirming this diagnosis.

Choice C rationale:

Erythrocyte sedimentation rate (ESR) is a nonspecific marker of inflammation in the body. Elevated ESR levels indicate the presence of inflammation but do not confirm a specific diagnosis. In the context of suspected rheumatic fever, elevated ESR levels, along with other clinical findings, can support the diagnosis.

Choice D rationale:

Antistreptolysin O (ASO) titer measures the level of antibodies against streptolysin O, a toxin produced by group A Streptococcus bacteria. Elevated ASO titers indicate a recent streptococcal infection, which is a common trigger for rheumatic fever. Positive ASO titers, along with clinical symptoms and other laboratory findings, contribute to confirming the diagnosis of rheumatic fever.

Choice E rationale:

C-reactive protein (CRP) is another marker of inflammation in the body. Elevated CRP levels indicate the presence of inflammation but do not confirm a specific diagnosis. In the context of suspected rheumatic fever, elevated CRP levels, along with other clinical and laboratory findings, can support the diagnosis by indicating the presence of inflammation.

Choice A rationale:

Abdominal pain in a postoperative patient, especially after an appendectomy, is concerning and should be reported to the provider immediately. It could indicate complications such as infection, ileus, or surgical site issues. Prompt reporting and assessment are crucial to prevent further complications and ensure the patient's well-being.

Choice B rationale:

Muscle rigidity is not a typical finding 1 hour postoperative following an appendectomy. While muscle rigidity can be a sign of various conditions, it is not a common immediate concern after this type of surgery, especially in the early postoperative period.

Choice C rationale:

A temperature of 36.4°C (97.5°F) is within the normal range for body temperature. While it's important to monitor the patient's temperature for signs of infection, this temperature alone is not a cause for immediate concern.

Choice D rationale:

A heart rate of 63/min is within the normal range for an adolescent at rest. Heart rate can vary based on factors such as age, activity level, and overall health. A heart rate of 63/min does not indicate an immediate problem and is not a cause for immediate concern in this context.

Choice A rationale:

Attaching the feeding bag tubing to the end of the NG tube is a step in the enteral feeding process, but it is not the first action the nurse should take. First, the nurse needs to assess the pH of the gastric secretions to confirm the NG tube placement in the stomach. If the pH is acidic (usually below 5.5), it indicates that the NG tube is in the stomach. If the pH is alkaline, it may suggest the tube is in the respiratory tract, and feeding should not be initiated. Therefore, this choice is not the correct first action.

Choice B rationale:

Flushing the tube with water is important to ensure it is clear and not clogged. However, it is not the first action the nurse should take. Checking the pH of the gastric secretions is crucial to confirm the NG tube placement before any other interventions. If the nurse encounters resistance while flushing the tube, it could indicate a misplaced tube, emphasizing the importance of checking the pH first.

Choice C rationale:

Checking the pH of the gastric secretions is the correct first action before administering enteral feeding. Gastric secretions are acidic (usually below 5.5), confirming the tube's placement in the stomach. This step ensures the safety of the feeding process and prevents complications such as aspiration pneumonia. Once the placement is confirmed, the nurse can proceed with other steps, such as attaching the feeding bag tubing and setting the administration rate on the feeding pump.

Choice D rationale:

Setting the administration rate on the feeding pump is a necessary step in enteral feeding but should only be done after confirming the tube placement by checking the pH of the gastric secretions. If the nurse administers the feeding without confirming the tube placement, there is a risk of aspiration, which can be life-threatening.

Choice A rationale:

Adjusting the straps of the Pavlik harness daily is essential to ensure a proper fit as the infant grows. Developmental dysplasia of the hip requires appropriate positioning of the hip joint to allow normal development. The Pavlik harness helps maintain the hip joint in the correct position. Adjusting the straps daily ensures that the harness continues to provide the necessary support and alignment, promoting optimal hip development.

Choice B rationale:

Placing the diaper under the straps is incorrect. The straps of the Pavlik harness should be in direct contact with the infant's skin to provide the necessary support and maintain proper positioning of the hip joint. Placing a diaper under the straps could alter the harness's effectiveness, leading to inadequate treatment of developmental dysplasia of the hip.

Choice C rationale:

Wearing the Pavlik harness for only two weeks is not accurate. The duration of harness wear depends on the severity of the hip dysplasia and the child's response to treatment. In many cases, the harness needs to be worn for several weeks to months to allow the hip joint to properly develop. The healthcare provider will monitor the progress and determine when it is appropriate to discontinue using the harness.

Choice D rationale:

Applying lotion to the skin under the straps is incorrect. Lotions and creams can interfere with the harness's fit and may cause skin irritation. It's important to keep the skin clean and dry under the harness to prevent discomfort and skin problems.

Choice A rationale:

An increase in venous pressure is not an indication that furosemide, a loop diuretic, is effective. In fact, increased venous pressure could suggest worsening heart failure. Loop diuretics like furosemide work by promoting the excretion of excess fluid and sodium from the body, leading to a decrease in blood volume and relieving symptoms of heart failure, such as peripheral edema and pulmonary congestion.

Choice B rationale:

A decrease in cardiac output is not the desired effect of furosemide. Furosemide helps reduce fluid overload and congestion in the heart and lungs, ultimately improving cardiac output. If cardiac output decreases, it indicates that the medication might not be effective or the heart failure is worsening.

Choice C rationale:

An increase in potassium levels is not directly related to the effectiveness of furosemide. Furosemide can cause potassium depletion as it increases the excretion of potassium in the urine. Monitoring potassium levels is essential because severe hypokalemia can lead to cardiac arrhythmias. However, the absence of an increase in potassium levels does not indicate furosemide's effectiveness.

Choice D rationale:

A decrease in peripheral edema is the desired effect of furosemide. By reducing fluid retention, furosemide helps decrease peripheral edema, which is a common symptom of heart failure. The nurse should assess the child for a decrease in peripheral edema to determine the medication's effectiveness. Monitoring daily weights and assessing for reduced edema are key indicators of furosemide's efficacy.

Choice A rationale:

This choice is not the correct answer. To calculate the correct dose of amoxicillin, the nurse needs to use the formula: Dose = Weight × Dose per kg Dose=Weight×Dose per kg. For this 2-year-old child weighing 10 kg, the calculation would be: 10   kg × 80   mg/kg/day = 800   mg/day 10kg×80mg/kg/day=800mg/day. Since the prescribed dose is divided into two doses daily, each dose would be 800   mg 2 = 400   mg 2 800mg ​ =400mg. To convert this dose to mL using the available concentration (400 mg/5 mL), the nurse should calculate: 400   mg 5   mL = 80   mL 5mL 400mg ​ =80mL. Therefore, the nurse should administer 80 mL of amoxicillin suspension per dose.

Choice B rationale:

This choice is the correct answer based on the correct calculation explained above. Administering 80 mL of amoxicillin suspension per dose ensures the child receives the prescribed dose of 80 mg/kg/day divided into two doses daily. Rounding the answer to the nearest whole number is appropriate in this context.

Choice C rationale:

This choice is not the correct answer. Using the given dose (80 mg/kg/day) and the child's weight (10 kg), the calculated dose is 800 mg/day. Administering 10 mL of the suspension would provide only 200 mg of amoxicillin, which is not the prescribed dose for this child.

Choice D rationale:

This choice is not the correct answer. Administering 2 mL of the suspension would provide only 160 mg of amoxicillin, which is below the prescribed dose of 800 mg/day for this child. It's important to calculate the correct dose based on the child's weight and the prescribed dose per kg.

Choice A rationale:

Placing the child on a clear liquid diet for 24 hours following the arterial cardiac catheterization procedure is not necessary. The procedure does not typically require dietary restrictions. However, the healthcare provider may provide specific pre-procedure dietary instructions if needed, but it's not a standard practice.

Choice B rationale:

Instructing the child that they will be on bed rest for 2 days after the procedure is not accurate. While the child may need to rest after the procedure, the duration of bed rest is typically much shorter than 2 days. It's important to provide accurate information to the child to reduce anxiety and promote understanding.

Choice C rationale:

Explaining to the child that they will need to keep their leg straight for 8 hours following the procedure is important and accurate information. Arterial cardiac catheterization often involves the insertion of a catheter through an artery in the leg, and keeping the leg straight helps prevent complications at the insertion site. This information is essential for the child to follow post-procedure instructions correctly.

Choice D rationale:

Telling the child that their dressing will be removed 12 hours after the procedure is not accurate. Dressing removal timing may vary depending on the healthcare provider's protocol, but it's not typically done immediately after the procedure. Providing inaccurate information may lead to confusion and anxiety for the child.

Choice A rationale:

The nurse should not provide false information about the medication to convince the preschooler. Telling the child that the medication tastes like candy when it doesn't might lead to mistrust in the future.

Choice B rationale:

While this choice provides information about the purpose of the medication, it might not be sufficient to convince the child to take it. Moreover, it assumes the child understands what a hypersensitivity reaction is, which might not be the case for a preschooler.

Choice C rationale:

This is the correct choice because it empowers the preschooler to have some control over the situation. By allowing the child to express readiness, the nurse respects the child's autonomy, potentially making it easier for them to take the medication when they feel more comfortable.

Choice D rationale:

This choice acknowledges the child's emotions, but it doesn't offer a solution or provide any information about the medication. It might not effectively address the situation at hand.

Choice A rationale:

A respiratory rate of 28/min alone might not indicate dehydration. It's within the normal range for an infant (30-60 breaths/min) This finding does not specifically point towards dehydration.

Choice B rationale:

Bradycardia (abnormally slow heart rate) is not a typical sign of moderate dehydration. Dehydration often leads to tachycardia (increased heart rate) as the body compensates for decreased blood volume.

Choice C rationale:

Capillary refill time of 1 second is abnormal. In a well-hydrated infant, capillary refill time should be less than 2 seconds. However, in this context, it indicates moderate dehydration because it suggests decreased peripheral perfusion.

Choice D rationale:

Weight loss of 7% is a significant indicator of dehydration in an infant. However, this choice alone doesn't give a real-time indication of the current state of the infant. Capillary refill time is a more immediate and practical parameter to assess dehydration in this scenario.

Choice A rationale:

The preschool-age child with muffled voice and no spontaneous cough might be experiencing a medical emergency, possibly epiglottitis. This condition can rapidly progress and compromise the airway, necessitating immediate assessment and intervention.

Choice B rationale:

The school-age child with diabetes and a blood glucose of 200 mg/dL requires attention, but it is not an immediate concern unless the child is showing signs of diabetic ketoacidosis (DKA), such as altered mental status or deep, labored breathing, which are not mentioned in the question.

Choice C rationale:

The toddler with nephrotic syndrome and facial edema needs monitoring and intervention, but it doesn't indicate an immediate life-threatening condition compared to the child with potential airway compromise (muffled voice and no spontaneous cough)

Choice D rationale:

The adolescent with Crohn's disease and recent weight loss also needs attention, but it's not as urgent as the child with potential airway obstruction. Weight loss alone, while concerning, doesn't necessitate immediate assessment in this context.

Choice A rationale:

Offering a pacifier during feedings might interfere with the infant's ability to suck and swallow properly, especially if they are receiving enteral feedings through a gastrostomy tube. This choice can potentially lead to aspiration.

Choice B rationale:

Placing the infant in supine position during feedings can increase the risk of aspiration. The head of the bed should be elevated to prevent reflux and aspiration during and after feedings.

Choice C rationale:

Heating the formula to 39°C (102°F) might scald the infant's mouth and esophagus, causing injury. Enteral feedings should be at room temperature or body temperature to prevent thermal injury to the infant's gastrointestinal tract.

Choice D rationale:

Checking for residual volumes by aspirating stomach contents is important to ensure the infant is tolerating the feeding and to prevent overfeeding or aspiration. This action helps in determining the appropriate amount of formula to administer during each feeding.

Choice E rationale:

Instilling the formula over a period of 30 to 45 minutes allows for slow and gradual feeding, reducing the risk of aspiration. Rapid administration can overwhelm the infant's ability to handle the volume, leading to aspiration or discomfort.

Choice A rationale:

Contacting the client's parents for phone consent might breach the adolescent's confidentiality, especially if they are seeking STI testing. In many jurisdictions, adolescents have the right to confidential healthcare, including STI testing and treatment, without parental consent. Respecting the adolescent's autonomy and confidentiality is crucial in this situation.

Choice B rationale:

Obtaining written consent from the client, if they are of legal age (which is often 16 or older in many jurisdictions), is appropriate and respects the adolescent's autonomy and legal rights. Written consent ensures that the adolescent fully understands the tests being conducted and gives informed consent for the procedure.

Choice C rationale:

Requesting verbal consent from the social worker is not appropriate. Verbal consent can be ambiguous and may not provide sufficient legal documentation of informed consent, especially for sensitive procedures like STI testing.

Choice D rationale:

Postponing the testing until the client's parents are present might not be in the best interest of the adolescent, especially if they are seeking timely healthcare. Delays in testing and treatment could lead to complications or the spread of STIs. Respecting the adolescent's autonomy and providing appropriate, timely care is essential in this situation.

Choice A rationale:

Teaching the child about cast care is essential, but it is not the first priority. The immediate concern is addressing the child's comfort and preventing complications associated with the fractured right tibia. Teaching can come after addressing the acute needs.

Choice B rationale:

Petaling the edges of the cast might be necessary to prevent skin irritation, but it is not the first action to take. Elevating the child's leg is crucial to reduce swelling and promote blood circulation, which is the priority in this situation.

Choice C rationale:

Administering pain medication is important for the child's comfort, but it should not be the first action. Elevating the leg helps in reducing pain and swelling and promotes overall healing.

Choice D rationale:

Elevating the child's leg is the first action the nurse should take. Elevating the leg above heart level helps reduce swelling and improves blood circulation, which is crucial in the initial phase after applying the cast. This action can help prevent complications and promote the healing process. Once the leg is elevated, the nurse can then proceed with teaching the child about cast care and administering pain medication if needed.

Choice A rationale:

Increased heart rate is not a direct indication of the effectiveness of chest physiotherapy treatments in a child with cystic fibrosis. The primary goal of chest physiotherapy is to clear mucus from the airways and improve breathing.

Choice B rationale:

Increased urine output is not directly related to the effectiveness of chest physiotherapy treatments. The focus of chest physiotherapy is on respiratory function and mucus clearance.

Choice C rationale:

Increased expectoration (coughing up mucus) is a positive sign that chest physiotherapy treatments have been effective. Improved clearance of mucus from the airways helps in breathing and reduces the risk of respiratory infections. It indicates that the treatments are helping the child clear the mucus, which is a common problem in cystic fibrosis.

Choice D rationale:

Reduced pain is not the primary goal of chest physiotherapy treatments for cystic fibrosis. While it's essential for the child to be comfortable, the main focus is on improving respiratory function and clearing mucus from the airways.

Choice A rationale:

Limb withdrawal is a pain response and indicates that the infant is experiencing pain. The goal of opioid pain medication is to alleviate pain, so limb withdrawal suggests inadequate pain control.

Choice B rationale:

A relaxed facial expression indicates that the infant is comfortable and not experiencing pain. It is a positive sign that the medication is having a therapeutic effect by providing pain relief.

Choice C rationale:

Increased blood pressure is not a typical response to opioid pain medication. Opioids often cause a decrease in blood pressure and can lead to hypotension.

Choice D rationale:

Bradycardia (slow heart rate) is not a common response to opioid pain medication. Opioids can cause respiratory depression and bradypnea (slow breathing), but they do not typically cause bradycardia.

Choice A rationale:

Feeding the infant a specific volume of formula is not the priority when caring for a child with a cleft of the soft palate. Infants with cleft palate may have difficulty creating suction during feeding, which can lead to inefficient feeding and inadequate intake. It is essential to focus on proper feeding techniques rather than a specific volume.

Choice B rationale:

Elevating the infant's head to a 10° angle during feedings is the correct action. This positioning helps prevent formula or breast milk from flowing into the nasal cavity, reducing the risk of aspiration. Aspiration can lead to respiratory issues and other complications. Elevating the head facilitates swallowing and reduces the risk of choking.

Choice C rationale:

Discontinuing a feeding if the infant's eyes become watery is not a valid indication to stop feeding. Watery eyes are not directly related to feeding difficulties in infants with a cleft palate. It is essential to assess the infant's overall feeding performance and address specific issues such as inadequate suction or swallowing difficulties.

Choice D rationale:

Postponing burping until after completing each feeding is not appropriate. Burping should be done periodically during feedings to prevent the accumulation of air in the infant's stomach, which can cause discomfort and contribute to reflux. Burping helps release trapped air and promotes comfortable feeding experiences for the infant.

Choice A rationale:

Oliguria is a decreased urine output, usually below 0.5 mL/kg/hr in children, and is associated with dehydration or kidney dysfunction. It is not directly related to potassium levels.

Choice B rationale:

Hypertension is elevated blood pressure, often defined as systolic and diastolic pressures above the 95th percentile for a child's age, sex, and height. Hypertension is not typically associated with abnormal potassium levels.

Choice C rationale:

Hyporeflexia is reduced or absent deep tendon reflexes and is often seen in conditions like hypothyroidism or electrolyte imbalances, but it is not a common manifestation of low potassium levels.

Choice D rationale:

Hyperactive bowel sounds are loud, rushing, high-pitched bowel sounds that indicate increased peristalsis. In the context of gastroenteritis, where the gut is irritated and inflamed, hyperactive bowel sounds are a common finding. Gastroenteritis can cause electrolyte imbalances, including hypokalemia (low potassium levels), leading to increased bowel sounds. Thus, a preschooler with gastroenteritis and a potassium level of 3.2 mEq/L would likely have hyperactive bowel sounds due to the gastrointestinal irritation and electrolyte imbalance.

Choice A rationale:

Rotavirus is a common cause of diarrhea in children and is preventable by vaccination. However, it is not specifically indicated for a child with sickle cell anemia.

Choice B rationale:

Pneumococcal conjugate (PCV13) vaccine protects against infections caused by the bacteria Streptococcus pneumoniae, which can lead to severe complications in individuals with sickle cell anemia, including pneumonia and sepsis. Immunization with PCV13 is crucial to prevent these potentially life-threatening infections in individuals with sickle cell anemia.

Choice C rationale:

Measles, mumps, and rubella (MMR) vaccine is essential for preventing these viral infections. However, it is not directly related to the specific health needs of a child with sickle cell anemia.

Choice D rationale:

Respiratory syncytial virus (RSV) is a common respiratory virus that can cause severe respiratory infections in young children, especially those with underlying health conditions like sickle cell anemia. RSV immunization is important to prevent serious respiratory complications in these vulnerable individuals.

Choice A rationale:

Staying under a beach umbrella during morning hours provides some protection from direct sunlight but does not offer comprehensive coverage, especially when the sun's rays are strong. It is not the best option for protecting a toddler from sun exposure.

Choice B rationale:

SPF (Sun Protection Factor) 10 sunscreen is relatively low and may not provide adequate protection, especially for a toddler. Higher SPF sunscreens are recommended, typically SPF 30 or higher, to effectively block harmful UV rays.

Choice C rationale:

Loose-weave clothing may allow sunlight to penetrate, leading to sunburn. Tight-knit, dark-colored clothing offers better protection. Loose-weave clothing is not the most effective choice for sun protection.

Choice D rationale:

Wearing a wide-brimmed hat provides shade to the face, neck, and ears, offering additional protection from direct sunlight. This choice indicates a good understanding of the need for comprehensive sun protection for the toddler.

Choice A rationale:

Inserting an IV catheter is essential for administering medications and fluids but is not the immediate priority in this scenario. The toddler's airway and breathing are compromised, making airway management the top priority.

Choice B rationale:

Administering an antibiotic is necessary for treating a potential infection, but securing the airway takes precedence when a child is experiencing severe dyspnea and drooling. The toddler's ability to breathe effectively needs to be addressed urgently.

Choice C rationale:

Obtaining a blood culture is important for identifying the source of infection but does not address the toddler's immediate breathing difficulty. Securing the airway is the primary concern in this situation.

Choice D rationale:

Hyperpyrexia (extremely high fever) along with severe dyspnea and drooling suggests a potentially life-threatening condition like epiglottitis, which requires immediate intervention. Nasotracheal intubation ensures a patent airway, allowing the child to breathe adequately. Once the airway is secure, further assessments and treatments can be administered.

Choice A rationale:

Varicella (chickenpox) is highly contagious and spreads through the air via respiratory droplets. Initiating airborne precautions, such as wearing masks and isolating the patient in a negative pressure room, helps prevent the spread of the virus to other patients and healthcare workers.

Choice B rationale:

Providing a warm blanket is a comfort measure and does not address the contagious nature of varicella. While keeping the child comfortable is important, preventing the spread of the infection to others is a higher priority.

Choice C rationale:

Koplik spots are small, white spots with blue or red centers that can appear on the oral mucosa in individuals with measles. Varicella does not cause Koplik spots; this finding is specific to measles. Therefore, assessing for Koplik spots is not relevant in the context of varicella.

Choice D rationale:

Administering aspirin to a child with varicella is contraindicated due to the risk of Reye's syndrome, a potentially fatal condition characterized by acute brain and liver damage. Acetaminophen is the preferred antipyretic for managing fever in children with varicella.

Choice A rationale:

Weighing the child once each month is not the most relevant information to include in teaching parents of a preschool-age child with heart failure. Monitoring weight is important, but it should be done more frequently, preferably daily, to track any sudden weight gain, which could indicate fluid retention and worsening heart failure.

Choice B rationale:

Withholding digoxin if the child's pulse is greater than 100/min is not appropriate. Digoxin is commonly prescribed for heart failure in pediatric patients to strengthen the heartbeat. Instead, the nurse should teach the parents to monitor the child's pulse rate regularly and report any significant changes to the healthcare provider.

Choice C rationale:

Increasing the child's oxygen flow rate until the child no longer has cyanosis is incorrect. While oxygen therapy might be necessary for a child with heart failure, adjusting the oxygen flow rate based on cyanosis is not the appropriate approach. Oxygen therapy should be prescribed and monitored by healthcare providers based on the child's oxygen saturation levels.

Choice D rationale:

Providing for periods of rest is the correct choice. Children with heart failure often tire easily due to the heart's reduced ability to pump blood effectively. Allowing the child to rest helps conserve energy and prevents additional strain on the heart. This instruction promotes the overall well-being and comfort of the child, aligning with the management of heart failure.

Choice Arationale:

A temperature of 37.2°C (99°F) is slightly elevated but not a contraindication for the MMR vaccine. Low-grade fever is a common side effect of vaccines and is not a reason to withhold vaccination. The nurse should advise the parents to consult with the healthcare provider if the child has a moderate to high fever.

Choice Brationale:

Family history of seizures is not a contraindication for the MMR vaccine. The MMR vaccine is safe for individuals with a family history of seizures. However, if the child has a personal history of seizures, especially related to fever (febrile seizures), the healthcare provider should be consulted before vaccination.

Choice C rationale:

An upper respiratory infection 2 days ago is not a contraindication for the MMR vaccine. Minor illnesses without fever or systemic symptoms are not reasons to postpone routine vaccinations. The child should receive the vaccine as scheduled.

Choice D rationale:

Allergy to neomycin is the correct choice. Neomycin is an antibiotic that is sometimes present in vaccines, including the MMR vaccine. Individuals with a known allergy to neomycin should not receive vaccines containing this substance due to the risk of an allergic reaction. It is essential to screen for allergies to vaccine components to ensure the child's safety during vaccination.

Choice A rationale:

Instructing the child to walk the bicycle through intersections promotes safety by reducing the risk of accidents. Walking the bicycle ensures better visibility to drivers and allows the child to react quickly to any unexpected situations. This instruction aligns with safe biking practices and helps prevent collisions at intersections.

Choice B rationale:

Riding the bicycle against the flow of traffic is unsafe and increases the risk of accidents. Bicyclists should always ride in the same direction as traffic, following the rules of the road. Riding against traffic confuses drivers and reduces the child's visibility, making it more likely to be involved in an accident.

Choice C rationale:

Keeping the bicycle at least 3 feet from the curb while riding in the street is a good safety practice. This distance provides a buffer zone between the child and passing vehicles, reducing the risk of sideswipe accidents. Maintaining a safe distance from the curb allows the child room to maneuver and avoids hazards like potholes or debris at the edge of the road.

Choice D rationale:

Having the child's feet 3 to 6 inches off the ground when seated on the bicycle is an appropriate guideline. The child should be able to touch the ground with their feet while sitting on the bicycle seat. This ensures stability and allows the child to stop the bicycle easily when needed, enhancing overall control and safety while riding.

Choice A rationale:

A respiratory rate of 26 breaths per minute is above the normal range for a 2-year-old child, which is typically 20-30 breaths per minute. An elevated respiratory rate could indicate respiratory distress, infection, or other underlying issues. The nurse should report this finding to the provider for further evaluation and appropriate intervention.

Choice B rationale:

A pulse rate of 98 beats per minute falls within the normal range for a 2-year-old child, which is typically 80-130 beats per minute. This pulse rate is considered normal for the child's age, indicating a healthy heart rate.

Choice C rationale:

A blood pressure of 118/74 mm Hg is within the normal range for a 2-year-old child. Blood pressure norms can vary based on age, height, and weight, but this reading does not raise concern for a child of this age.

Choice D rationale:

A temperature of 37.2°C (99°F) is slightly elevated but generally considered within the normal range for body temperature. It may indicate a mild fever or be within the range of normal variations. Unless accompanied by other concerning symptoms, a mild elevation in temperature may not warrant immediate intervention.

Choice A rationale:

Increased respiratory rate is an expected finding in a severely dehydrated infant. Dehydration can lead to an increased breathing rate as the body tries to compensate for reduced blood volume and oxygenation. Respiratory rate may be rapid, and the infant may appear tachypneic. This compensatory mechanism helps maintain oxygen levels in the body.

Choice B rationale:

Capillary refill of 2 seconds is within the normal range and is not indicative of severe dehydration. Prolonged capillary refill time (>2 seconds) can be a sign of poor perfusion and dehydration, but a capillary refill time of 2 seconds is normal.

Choice C rationale:

Increased urine output is not an expected finding in severe dehydration. Dehydration leads to reduced urine output as the body tries to conserve fluids. In a dehydrated infant, urine output may be significantly decreased, indicating a lack of fluid intake and reduced renal perfusion.

Choice D rationale:

Hypertension is not a typical finding in severe dehydration. Dehydration often leads to decreased blood volume, which can result in low blood pressure rather than hypertension. Hypotension, not hypertension, is a common clinical manifestation of severe dehydration.

Choice A rationale:

Showing teeth while smiling assesses the facial nerve (cranial nerve VII), not the accessory nerve (cranial nerve XI) The facial nerve controls facial expressions, including smiling.

Choice B rationale:

Following a light in the six cardinal positions assesses extraocular eye movements, which are controlled by the oculomotor nerve (cranial nerve III), trochlear nerve (cranial nerve IV), and abducens nerve (cranial nerve VI) This action does not assess the accessory nerve.

Choice C rationale:

Shrugging the shoulders against mild pressure assesses the function of the accessory nerve (cranial nerve XI) The accessory nerve controls the sternocleidomastoid and trapezius muscles, which are responsible for head rotation and shoulder shrugging. Assessing the strength of these muscles helps evaluate the integrity of the accessory nerve.

Choice D rationale:

Moving the tongue in all directions assesses the hypoglossal nerve (cranial nerve XII), which controls tongue movements. This action does not assess the accessory nerve.

Choice A rationale:

Using half-strength formula might not provide enough nutrition for the infant, especially if they have failure to thrive. It's essential to provide adequate nutrition to support growth and development.

Choice B rationale:

Giving fruit juice between feedings can fill the baby's stomach with low-nutrient beverages, decreasing the intake of essential nutrients needed for growth.

Choice C rationale:

Keeping the infant in a visually stimulating environment is important for cognitive and sensory development. However, this alone will not address the underlying issue of failure to thrive, which often requires medical and nutritional interventions.

Choice D rationale:

Assigning consistent nursing staff to care for the infant promotes a stable and trusting environment for the infant. Consistency in care can enhance the infant's sense of security and facilitate bonding. Additionally, it ensures that the infant's progress or any changes in condition are closely monitored by familiar caregivers, leading to prompt interventions if needed.

D.

Choice A rationale:

Fever is a common sign of acute otitis media, indicating an infection. Elevated body temperature is a natural response to infection as the body tries to fight off the invading pathogens.

Choice B rationale:

Crying is a common symptom in infants with acute otitis media due to ear pain and discomfort caused by the infection. It is a way for the infant to express distress.

Choice C rationale:

Enlarged subclavicular lymph node is not a typical finding in acute otitis media. Enlarged lymph nodes can indicate an immune response but are not specific to this condition.

Choice D rationale:

Restlessness can be a symptom of acute otitis media. Infants may become irritable and have difficulty sleeping due to ear pain and discomfort.

Choice E rationale:

Increased appetite is not a typical finding in acute otitis media. Illnesses often cause a decreased appetite rather than an increased one.

Choice A rationale:

Providing frequent range of motion to the neck and shoulders is not appropriate for an infant with bacterial meningitis. Meningitis is an inflammation of the membranes surrounding the brain and spinal cord and can cause severe neck pain and stiffness. Range of motion exercises could exacerbate the discomfort and should be avoided.

Choice B rationale:

Keeping the television on in the room to provide background noise is not appropriate for an infant with bacterial meningitis. Infants with meningitis need a quiet and calm environment to reduce stimuli and promote healing.

Choice C rationale:

Padding the side rails of the crib is important to prevent injury during seizures, which can occur in bacterial meningitis. Seizures can cause uncontrolled movements, and padding the crib rails can prevent the infant from getting hurt during these episodes.

Choice D rationale:

Placing the infant in a semiprivate room is not appropriate for bacterial meningitis. Infants with meningitis need isolation to prevent the spread of the infection to other patients. They should be placed in a private room with strict infection control measures in place.

Choice A rationale:

Soaking combs and brushes in boiling water for 10 minutes is a good practice to kill scabies mites that might be present on these items. However, it's not the primary mode of transmission for scabies. Scabies spreads through direct, prolonged, skin-to-skin contact with a person who has scabies. While cleaning items like combs and brushes is essential, treating close contacts is more critical to prevent reinfestation.

Choice B rationale:

Treating everyone who came into close contact with the child is the correct approach. Scabies is highly contagious and can easily spread to family members and close contacts. To effectively control the spread of the infestation, everyone who has been in close contact with the infested person should be treated simultaneously, even if they do not show symptoms.

Choice C rationale:

Applying petroleum jelly to the affected areas is not a recommended treatment for scabies. Scabies is caused by the Sarcoptes scabiei mite burrowing into the skin, and petroleum jelly does not effectively kill the mites. Medicated creams or lotions prescribed by a healthcare provider are the standard treatment for scabies.

Choice D rationale:

Washing the child's hair with shampoo containing ketoconazole is not a recommended treatment for scabies. Ketoconazole is an antifungal medication and is not effective against scabies mites. The primary treatment for scabies involves topical medications, such as permethrin cream or oral medications in severe cases.

When caring for a school-age child immediately following a tonsillectomy in the Post-Anesthesia Care Unit (PACU), the nurse should prioritize actions that promote the child's comfort and recovery while minimizing the risk of complications. The most appropriate action is:

c) Offer the child ice cream when alert.

After a tonsillectomy, cold and soothing foods like ice cream can help alleviate throat pain and reduce swelling. However, it's crucial to wait until the child is fully alert and able to swallow safely. Ice cream provides a cool and gentle way to soothe the surgical site.

The other options may not be suitable immediately following a tonsillectomy:

a) Placing the child in a side-lying position: While positioning can be essential for airway management, it's not a specific intervention related to a tonsillectomy in the immediate postoperative period.

b) Instructing the child to drink fluids through a straw: Drinking through a straw may increase the risk of bleeding, which is a concern after a tonsillectomy. It's often recommended to avoid straws initially.

d) Encouraging the child to deep breathe and cough: While respiratory care is generally important, the immediate focus after a tonsillectomy is on maintaining a clear airway and managing pain. Deep breathing and coughing exercises may be introduced later in the recovery process.

It's important for the nurse to follow the specific postoperative guidelines provided by the surgical team and be attentive to the child's individual needs and responses.

Choice A rationale:

Avoiding vigorous activity immediately after feeding is not directly related to managing gastroesophageal reflux. The rationale behind this is that keeping the infant upright after feeding helps prevent stomach contents from flowing back into the esophagus. Gravity can help reduce reflux symptoms. Vigorous activities do not impact reflux directly.

Choice B rationale:

Holding the infant in an upright position for 30 minutes after feeding is the correct choice. This position utilizes gravity to keep stomach contents down and prevents reflux. It allows time for the food to move from the stomach to the small intestine, reducing the likelihood of reflux. This intervention is widely recommended for infants with gastroesophageal reflux.

Choice C rationale:

Enlarging the bottle's nipple opening when using thickened feedings is not a recommended practice. Thickened feedings can help reduce reflux, but changing the nipple opening size is not necessary for managing reflux symptoms. The thickness of the feeding itself can help prevent regurgitation.

Choice D rationale:

Propping the bottle during feedings is not recommended. It can lead to aspiration, where the milk can enter the infant's airways, causing respiratory issues. It's essential for the infant to be held in an upright position during feedings to prevent reflux symptoms effectively.

Choice E rationale:

Feeding the infant in a side-lying position is not recommended for infants with gastroesophageal reflux. This position can increase the risk of regurgitation and aspiration. Keeping the infant upright, as mentioned in choice B, is the preferred position to minimize reflux symptoms.

Choice A rationale:

Inserting a tongue blade between the teeth during a seizure is not recommended. Doing so can cause injury to the child's mouth or teeth. It's essential to keep the child's mouth open to prevent choking, but using a tongue blade is not the appropriate method.

Choice B rationale:

Placing the child in a prone position (face down) during a seizure can obstruct the airway and lead to difficulty breathing. It's crucial to maintain an open airway during a seizure. The correct position is to place the child on their side (recovery position) to prevent choking and ensure proper breathing.

Choice C rationale:

Clearing the area of hard objects is the correct action during a seizure. Seizures can involve uncontrolled movements, and clearing the surrounding area of any hard or sharp objects can prevent injuries. Creating a safe environment is essential to minimize the risk of harm during a seizure.

Choice D rationale:

Minimizing movement of the limbs is not entirely accurate. While it's essential to prevent injury during a seizure, attempting to restrict the child's movements forcefully can lead to injuries or fractures. The focus should be on creating a safe environment and ensuring the child is placed in a recovery position to prevent choking.

Choice A rationale:

Administering acyclovir PO (by mouth) is not the appropriate treatment for impetigo. Acyclovir is an antiviral medication used to treat viral infections, such as herpes simplex virus infections. Impetigo is a bacterial skin infection and is typically treated with topical or oral antibiotics targeting the responsible bacteria.

Choice B rationale:

Applying bactericidal ointment to lesions is the correct choice. Impetigo is a bacterial skin infection caused by Staphylococcus aureus or Streptococcus pyogenes. Topical antibiotics, such as mupirocin, are effective in treating impetigo. These medications help eliminate the bacteria, promoting healing of the skin lesions.

Choice C rationale:

Soaking hairbrushes in boiling water for 10 minutes is not a relevant instruction for impetigo management. Impetigo is primarily spread through direct contact with the infected skin lesions, not through contaminated objects like hairbrushes. The focus should be on maintaining good hygiene, such as regular handwashing, to prevent the spread of the infection.

Choice D rationale:

Sealing soft toys in a plastic bag for 14 days is not a necessary measure for impetigo management. Impetigo is primarily spread through direct contact with the infected skin lesions, not through soft toys. The key prevention strategies include proper

Choice A rationale:

Acute acetylsalicylic acid (aspirin) poisoning can lead to hyperpyrexia, which is an extremely high fever, often above 106°F (41.1°C) This hyperpyrexia occurs due to the toxic effects of salicylates on the hypothalamus, the part of the brain that regulates body temperature. Aspirin poisoning can disrupt the body's ability to regulate temperature, leading to a dangerously high fever.

Choice B rationale:

Neck vein distention is not a common symptom of acute acetylsalicylic acid poisoning. This finding is more indicative of issues related to the cardiovascular system, such as heart failure or fluid overload.

Choice C rationale:

Polyuria (excessive urination) is not a typical symptom of acute aspirin poisoning. Aspirin toxicity is more likely to cause dehydration due to increased respiratory rate and metabolic acidosis.

Choice D rationale:

Jaundice, the yellowing of the skin and eyes, is not a characteristic symptom of acute acetylsalicylic acid poisoning. Jaundice typically occurs in conditions affecting the liver, such as hepatitis or liver failure.

Choice A rationale:

Rhinorrhea (runny nose) is a common symptom of respiratory syncytial virus (RSV) infection and is not a cause for immediate concern. It is often accompanied by other upper respiratory symptoms in infants and young children.

Choice B rationale:

Tachypnea (rapid breathing) is a concerning sign in infants with RSV infection. Rapid breathing can indicate respiratory distress and difficulty in oxygen exchange, which is common in severe RSV cases. Infants with RSV may exhibit rapid, shallow breathing, flaring nostrils, and chest retractions as they struggle to breathe.

Choice C rationale:

Pharyngitis (sore throat) can be a symptom of RSV infection but is not a critical finding that requires immediate reporting to the provider. Respiratory distress and signs of respiratory failure, such as tachypnea, are more urgent concerns.

Choice D rationale:

Coughing is a common symptom of RSV infection and may not necessarily warrant immediate reporting, especially if the cough is mild and not accompanied by severe respiratory distress. However, persistent coughing, especially if it leads to difficulty in breathing, should be assessed promptly.

Choice A rationale:

The statement in question does identify the variables being investigated. It mentions that the study aims to evaluate whether short-term, cultural immersion, clinical experiences could affect change in cultural sensitivity and cultural self-efficacy. Both cultural sensitivity and cultural self-efficacy are the variables of interest in this research.

Choice B rationale:

While the statement does mention the independent variable (short-term, cultural immersion, clinical experiences), it also includes the dependent variables (cultural sensitivity and cultural self-efficacy) So, the independent variable is indeed identified in the statement.

Choice C rationale:

The missing characteristic in the research statement is the population being studied. It does not specify who the participants or subjects of the study are. The population being studied is a crucial element in a research statement because it helps define the scope and applicability of the research findings.

Choice D rationale:

The statement does imply the possibility of empirical testing by stating that "a study was conducted," indicating that there was likely data collection and analysis involved. Therefore, the possibility of empirical testing is not missing from the statement.

Choice A rationale:

The sleeping pattern is mentioned, but it does not provide relevant information regarding the infant's condition. The fact that the infant is sleeping through the night does not address the concerns related to gastroesophageal reflux.

Choice B rationale:

Irritability is mentioned in the notes, but it is not a parameter that directly reflects the improvement or worsening of the infant's condition. While irritability can be a symptom of discomfort due to reflux, it's not a parameter to monitor progress over time.

Choice C rationale:

Monitoring the infant's weight is crucial in this scenario. Weight gain is a significant indicator of the infant's overall health and nutritional status. A decrease in weight gain could indicate feeding difficulties or other health issues. In this case, the weight has increased, suggesting improvement in the infant's condition.

Choice D rationale:

Regurgitation is one of the main symptoms of gastroesophageal reflux. Monitoring the frequency and severity of regurgitation is essential to assess the effectiveness of interventions, such as thickened feedings. The persistence of regurgitation in this case indicates that the condition has not completely resolved.

Choice E rationale:

Heart rate is not mentioned in the provided information, and it does not provide relevant information about the infant's condition in this context.

Choice F rationale:

Bottle feeding is mentioned, specifically the thickening of feedings. This information is crucial in assessing the effectiveness of interventions for gastroesophageal reflux. Thickened feedings are often recommended to reduce regurgitation, and the fact that the parents have been thickening the feedings suggests an attempt to manage the condition.

Choice A rationale:

The sleeping pattern is mentioned, but it does not provide relevant information regarding the infant's condition. The fact that the infant is sleeping through the night does not address the concerns related to gastroesophageal reflux.

Choice B rationale:

Irritability is mentioned in the initial notes, indicating the infant's discomfort. However, in the follow-up visit, there is no mention of irritability, suggesting an improvement in this symptom. Monitoring irritability is essential to assess the effectiveness of interventions for gastroesophageal reflux.

Choice C rationale:

Weight is mentioned in both the initial and follow-up notes. While monitoring weight is essential, there is no indication of weight loss or inadequate weight gain in the follow-up, suggesting that the infant's nutritional status is stable.

Choice D rationale:

Regurgitation is one of the main symptoms of gastroesophageal reflux. Monitoring the frequency and severity of regurgitation is essential to assess the effectiveness of interventions, such as thickened feedings. The persistence of regurgitation in this case indicates that the condition has not completely resolved.

Choice E rationale:

Heart rate is not mentioned in the provided information, and it does not provide relevant information about the infant's condition in this context.

Choice F rationale:

Bottle feeding is mentioned, specifically the thickening of feedings. This information is crucial in assessing the effectiveness of interventions for gastroesophageal reflux. Thickened feedings are often recommended to reduce regurgitation, and the fact that the parents have been thickening the feedings suggests an attempt to manage the condition.

Choice A rationale:

Rhinorrhea (runny nose) is a common symptom of respiratory syncytial virus (RSV) infection and is not a cause for immediate concern. It is often accompanied by other upper respiratory symptoms in infants and young children.

Choice B rationale:

Tachypnea (rapid breathing) is a concerning sign in infants with RSV infection. Rapid breathing can indicate respiratory distress and difficulty in oxygen exchange, which is common in severe RSV cases. Infants with RSV may exhibit rapid, shallow breathing, flaring nostrils, and chest retractions as they struggle to breathe.

Choice C rationale:

Pharyngitis (sore throat) can be a symptom of RSV infection but is not a critical finding that requires immediate reporting to the provider. Respiratory distress and signs of respiratory failure, such as tachypnea, are more urgent concerns.

Choice D rationale:

Coughing is a common symptom of RSV infection and may not necessarily warrant immediate reporting, especially if the cough is mild and not accompanied by severe respiratory distress. However, persistent coughing, especially if it leads to difficulty in breathing, should be assessed promptly. Please note that questions 73 and 74 could not be answered accurately due to the lack of specific options and context provided. If you can provide the options for these questions, I would be happy to assist you further.