Choice A reason: A 24-gauge catheter is appropriate for a small and fragile vein of a 12-month-old infant. It minimizes the risk of damaging the vein and ensures the comfort of the infant during IV therapy.

Choice B reason: Starting an IV in the infant's foot is not the first choice due to the risk of movement dislodging the catheter. The hand or the antecubital fossa are preferred sites for IV insertion in infants.

Choice C reason: While it is important to cover the IV insertion site, an opaque dressing is not necessary. A transparent dressing is preferred as it allows for continuous visibility of the site for signs of infection or phlebitis.

Choice D reason: The IV site should not be routinely changed every 3 days. It should be changed based on clinical indications such as signs of infection, infiltration, or phlebitis, or if the IV becomes dislodged.

Choice A reason: This statement is developmentally appropriate and helps to alleviate the child's anxiety about pain during the procedure. It uses language that a 4-year-old can understand without causing unnecessary fear.

Choice B reason: While it is comforting to know a parent will be close by, this statement is not accurate as parents are typically not present in the operating room during the procedure. It could lead to confusion and distress when the parent is not there.

Choice C reason: This statement is too vague and may not be fully understood by a child. It lacks the reassurance that the child will not feel pain, which is an important aspect to address.

Choice D reason: Although this statement is positive and forward-looking, it does not address the child's immediate concerns about the procedure itself. It is important to reassure the child about what to expect during the surgery.

Choice A reason: Asking the parent to leave the room during the injections is not recommended as the presence of a parent can provide comfort to the infant, which may help in reducing pain and anxiety.

Choice B reason: Administering the injections while the infant is breastfeeding is an effective method to decrease pain. Breastfeeding provides comfort and distraction, and the natural sugars in breast milk can have a mild analgesic effect.

Choice C reason: Applying a warm pack to the injection site prior to administration is not a standard practice for reducing pain from immunizations. Instead, using a cold compress after the injection can help to reduce swelling and discomfort.

Choice D reason: Administering injections in the deltoid muscle is not appropriate for a 2-month-old infant due to the underdeveloped muscle mass. The anterolateral thigh is the recommended site for immunizations in infants.

Choice A reason: Loosening tight clothing around the child's neck is important to ensure that the child can breathe easily and to prevent any additional discomfort or injury during the seizure.

Choice B reason: It is not recommended to firmly hold the child's arms to one side as this can cause injury. Instead, the nurse should ensure the child's safety by clearing the area of any hard or sharp objects.

Choice C reason: Placing a pillow under the child's head can help to protect the head from injury during the seizure. It provides a soft cushion to prevent the child from hitting their head on hard surfaces.

Choice D reason: Inserting a tongue blade into the child's mouth is not advised as it can cause injury to the child's mouth or teeth, and there is a risk of the child biting down and breaking the blade.

Choice E reason: Clearing the area of hard objects is crucial to prevent injury to the child during the seizure. Removing any potential hazards ensures a safer environment for the child to move without harm.

Choice A reason: Constipation is not typically associated with nephrotic syndrome. It may be related to dietary factors, dehydration, or other gastrointestinal issues.

Choice B reason: Increased abdominal girth can be an indication of nephrotic syndrome due to the accumulation of fluid in the abdomen (ascites) as a result of low albumin levels in the blood, which is a characteristic of this condition.

Choice C reason: Irritability can be a non-specific symptom and may be caused by a variety of factors. It is not a direct indication of nephrotic syndrome.

Choice D reason: Increased urinary output is not characteristic of nephrotic syndrome. In fact, decreased urine output may be observed due to the loss of protein in the urine and subsequent fluid retention in the body.

Choice A reason: Recommending the use of a wheelchair can help prevent stress on the lower extremities, which is important for an adolescent with muscular dystrophy. This condition can lead to muscle weakness and using a wheelchair can aid in mobility and independence.

Choice B reason: Avoiding influenza and pneumococcal vaccines is not recommended. Vaccinations are important for preventing infections, especially in individuals with compromised health conditions like muscular dystrophy.

Choice C reason: Initiating a referral for chest physiotherapy every 4 hours can be beneficial for an adolescent with muscular dystrophy. This therapy can help clear mucus from the lungs and improve respiratory function, which is often compromised in this condition.

Choice D reason: Encouraging the adolescent to perform incentive spirometry is important to maintain lung capacity. Muscular dystrophy can affect the muscles used for breathing, and incentive spirometry can help strengthen these muscles and improve respiratory health.

Choice A reason: Producing tears when crying is not typically a sign of severe dehydration. In fact, the ability to produce tears may suggest that the infant is not severely dehydrated.

Choice B reason: A sunken anterior fontanel is a classic sign of severe dehydration in infants. The fontanel, which is the soft spot on the top of a baby's head, can appear sunken when there is significant fluid loss.

Choice C reason: While weight loss can be a sign of dehydration, a 5% weight loss alone does not necessarily indicate severe dehydration. Other clinical signs should also be considered.

Choice D reason: A capillary refill time of 3 seconds is at the upper limit of normal. Prolonged capillary refill time can be a sign of dehydration, but it is not as specific as a sunken anterior fontanel for severe dehydration.

Choice Areason: Decreased urine output is not directly related to ventriculoperitoneal shunt displacement. It may indicate other issues such as dehydration or kidney problems.

Choice Breason: Increased sleeping is not a specific indicator of shunt displacement. While it may be a concern if there are significant changes in the child's sleep patterns, it is not a definitive sign of this complication.Choice C reason: Hyperactive bowel sounds are not associated with shunt displacement. They may indicate gastrointestinal issues but are not relevant to the function of a ventriculoperitoneal shunt.

Choice D reason: An elevated temperature can be an indicator of shunt displacement, as it may suggest an infection or other complications related to the shunt. Parents should be aware of this sign and seek medical attention if it occurs.

Choice A reason: Introducing popcorn as a healthy snack at 12 months of age is not recommended due to the risk of choking. Popcorn is a choking hazard for young children and should be avoided until they are older.

Choice B reason: Providing 36 oz of milk per day to a toddler may be excessive and can lead to iron deficiency anemia due to the displacement of other iron-rich foods. The American Academy of Pediatrics recommends 16-24 oz of milk per day for toddlers.

Choice C reason: Offering 8 to 10 oz of juice per day to a preschooler exceeds the American Academy of Pediatrics' recommendation of limiting juice to 4-6 oz per day for children 1-6 years old to prevent dental caries and ensure they consume more whole fruits.

Choice D reason: Encouraging a 15-year-old to increase calcium intake is appropriate as adolescence is a critical period for bone development. Adequate calcium intake supports optimal bone growth and density, helping to prevent osteoporosis later in life.

Choice A reason: Treating everyone who came into close contact with the child is essential because scabies is highly contagious. The mites that cause scabies can easily spread to others through direct skin contact or by sharing personal items.

Choice B reason: Soaking combs and brushes in boiling water for 10 minutes is a good practice to kill any mites that may be present. However, it is not the primary method of treating scabies, which requires medication.

Choice C reason: Washing the child's hair with shampoo containing ketoconazole is not a standard treatment for scabies. Ketoconazole is an antifungal medication, and scabies is caused by mites, not fungi.

Choice D reason: Applying petroleum jelly to the affected areas is not an effective treatment for scabies. Scabies requires prescription medications, such as topical permethrin or oral ivermectin, to eliminate the mites.

Choice A reason: Slurred speech may indicate a stroke or other neurological complication, which is a medical emergency. Sickle cell anemia can lead to such complications, and immediate assessment is crucial.

Choice B reason: While a partial-thickness burn requires care, it is not as immediately life-threatening as potential neurological complications. The toddler should be assessed after more urgent cases.

Choice C reason: A pain level of 7 is significant, but pain management can be addressed after more critical needs are met. The adolescent's pain should be managed effectively once urgent cases are stabilized.

Choice D reason: Administering an IV bolus of nafcillin for osteomyelitis is important, but it does not take precedence over potential neurological issues. The toddler should receive the medication promptly after urgent assessments.

Choice A reason: A blood pressure reading of 150/90 mmHg is significantly high for a 7-year-old child and indicates hypertension, which can be a serious complication of acute glomerulonephritis. It is a priority to report this finding to the provider as it may require immediate intervention.

Choice B reason: A BUN level of 20 mg/dL is within the normal range for children and is not typically a cause for immediate concern. However, it should be monitored along with other kidney function tests.

Choice C reason: Urine protein of 12 mg/dL is a common finding in acute glomerulonephritis due to increased permeability of the glomerular membrane. It is important but not as urgent as the blood pressure finding.

Choice D reason: 2+ pedal edema is a sign of fluid retention, which is expected in acute glomerulonephritis. While it should be addressed, it is not as immediately concerning as severe hypertension.

Choice A reason: Using a 20-gauge needle for injections in a 3-month-old infant is not appropriate as it is too large. A smaller gauge needle should be used to minimize pain and tissue trauma.

Choice B reason: Providing a pacifier coated with an oral sucrose solution prior to the injections is an evidence-based practice to reduce pain in infants. The sweet taste of sucrose has a soothing effect and can help to distract the infant from the discomfort of the injection.

Choice C reason: Injecting immunizations into the deltoid muscle is not recommended for a 3-month-old infant as their muscle mass is not yet fully developed. The anterolateral thigh is the preferred site for intramuscular injections in infants.

Choice D reason: Applying eutectic mixture of local anesthetics (EMLA) cream immediately before the injections can help to numb the skin and reduce pain. However, it needs to be applied at least one hour before the procedure to be effective.

Choice A reason: A creatinine level of 1.4 mg/dL is higher than the normal range for a 4-year-old child and could indicate kidney impairment, which is a concern when administering gentamicin due to its potential nephrotoxic effects. The provider should be informed immediately to assess kidney function and adjust the medication if necessary.

Choice B reason: A BUN level of 5 mg/dL is within the normal range for children and does not typically warrant immediate concern. However, it should be monitored along with creatinine levels to assess kidney function.

Choice C reason: A creatinine level of 0.3 mg/dL is within the normal range for a 4-year-old child and does not indicate an immediate concern. It should be monitored for any changes, especially when on gentamicin.

Choice D reason: A WBC count of 15,000/mm³ is slightly elevated, which may be expected in a child with meningitis as it indicates an immune response to infection. However, it is not as critical as an abnormal creatinine level in the context of gentamicin therapy.

Choice A reason: For individuals who are lactose intolerant, it is important to find alternative sources of calcium. Non-dairy sources such as fortified plant-based milks, leafy greens, and calcium-fortified foods can provide the necessary calcium without causing discomfort.

Choice B reason: Flavored yogurt often contains added sugars and may still have lactose, which can cause symptoms in those who are lactose intolerant. It's better to choose lactose-free options or plant-based alternatives.

Choice C reason: Lactose intolerance means that the body cannot effectively digest lactose found in milk, regardless of whether it is plain or chocolate. Therefore, it is not advisable to consume any milk that contains lactose.

Choice D reason: Drinking milk on an empty stomach can actually worsen symptoms for someone who is lactose intolerant. It is better to avoid milk or choose lactose-free alternatives.

Choice A reason: Hypothermia is not a common finding associated with inhalation of gasoline. It typically occurs due to exposure to cold temperatures and is not related to chemical inhalation.

Choice B reason: Hyperactive reflexes are not typically associated with gasoline inhalation. They can be a sign of neurological disorders or a response to certain medications, but not commonly from inhalants.

Choice C reason: Mydriasis, which is the dilation of the pupils, can occur with inhalation of gasoline due to its effect on the nervous system. It is a sign that the nurse should be aware of during the assessment.

Choice D reason: Pinpoint pupils are more commonly associated with opioid overdose and not with inhalation of gasoline. The nurse should expect to see dilated pupils rather than constricted ones.

Choice A reason: A creatinine level of 1.4 mg/dL is higher than the normal range for a 4-year-old child and could indicate kidney impairment, which is a concern when administering gentamicin due to its potential nephrotoxic effects. The provider should be informed immediately to assess kidney function and adjust the medication if necessary.

Choice B reason: A BUN level of 6 mg/dL is within the normal range for children and does not typically warrant immediate concern. However, it should be monitored along with creatinine levels to assess kidney function.

Choice C reason: A creatinine level of 0.3 mg/dL is within the normal range for a 4-year-old child and does not indicate an immediate concern. It should be monitored for any changes, especially when on gentamicin.

Choice D reason: A BUN level of 12 mg/dL is slightly elevated but may not be immediately concerning. It should be evaluated in conjunction with other laboratory values and clinical findings.

Choice A reason: Soaking hairbrushes in boiling water is a good practice for decontamination, but it is not specific to the treatment of impetigo, which is a bacterial skin infection.

Choice B reason: Acyclovir is an antiviral medication and would not be effective against impetigo, which is caused by bacteria, typically Staphylococcus aureus or Streptococcus pyogenes.

Choice C reason: Sealing soft toys in a plastic bag for 14 days may help to prevent the spread of infection, but it is not a direct treatment for impetigo itself.

Choice D reason: Applying a bactericidal ointment, such as mupirocin, is a standard treatment for impetigo. It helps to eliminate the bacteria causing the infection and promotes healing of the skin lesions.

Choice A reason: Hyperpyrexia, or extremely high fever, is a common symptom of acetylsalicylic acid (aspirin) poisoning. The body's response to the toxic levels of aspirin can lead to an elevated temperature as part of a systemic inflammatory response.

Choice B reason: Jaundice is not a typical symptom of acute acetylsalicylic acid poisoning. It is more commonly associated with liver conditions that cause an increase in bilirubin levels.

Choice C reason: Neck vein distention is not a common finding in acetylsalicylic acid poisoning. It is often seen in conditions that cause increased pressure in the venous system, such as heart failure.

Choice D reason: Polyuria, or excessive urination, is not a direct symptom of acetylsalicylic acid poisoning. While changes in urination can occur due to renal involvement, hyperpyrexia is a more immediate concern.

Choice A reason: Clearing the area of hard objects is crucial to prevent injury during a seizure. It helps to ensure that the child does not hit or get hurt by any objects in the vicinity while experiencing convulsions.

Choice B reason: Minimizing movement of the limbs is not recommended as it can cause injury to the child. Instead, the child should be allowed to move freely without restraint to avoid causing harm to their joints or muscles.

Choice C reason: Inserting a tongue blade between the teeth is an outdated and dangerous practice. It can cause injury to the child's mouth or teeth and may lead to choking if the tongue blade breaks.

Choice D reason: Placing the child in a prone position is not advised as it can obstruct the airway. The child should be placed on their side in the recovery position to keep the airway clear and allow fluids to drain from the mouth.

Choice A reason: Rhinorrhea, or a runny nose, is a common symptom of RSV and, while it should be monitored, it is not typically an urgent concern that requires immediate reporting to a provider.

Choice B reason: Pharyngitis, or a sore throat, is another symptom that can be associated with RSV. Like rhinorrhea, it should be monitored but does not usually necessitate immediate reporting.

Choice C reason: Coughing is a typical symptom of RSV and is expected. It should be monitored for changes in character or severity but is not generally an urgent concern for immediate reporting.

Choice D reason: Tachypnea, or rapid breathing, is a sign of respiratory distress and is a critical finding in an infant with RSV. It indicates that the infant's ability to breathe effectively is compromised and requires immediate attention from a healthcare provider.

Choice A reason: Preparing to administer a potassium IV bolus is not typically indicated in sickle cell crisis unless there is a documented potassium deficiency. Potassium levels must be carefully monitored to avoid hyperkalemia.

Choice B reason: Providing hydration both orally and intravenously is crucial in managing sickle cell crisis. Hydration helps to reduce blood viscosity and improve circulation, which can alleviate the pain and prevent further sickling of red blood cells.

Choice C reason: Requesting a prescription for meperidine is not recommended for pain management in sickle cell crisis due to the risk of seizures and other side effects. Other pain medications, such as morphine, are preferred.

Choice D reason: Administering multiple units of platelets is not a standard treatment for sickle cell crisis. Platelet transfusion is typically reserved for patients with thrombocytopenia or active bleeding, not for sickle cell crisis.

Choice A reason: While exposure to secondhand smoke is unhealthy and should be avoided, it is not commonly listed as a trigger for seizures. The primary concern with secondhand smoke is its impact on respiratory health.

Choice Breason: A prolonged headache can be a symptom of various conditions, but it is not generally considered a direct trigger for seizures. However, if a headache is related to a neurological condition, it may be associated with an increased risk of seizures.

Choice Creason: Decreased temperature, or being cold, is not typically a trigger for seizures. Seizure triggers are usually related to changes in the body's internal environment or external stimuli that affect the nervous system.

Choice D reason: Inadequate sleep is a well-known trigger for seizures. Sleep deprivation can lead to increased seizure activity in individuals with seizure disorders. Ensuring adequate and regular sleep is an important part of managing seizure disorders.

Choice A reason: Providing frequent range of motion to the neck and shoulders is not recommended for an infant with bacterial meningitis, as it could cause discomfort or pain due to the inflammation of the meninges.

Choice B reason: Keeping the television on to provide background noise is not advisable, as infants with meningitis may be sensitive to noise, and it could potentially increase their discomfort or agitation.

Choice C reason: Padding the siderails of the crib is important to ensure the safety of the infant. It helps to prevent injury if the infant has seizures, which can be a complication of meningitis.

Choice D reason: Placing the infant in a semi-private room is not a specific intervention for the care of an infant with bacterial meningitis. It is more important to focus on interventions that address the infant's immediate health needs.

Choice A reason: Talking to a toddler about the meaning of death may not be appropriate or helpful, as they may not fully understand the concept. It's important to provide comfort rather than potentially causing confusion or distress.

Choice B reason: While encouraging friends to visit can provide social support, it may not always be feasible or in the best interest of the child's health, especially if the child is very ill or immunocompromised.

Choice C reason: Staying close to the child provides emotional support and comfort, which is crucial during this difficult time. Physical presence and affection can be very reassuring for both the child and the parents.

Choice D reason: Changing the child's schedule every day can be disruptive and may cause additional stress. Consistency and routine can provide a sense of security and stability for a child who is terminally ill.