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A nurse is reviewing a hospital's protocol for managing pediatric ingestions. Which step should be prioritized in the protocol?
- A. Administer an antidote immediately.
- B. Obtain a detailed history of the ingestion.
- C. Perform a physical examination.
- D. Order laboratory tests.
Correct Answer: B
Rationale: A detailed history (substance, amount, time) guides management decisions. Antidotes, exams, or labs follow based on history findings.
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The nurse is assessing the infant shown in the figure. On observing the client from this angle, the nurse should document that this infant has which of the following?
- A. Ortolani’s “click.”
- B. Limited abduction.
- C. Galeazzi’s sign.
- D. Asymmetric gluteal folds.
Correct Answer: D
Rationale: This infant with congenital hip dysplasia has asymmetric gluteal folds. The Ortolani “click” occurs when the nurse feels the femur sliding into the acetabulum with a “click.” Limited abduction may be observed during an attempt to abduct the infant’s thighs. Galeazzi’s sign reveals femoral foreshortening and is observed by fl exing the thighs.
Nonsteroidal anti-inflammatory drugs are the first choice in treating a child with juvenile idiopathic arthritis. Which adverse effects should the nurse include in the teaching plan for the parents? Select all that apply.
- A. Weight gain.
- B. Abdominal pain.
- C. Blood in the stool.
- D. Folic acid deficiency.
- E. Reduced blood clotting ability.
Correct Answer: B,C,E
Rationale: NSAIDs can cause gastrointestinal issues like abdominal pain and blood in the stool, and they may reduce blood clotting ability due to their effect on platelet function.
Which of the following should the nurse assess in a newborn diagnosed with an anorectal malformation? Select all that apply.
- A. Abdominal distension.
- B. Loose stools.
- C. Vomiting.
- D. Meconium in the urine.
- E. Meconium stools.
Correct Answer: A,C,D
Rationale: Anorectal malformations can cause abdominal distension, vomiting, and meconium in the urine due to obstruction or fistulas.
The nurse should instruct the family of a child with newly diagnosed hyperthyroidism to:
- A. Keep their home warmer than usual.
- B. Encourage twenty or outdoor activities.
- C. Promote interactions with one friend instead of groups.
- D. Limit bathing to prevent skin irritation.
Correct Answer: C
Rationale: Hyperthyroidism causes irritability and hyperactivity, so limiting social interactions to one friend reduces overstimulation. Warmer homes, excessive activity, and limited bathing are inappropriate.
An infant is to be discharged after surgery for intussusception. In developing the discharge teaching plan, the nurse should tell the mother?
- A. The infant will experience a change in the normal home routine.
- B. The infant can return to the prehospital routine immediately.
- C. The infant needs to ingest more calories at home than normal.
- D. The infant will continue to experience abdominal cramping for a few days.
Correct Answer: B
Rationale: After successful surgery, the infant can typically resume normal routines unless complications arise.