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The parents of a 14-month-old child, hospitalized due to febrile seizures, express their concern to the nurse about their child having seizures for life. What information should the nurse share with these parents?
- A. Avoid overstimulation as it can trigger seizure activity.
- B. Assure the parents that the frequency of febrile seizures decreases as the child ages.
- C. Suggest giving the child a sponge bath when the temperature exceeds 100.6°F (38.1°C).
- D. Advise the prophylactic use of Ibuprofen to prevent febrile seizures.
Correct Answer: B
Rationale: Febrile seizures typically decrease with age, often resolving by age 5.
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A newborn, who has had gastroschisis repair, is transferred to the pediatric unit after spending several days in the pediatric intensive care unit. The infant is on parenteral nutrition and continuous enteral feedings. What action should the nurse include in the plan of care to promote the infant's normal growth and development?
- A. Discuss with the healthcare provider about starting physical therapy
- B. Offer a pacifier for non-nutritive sucking
- C. Confirm placement of the enteral tube with an abdominal x-ray
- D. Use sterile technique during feedings .
Correct Answer: B
Rationale: Non-nutritive sucking via a pacifier stimulates the sucking reflex and supports feeding development, promoting normal growth.
A male adolescent comes to the clinic reporting severe testicular pain that started during a high school football practice. The nurse notes significant redness and swelling of the scrotum. What should the nurse do next?
- A. Provide the adolescent with a urinal for urinary hesitancy
- B. Immediately report the findings to the healthcare provider
- C. Collect a sterile urine sample for culture and sensitivity
- D. Obtain a swab of secretions from the penis and urethra
Correct Answer: B
Rationale: Severe testicular pain with redness and swelling suggests testicular torsion, a medical emergency requiring immediate reporting to the healthcare provider.
The nurse is evaluating a child with acute glomerulonephritis who presents at the clinic with increased fatigue, facial swelling, and decreased appetite. The child's urine sample is dark yellow. What additional finding should the nurse report to the healthcare provider?
- A. Blood pressure 88/50 mmHg
- B. Weight loss
- C. Maculopapular rash over the trunk of the body
- D. Positive rapid strep test of the oropharynx
Correct Answer: D
Rationale: A positive strep test indicates a recent infection, a common cause of glomerulonephritis, requiring reporting.
The nurse is getting ready to give medications to an eight-month-old infant diagnosed with heart failure. The infant's vital signs are as follows: blood pressure 114/66 mm Hg, apical pulse 88 beats/minute, and respirations 30 breaths/minute. Which medication should the nurse hold and inform the health care provider?
- A. Enalapril
- B. Digoxin
- C. Furosemide
- D. Hydralazine
Correct Answer: B
Rationale: The infant's apical pulse of 88 beats/minute is below the normal range (100-160 beats/minute) for an eight-month-old, indicating a need to hold Digoxin and notify the provider.
While checking the vital signs of a 10-year-old child who underwent a tonsillectomy earlier in the day, the nurse notices the child swallowing every 2 to 3 minutes. What action should the nurse take next?
- A. Check for signs of teeth clenching or grinding
- B. Inspect the back of the throat
- C. Stimulate the gag reflex by touching the tonsillar pillars
- D. Ask the child to speak to assess for any changes in voice tone .
Correct Answer: B
Rationale: Frequent swallowing may indicate post-tonsillectomy bleeding, requiring throat inspection.