A nurse in a pediatric clinic is assessing a toddler at a well-child checkup. After reviewing the child's current medical record, which of the following interventions should the nurse expect the provider to prescribe? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Antibiotic therapy

Protective environment

Blood transfusion

Iron supplementation

Answer and Explanation

The Correct Answer is D

A. Antibiotic therapy. This is incorrect because there is no indication of an infection. The WBC count is within the normal range, and there are no symptoms suggestive of a bacterial infection.
B. Protective environment. This is incorrect because a protective environment is used for immunocompromised clients, such as those undergoing chemotherapy or with severe neutropenia, which is not the case here.
C. Blood transfusion. This is incorrect because although the hemoglobin level is low (8.1 g/dL), it is not critically low enough to require a transfusion. Instead, iron supplementation is the preferred treatment.
D. Iron supplementation. This is correct because the child’s hemoglobin and hematocrit levels indicate mild anemia, likely due to excessive cow’s milk intake, which can lead to iron deficiency anemia in toddlers. Iron supplementation will help correct the deficiency.

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Correct Answer is ["B","D"]

Explanation

A. Blood pressure: The client’s BP is 128/84 mm Hg, which is within the normal range. Although the client has chronic hypertension, this BP reading does not indicate an immediate concern.

B. Fetal heart rate: The fetal heart rate (FHR) is 165/min, which is tachycardia (normal FHR range is 110–160/min). Fetal tachycardia can indicate infection, maternal fever, fetal distress, or hypoxia and requires immediate follow-up.

C. Fetal station: The station is 0, which means the presenting part is at the level of the ischial spines. This is normal for a laboring client at 4 cm dilation and does not require immediate intervention.

D. Characteristics of amniotic fluid: The fluid is green, indicating the presence of meconium-stained amniotic fluid, which suggests fetal distress or hypoxia. This requires immediate follow-up, as the baby is at risk for meconium aspiration syndrome.

E. Duration of contraction: The contraction lasted 40 seconds, which is within the normal range (30–90 seconds). This is not an immediate concern.

A. Apply restraints if the client is agitated. B. Ambulate the client. C. Position the client on their side. D. Raise all of the side rails on the client's bed.

Correct Answer is C

Explanation

A. Apply restraints if the client is agitated. Restraints are not necessary and may increase distress. Post-seizure agitation should be managed with reassurance and monitoring.
B. Ambulate the client. This is unsafe because the client may be disoriented or weak, increasing the risk of falls. Rest and recovery should be prioritized.
C. Position the client on their side. This helps maintain an open airway, prevents aspiration, and facilitates secretion drainage, making it the priority intervention.
D. Raise all of the side rails on the client's bed. Raising all four side rails is considered a restraint. A safer environment should be maintained without unnecessary restriction.

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Naxlex Comprehensive Predictor Exams

A nurse in an antepartum unit is caring for a client. Exhibits Select the 2 findings that require immediate follow-up.

Correct Answer is ["B","D"]

Explanation

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Correct Answer is C

Explanation

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