A nurse is contributing to the plan of care of a 14-month-old toddler who is 24 h following interventions should the nurse include in the plan?
Give the toddler a hard-tipped sippy cup to drink liquid
Suction the toddler nose and mouth every hour
Maintain elbow restraint
Provide soft foods for the toddler
The Correct Answer is D
A. Give the toddler a hard-tipped sippy cup to drink liquid:
Giving a toddler a hard-tipped sippy cup with a hard spout can increase the risk of injury, especially if the toddler falls while using it. Toddlers at this age are still developing coordination and may not have the motor skills to handle a hard-tipped cup safely. Therefore, this choice would not be appropriate and could potentially harm the toddler.
B. Suction the toddler nose and mouth every hour:
Frequent suctioning of the nose and mouth every hour can cause irritation and discomfort to the toddler. While suctioning may be necessary in certain medical situations, such as clearing mucus or secretions, it should not be done routinely every hour without a specific medical indication. Overuse of suctioning can damage the delicate tissues in the nose and mouth and disrupt the normal mucous membranes.
C. Maintain elbow restraint:
Maintaining elbow restraint is not a standard intervention for a toddler who is 24 hours post-intervention unless there is a specific medical reason for it, such as preventing the toddler from accessing an IV site or medical device. Restraining a toddler's elbows without a clear medical indication can be distressing for the child and may impede their ability to move and explore their environment, which is important for their development.
D. Provide soft foods for the toddler:
Providing soft foods for the toddler is the most appropriate intervention in this scenario. Soft foods are easier for toddlers to chew and swallow, reducing the risk of choking or discomfort, especially if the toddler has undergone certain interventions that may affect their ability to eat solid foods comfortably. Soft foods can include mashed fruits and vegetables, cooked grains, pureed meats, and other easily digestible options suitable for a toddler's age and developmental stage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Apical:
The apical pulse is the most reliable location to assess the pulse in infants. It is located at the apex of the heart, which is typically found at the fifth intercostal space at the midclavicular line. Assessing the apical pulse allows for a direct measure of the heart rate and rhythm, which is especially important in infants to evaluate cardiac function accurately. The apical pulse is commonly assessed using a stethoscope placed at the point of maximum impulse (PMI) on the chest.
B. Dorsalis pedis:
The dorsalis pedis pulse is located on the top of the foot, typically in the region between the first and second metatarsal bones. While the dorsalis pedis pulse can be palpated in older children and adults, it may be difficult to palpate accurately in infants, especially those with smaller or more delicate feet. Therefore, it is not the preferred site for pulse assessment in infants.
C. Temporal:
The temporal pulse is located on the side of the head, just above the ear. While the temporal pulse can be palpated in some individuals, it is not typically used to assess the pulse in infants. Palpating the temporal pulse in infants may be more challenging and less reliable compared to other pulse sites, especially given the smaller size of the temporal artery in infants.
D. Carotid:
The carotid pulse is located in the neck, alongside the trachea, and can be palpated by gently pressing the fingers against the carotid artery. While the carotid pulse is easily palpable in adults and older children, it is not typically the preferred site for pulse assessment in infants. Palpating the carotid pulse in infants carries a risk of injury to the delicate structures in the neck and may not provide an accurate representation of the pulse rate.
Correct Answer is D
Explanation
A. Flaccid paralysis of lower extremities:
Flaccid paralysis refers to a weakness or loss of muscle tone in the affected muscles, leading to decreased or absent movement. This finding is not typically associated with spina bifida occulta. Instead, it is more commonly seen in more severe forms of spina bifida, such as myelomeningocele, where there is significant involvement of the spinal cord and nerves.
B. Hip dislocation:
Hip dislocation can occur in individuals with myelomeningocele due to muscle weakness, abnormal muscle tone, and joint deformities associated with spinal cord defects. However, it is not typically associated with spina bifida occulta, which usually presents with less severe spinal cord involvement.
C. Hydrocephalus:
Hydrocephalus, characterized by the accumulation of cerebrospinal fluid within the brain, is a common complication of myelomeningocele due to disturbances in the flow and absorption of cerebrospinal fluid caused by the spinal defect. It is less commonly associated with spina bifida occulta, which typically involves a less severe spinal cord defect.
D. Dimple in sacral area:
This is the correct choice. A dimple, patch of hair, or birthmark in the lower back or sacral area is a common finding in spina bifida occulta. It occurs due to the incomplete closure of the spinal column during fetal development, leading to a small defect in the vertebrae. This is often a subtle manifestation of spina bifida occulta and may not cause significant symptoms or functional impairment.
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