A nurse is planning care for a child who has varicella.
Which of the following interventions should the nurse plan to include?
Initiate airborne precautions.
Assess the oral cavity for Koplik spots.
Provide the child with a warm blanket.
Administer aspirin for fever.
Administer aspirin for fever.
The Correct Answer is A
Varicella (chickenpox) is highly contagious and can be spread through the air by coughing or sneezing.
Airborne precautions help prevent the spread of the disease to others.
Choice B is wrong because Koplik spots are a symptom of measles, not varicella.
Choice C is wrong because providing a warm blanket is not a specific intervention for a child with varicella.
Choice D is wrong because aspirin should not be given to children with varicella due to the risk of Reye’s syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is d. Exhibits head lag when pulled to a sitting position.
Choice A: Unable to hold a bottle At around 6 months of age, some babies can hold their own bottle. This is not a concerning finding for a 5-month-old infant. Therefore, this is not the correct answer.
Choice B: Unable to roll from back to abdomen Rolling over often starts around 4-6 months, so it’s not unusual for a 5-month-old to still be developing this skill. Therefore, this is not the correct answer.
Choice C: Absent grasp reflex The grasp reflex is an involuntary movement that your baby starts making in utero and continues doing until around 6 months of age. The grasp reflex lasts until the baby is about 5 to 6 months old. Therefore, this is not the correct answer.
Choice D: Exhibits head lag when pulled to a sitting position By the age of 5 months, most infants have developed enough strength in their neck and upper body to control their head movement. This means they should not exhibit a significant head lag when pulled to a sitting position1. If this is not the case, it could indicate a delay in motor development or a potential neurological issue, which should be reported to the healthcare provider for further evaluation. Therefore, this is the correct answer.
Correct Answer is ["A","B","D"]
Explanation
A. Offer the infant a pacifier during feedings.
B. Check for residual volumes by aspirating stomach contents.
D. Instill the formula over a period of 30 to 45 min.
Offering the infant a pacifier during feedings can help promote non-nutritive sucking and provide comfort to the infant.
Checking for residual volumes by aspirating stomach contents can help monitor gastric emptying and tolerance to enteral feeding.
Instilling the formula over a period of 30 to 45 min can help prevent overfeeding and reduce the risk of aspiration.
Choice C is wrong because placing the infant in a supine position during feedings increases the risk of aspiration.
The infant should be placed in an upright or semi-upright position during feedings.
Choice E is wrong because heating the formula to 39° C (102° F) prior to administration is not necessary and may even be harmful if the formula is overheated.
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