A nurse is planning care for a preschooler who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan?

Hold the child during assessments.

Maintain extended eye contact.

Engage in cooperative play.

Establish a reward system.

Answer and Explanation

The Correct Answer is D

A. Holding the child may increase distress in a child with autism. It's better to respect the child’s need for personal space.

B. Maintaining extended eye contact can be overwhelming for children with autism and may increase anxiety.

C. Cooperative play is typically difficult for preschoolers with autism due to social communication challenges, so individualized approaches are preferred.

D. Establishing a reward system can be effective in reinforcing positive behavior and encouraging cooperation in a preschooler with autism spectrum disorder.

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Correct Answer is C

Explanation

A. An apical pulse of 100/min is within the normal range for a toddler. Digoxin should be administered cautiously if the heart rate is too low (below 90-100/min for young children), but 100/min is not a concern.

B. A potassium level of 4.0 mEq/L is within the normal range for toddlers (3.4-4.7 mEq/L), so there is no indication to revise the plan of care.

C. Vomiting is a sign of digoxin toxicity, and it requires immediate attention. The nurse should reassess the digoxin dose and check for other signs of toxicity, such as nausea, bradycardia, and arrhythmias.

D. A digoxin level of 1.2 ng/mL is within the therapeutic range for a toddler (0.8-2 ng/mL), so there is no need to revise the plan of care based on this finding.

A. Positive Babinski reflex B. Presence of tears when crying C. Doll's eye reflex intact D. No head lag when pulled to a sitting position

Correct Answer is D

Explanation

A. The Babinski reflex is normal in infants up to 12-18 months and does not require intervention.

B. The presence of tears when crying is a normal finding and does not indicate a concern.

C. The Doll's eye reflex (in which the eyes remain fixed when the head is turned) is normal in infants and does not require intervention.

D. At 4 months of age, infants should still have head lag when pulled to a sitting position. If there is no head lag, this may indicate a neurological issue or developmental delay.

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A nurse is planning care for a preschooler who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a group of toddlers receiving digoxin therapy. For which of the following toddlers should the nurse revise the plan of care?

Correct Answer is C

Explanation

A nurse is assessing a 4-month-old infant during a well-baby visit. For which of the following findings should the nurse notify the provider?

Correct Answer is D

Explanation

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