A nurse is preparing to administer required immunizations to a toddler during a well-child visit. The parent asks the nurse how many baby aspirins he should administer if the toddler develops a fever.
Which of the following responses should the nurse make?
"You should follow the label directions based on your child's weight."
"You should avoid administering aspirin to your child."
"Your child will require an antibiotic if she develops a fever."
"Your child can have two baby aspirins every 4 hours."
The Correct Answer is B
Explanation:
The nurse should respond by recommending that the parent avoids administering aspirin to the child. The use of aspirin in children, especially those under the age of 18, is associated with the risk of developing Reye's syndrome, a rare but serious condition that affects the liver and brain. It is important to educate parents about the potential risks of using aspirin in children, particularly when they have a fever. Instead, the nurse should advise the parent to use appropriate dosages of acetaminophen or ibuprofen based on the child's weight and follow the label directions for administration.
Option a suggests following the label directions based on the child's weight, which may not specifically address the use of aspirin in children and the risk of Reye's syndrome. Option c, stating that the child will require an antibiotic if she develops a fever, is incorrect because antibiotics are not indicated for all fevers and should only be prescribed if there is an underlying bacterial infection. Option d, suggesting that the child can have two baby aspirins every 4 hours, is incorrect and contradicts the recommendation to avoid administering aspirin to the child.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Keeping a baby rear-facing in the car seat until they reach the age of 2 years old or until they reach the maximum height and weight limits recommended by the car seat manufacturer is a crucial safety guideline. Rear-facing car seats provide better support for a baby's head, neck, and spine in the event of a crash, reducing the risk of severe injuries.
"I should place my baby in the car seat at a 90-degree angle." The correct positioning for a rear-facing car seat is typically between a 30 to 45-degree angle. This angle helps ensure the baby's airway remains open and prevents their head from flopping forward.
"I should position the car seat's retainer clip at the level of my baby's belly button." The retainer clip of the car seat should be positioned at armpit level, not at the level of the baby's belly button. The retainer clip is designed to secure the harness straps and should be placed across the chest, resting on the bony part of the shoulders.
"I should enable the airbag when my baby is in the front seat of the car." It is not safe to have a rear-facing car seat with a baby in the front seat of a vehicle with an active airbag. Airbags can pose a significant risk to infants due to the force with which they deploy. It is recommended to place a rear-facing car seat in the back seat of the vehicle and disable the airbag in the front passenger seat if the baby needs to ride in the front.
It is important for parents to receive proper education on car seat safety and follow the guidelines set forth by car seat manufacturers, national recommendations, and local laws and regulations.
Correct Answer is B
Explanation
Answer: B. Stiff posture
Rationale:
A. Lip-smacking : Lip-smacking is not typically an indication of pain in newborns. It may be associated with hunger or neurological responses, but it does not directly indicate discomfort or pain caused by shoulder dystocia or other injuries.
B. Stiff posture : A stiff posture can indicate pain in newborns, as they often exhibit hypertonicity or rigidity when experiencing discomfort. This response is a protective mechanism and may suggest the newborn is reacting to pain from potential nerve or tissue damage caused by shoulder dystocia.
C. Weak cry : While a weak cry may indicate neurological or respiratory distress, it is not a specific sign of pain. In the context of shoulder dystocia, a weak cry could reflect complications such as brachial plexus injury but does not directly signify the presence of pain.
D. Tongue-darting : Tongue-darting is more commonly associated with neurological issues or feeding difficulties rather than pain. It is not a typical behavioral response to discomfort or injury in newborns experiencing complications like shoulder dystocia.
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