The nurse is assisting in planning care for a child.
Which of the following interventions should the nurse plan to include?
Obtain daily weights.
Obtain blood pressure every 8 hours.
Maintain seizure precautions.
Maintain a sodium-restricted diet.
Maintain strict bed rest.
Correct Answer : A,C
Choice A rationale
Obtaining daily weights is vital for monitoring fluid status and nutritional health, especially in children prone to rapid physiological changes. It provides insight into trends such as dehydration, edema, or growth concerns.
Choice B rationale
Blood pressure every 8 hours is a less frequent monitoring intervention and may not be sufficient for detecting acute changes. Vital signs often require more regular assessment in pediatric care.
Choice C rationale
Maintaining seizure precautions ensures immediate response readiness for children with neurological risks or past seizure history. It involves safeguards like padded bed rails and accessible emergency equipment to mitigate injury risks during seizures.
Choice D rationale
Sodium-restricted diets are less commonly applied in pediatric cases unless specifically indicated for conditions like nephrotic syndrome or severe hypertension. Routine care does not involve universal dietary sodium modifications.
Choice E rationale
Strict bed rest may lead to deconditioning and is only suitable for specific diagnoses necessitating immobility. Pediatric care often promotes movement within safe limits to prevent complications like pressure injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Prolonged crying is commonly associated with the discomfort of the injection but does not indicate an acute allergic reaction. It generally subsides with comfort measures and is not a priority finding.
Choice B rationale
Redness at the injection site is a localized inflammatory response, expected after immunization, and it does not suggest a systemic reaction.
Choice C rationale
Hives on the neck may indicate an allergic reaction, potentially leading to anaphylaxis. This immune response warrants immediate intervention to prevent airway obstruction or systemic complications.
Choice D rationale
A temperature of 37.7°C (99.9°F) is a mild fever, a normal post-immunization reaction, reflecting the body's immune response to the vaccine rather than an urgent concern.
Correct Answer is C
Explanation
Choice A rationale
Adjustable crib rails pose a risk of mechanical failure and potential injury to infants. Current safety guidelines recommend fixed rails to eliminate entrapment hazards, ensuring the crib complies with modern safety standards.
Choice B rationale
Walkers with wheels are linked to a higher risk of falls and injuries in infants. These devices can inadvertently promote mobility before adequate muscle development, leading to instability and accidents. They are not recommended for injury prevention.
Choice C rationale
One-piece pacifiers with loop handles minimize choking risks by eliminating small parts that could detach. The loop handle ensures the pacifier can be easily retrieved, reducing the likelihood of airway obstruction in infants.
Choice D rationale
Placing a plastic covering underneath crib sheets increases the risk of suffocation and overheating. Safe sleep guidelines advocate for firm mattresses with fitted sheets only, avoiding any additional layers that compromise an infant's breathing environment. .
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