The nurse is examining a 15-month-old child who was able to walk at the last visit and now can no longer walk. What will the nurse do?

Schedule a full neurological evaluation.

Recommend follow-up in 30 days after documenting the regression.

Question the parents about changes in the child's activity schedule.

Document the findings and schedule an 18-month well-visit.

Answer and Explanation

The Correct Answer is A

Choice A reason: Scheduling a full neurological evaluation is the appropriate action in this scenario. The sudden regression in the child's ability to walk is a significant concern that requires immediate investigation to rule out any underlying neurological or medical conditions. A full neurological evaluation will help identify any issues such as developmental delays, neuromuscular disorders, or other conditions that may be affecting the child's motor skills. Prompt evaluation and diagnosis are crucial for early intervention and appropriate management.

Choice B reason: Recommending follow-up in 30 days after documenting the regression is not an ideal approach in this situation. Given the severity of the regression in the child's walking ability, waiting for 30 days without further investigation could delay critical diagnosis and treatment. Immediate assessment is necessary to address potential underlying issues and provide timely intervention.

Choice C reason: Questioning the parents about changes in the child's activity schedule is important but should not be the sole action taken. While gathering information about the child's activities and environment can provide valuable context, it does not replace the need for a thorough medical evaluation. The primary concern here is the sudden regression in motor skills, which warrants a full neurological assessment.

Choice D reason: Documenting the findings and scheduling an 18-month well-visit is also not sufficient. While it is essential to document the observed regression, delaying further action until the next routine check-up could result in missed opportunities for early diagnosis and intervention. The priority should be to conduct a neurological evaluation to understand the cause of the regression and take appropriate steps to address it.

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Correct Answer is B

Explanation

Choice A reason: Bronchodilators are medications that help open the airways in the lungs, making it easier to breathe. They are often used for managing respiratory symptoms in cystic fibrosis, but they are not typically required specifically before meals.

Choice B reason: Digestive enzymes are essential for children with cystic fibrosis to take before meals. These enzymes help the body digest and absorb nutrients from food, which is crucial because cystic fibrosis can impair the pancreas's ability to produce these enzymes naturally.

Choice C reason: Mucolytics are medications that help thin and loosen mucus in the lungs, making it easier to cough up and clear from the airways. While important for managing respiratory symptoms, they are not specifically needed before meals.

Choice D reason: Aerosolized antibiotics are used to treat or prevent lung infections in individuals with cystic fibrosis. They are administered via inhalation and are not tied to meal times but rather prescribed as part of a daily treatment regimen.

A. Encourage the patient to ambulate intermittently and change positions. B. Place the patient in the left lateral position and increase the oxytocin rate. C. Administer oxygen 10 litters per minute via a non-rebreather mask. D. Teach the patient to push when she feels the urge during contractions.

Correct Answer is A

Explanation

Choice A reason: Encouraging the patient to ambulate intermittently and change positions can help alleviate early decelerations by improving uteroplacental blood flow and promoting fatal oxygenation. Movement and position changes can reduce compression on the umbilical cord and facilitate Labor progression.

Choice B reason: Placing the patient in the left lateral position can improve uteroplacental blood flow, but increasing the oxytocin rate is not indicated based on the current findings. Early decelerations are typically not a sign of Labor dystocia requiring oxytocin augmentation.

Choice C reason: Administering oxygen via a non-rebreather mask is generally reserved for situations where there is significant fatal distress or non-reassuring fatal heart rate patterns. Early decelerations are usually benign and do not necessitate supplemental oxygen.

Choice D reason: Teaching the patient to push when she feels the urge during contractions is appropriate during the second stage of Labor. However, the current findings with early decelerations do not indicate the need for this intervention at this time. The focus should be on monitoring and managing the fatal heart rate.

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The nurse is examining a 15-month-old child who was able to walk at the last visit and now can no longer walk. What will the nurse do?

Nursing Test Bank

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Correct Answer is B

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Correct Answer is A

Explanation

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