The nurse is teaching a group of first-time parents who are being discharged with their newborns. One parent asks the nurse what to do if the child has a temperature. After conducting teaching regarding how to care for a child with an elevated temperature, the caregivers make the following statements. Which statement would indicate a need for further teaching?
“A rectal temperature above 102.5 °F (39.1 °C) should be lowered.”
“I don’t plan to give my child medications, but the pediatrician might tell us to give our child acetaminophen every 4 to 6 hours if she has a fever.”
“If my child starts to shiver I will know that what I am doing is working and that her fever will soon come down.”
“Giving extra fluids is the way I have always heard to lower a temperature.”
The Correct Answer is C
Choice A reason: A rectal temperature above 102.5 °F (39.1 °C) warrants intervention to lower fever, aligning with pediatric guidelines. This statement reflects correct understanding of fever management, making it accurate and not indicative of a need for further teaching compared to the shivering misconception in infants.
Choice B reason: Considering acetaminophen per pediatrician guidance shows understanding of safe fever management, even if avoiding medications initially. This reflects appropriate knowledge of consulting professionals, making it correct and not requiring further teaching, unlike the incorrect shivering interpretation needing clarification for parents.
Choice C reason: Shivering during fever indicates the body raising its temperature set point, not fever reduction. This misconception suggests the fever is worsening, not improving, requiring further teaching to clarify fever physiology, aligning with pediatric nursing education, making it the correct choice for additional instruction.
Choice D reason: Giving extra fluids is a standard recommendation to prevent dehydration during fever, reflecting correct knowledge. This statement aligns with fever management guidelines, making it accurate and not needing further teaching, unlike the shivering statement, which misinterprets a critical fever response in children.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Rubbing the nose upward and backward, known as the "allergic salute," is a common response in allergic rhinitis to relieve nasal itching and congestion. This action temporarily opens air passages and alleviates discomfort, aligning with pediatric allergy evidence, making it the correct explanation for the child’s behavior observed in clinical settings.
Choice B reason: Drawing attention to the nose is not a typical response in allergic rhinitis. The "allergic salute" is a reflexive action to relieve itching and congestion, not a deliberate attempt to gain attention. This choice misinterprets the physiological basis of the behavior, making it incorrect for the child’s action in the context of allergic rhinitis symptoms.
Choice C reason: Nasal discharge may occur in allergic rhinitis, but rubbing upward and backward aims to relieve itching and open airways, not prevent discharge. This action is not primarily about controlling runny nose, making this choice less accurate compared to addressing the itching and congestion relief central to the child’s behavior.
Choice D reason: Preventing a sneeze is not the purpose of the "allergic salute." Rubbing the nose upward and backward relieves itching and congestion, common in allergic rhinitis. Sneezing is a separate reflex, and this action does not address it, making this incorrect for the child’s observed behavior in the context of allergy symptoms.
Correct Answer is C
Explanation
Choice A reason: Placing the probe on the chest is not a standard pulse oximetry site and gives inaccurate readings. Explaining the device’s purpose addresses the caregiver’s concern, making this ineffective and incorrect compared to educating about the sensor’s role in monitoring the infant’s oxygen levels.
Choice B reason: Pulse oximetry measures oxygen saturation, not respiratory retractions, which are observed visually. Clarifying its purpose reassures the caregiver, making this inaccurate and incorrect compared to explaining the device’s function to address concerns about the sensor’s use on the infant.
Choice C reason: Explaining that pulse oximetry measures oxygen saturation clarifies its importance, reassuring the caregiver about its necessity and addressing tightness concerns. This aligns with pediatric nursing education principles, making it the prioritized response to ensure compliance with monitoring the infant’s respiratory status.
Choice D reason: Checking the probe site every 8 hours prevents skin issues but doesn’t address the caregiver’s concern about tightness. Explaining the device’s purpose promotes understanding, making this secondary and incorrect compared to educating to maintain the sensor’s use on the infant.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
