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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Assuming fear of pregnancy may misinterpret the 12-year-old’s concerns, potentially shutting down dialogue. Asking about worries invites her to share specific fears, making this presumptive and incorrect compared to the nurse’s role in exploring the child’s feelings about menstruation openly.
Choice B reason: Suggesting fear of pain narrows the conversation, missing other possible concerns like embarrassment or myths. Asking about worries allows broader exploration, making this limiting and incorrect compared to the nurse’s approach to understanding the girl’s specific fears about getting her period.
Choice C reason: Dismissing the child’s fear by calling periods “good” may invalidate her feelings, discouraging openness. Asking about worries validates concerns, making this dismissive and incorrect compared to the nurse’s role in fostering a supportive dialogue about menstruation with the 12-year-old.
Choice D reason: Asking what the child has heard about periods encourages her to express specific worries, facilitating education and reassurance. This aligns with pediatric nursing communication principles, making it the most appropriate response to address the 12-year-old’s concerns about menarche during the check.
Correct Answer is D
Explanation
Choice A reason: Asking about family size is irrelevant, as growth norms are based on population standards, not family stature. The toddler’s 6-pound gain and 2.5-inch growth are normal for a 2-year-old, making this unhelpful and incorrect compared to reassuring based on standard growth parameters for toddlers.
Choice B reason: The child’s growth (6 pounds, 2.5 inches) is within normal limits for a 2-year-old, so stating it is less than expected is inaccurate. Gathering nutritional history is unnecessary without growth concerns, making this incorrect compared to reassuring the mother about normal development in her child.
Choice C reason: Requiring a follow-up in 3 months is unnecessary, as the toddler’s growth is normal (6 pounds, 2.5 inches in a year). Reassuring the mother addresses her concerns directly, avoiding unwarranted visits, making this incorrect for responding to a toddler with standard growth patterns.
Choice D reason: A 6-pound (2.7 kg) weight gain and 2.5-inch (6.4 cm) height increase are within normal limits for a 2-year-old, per pediatric growth charts. Reassuring the mother alleviates anxiety and aligns with evidence-based growth standards, making this the correct response to her concerns about growth.
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