While administering ear drops to a toddler, a nurse by pulls the auricle down and back. The mother asks, "Why are you pulling the ear that way?" Which of the following responses should the nurse make?

"When I use this technique the medication will not run out of the ear."

“This opens the ear canal, allowing medication to reach the inner ear region.”

“This is the safest and easiest way to administer this medication.”

“When I use the technique, your child experiences less pain.”

Answer and Explanation

The Correct Answer is B

A. "When I use this technique the medication will not run out of the ear."

This explanation is not entirely accurate. While pulling the auricle down and back may help prevent ear drops from immediately dripping out of the ear, the primary purpose of this technique is to straighten the ear canal, facilitating the passage of the medication into the inner ear region for optimal effectiveness. The prevention of medication runoff is a secondary benefit.

B. “This opens the ear canal, allowing medication to reach the inner ear region.”

This explanation is correct. Pulling the auricle down and back helps to straighten the ear canal, making it easier for the ear drops to enter the ear canal and reach the inner ear where they can effectively treat the condition. This is the main purpose of using this technique.

C. “This is the safest and easiest way to administer this medication.”

While pulling the auricle down and back is a commonly used technique for administering ear drops, describing it as the safest and easiest way may not fully capture its purpose. Safety and ease of administration are important considerations, but the primary rationale for this technique is to facilitate the delivery of medication to the inner ear.

D. “When I use the technique, your child experiences less pain.”

This explanation is inaccurate. Pulling the auricle down and back may not directly reduce pain. The main purpose of this technique is to ensure that the medication reaches the inner ear region for effective treatment. While discomfort during administration may be minimized with proper technique, the primary focus is on medication delivery rather than pain reduction.

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Correct Answer is A

Explanation

A. "Has your son had a sore throat recently?"

This question is relevant because acute rheumatic fever often occurs as a complication of untreated or inadequately treated streptococcal throat infection (strep throat). A recent history of sore throat could indicate a preceding streptococcal infection, which is an important predisposing factor for the development of acute rheumatic fever.

B. "Was your son born with this cardiac defect?"

This question is less relevant in the context of acute rheumatic fever. Acute rheumatic fever is not a congenital heart defect; it is an inflammatory condition that affects the heart valves following streptococcal infection. While it's important to assess the child's cardiac health, asking about congenital heart defects may not directly relate to the current condition.

C. "Are you aware that your son will have to be in isolation?"

This question is not applicable to acute rheumatic fever. Acute rheumatic fever is not a contagious condition that requires isolation. It is an autoimmune response triggered by streptococcal infection and does not pose a risk of transmission to others.

D. "Has your child had any injuries recently?"

Inquiring about recent injuries is not directly related to acute rheumatic fever. Acute rheumatic fever is an inflammatory condition primarily triggered by streptococcal infection and is not caused by physical injuries.

A. Restrain the toddler for 1 hr after the procedure. B. Swaddle the toddler in a warm blanket. C. Ask another nurse to assist with holding the toddler in a prone position. D. Place the toddler in a side-lying knee-chest position

Correct Answer is D

Explanation

A. Restrain the toddler for 1 hr after the procedure:

This choice involves restraining the toddler for a period of time after the lumbar puncture procedure. However, restraining a toddler for such a prolonged period is not typically necessary and may cause distress and discomfort to the child. Moreover, prolonged restraint is not recommended as it can hinder the child's mobility and may lead to emotional distress.

B. Swaddle the toddler in a warm blanket:

Swaddling a toddler in a warm blanket may provide comfort, but it is not directly relevant to the lumbar puncture procedure itself. While comfort measures are important for overall patient care, they should not replace or interfere with the specific positioning requirements for medical procedures like a lumbar puncture.

C. Ask another nurse to assist with holding the toddler in a prone position:

This choice involves having another nurse assist in holding the toddler in a prone (face-down) position during the lumbar puncture procedure. However, the prone position is not typically used for lumbar punctures in toddlers. Placing the toddler in a prone position might make the procedure more challenging and less safe for both the child and the healthcare provider.

D. Place the toddler in a side-lying knee-chest position:

Placing the toddler in a side-lying knee-chest position is the correct action for a lumbar puncture procedure in a toddler. This position maximizes the space between the vertebrae, making it easier for the healthcare provider to access the lumbar area safely and accurately. It also helps minimize the risk of injury and discomfort for the toddler during the procedure. Therefore, this choice is the most appropriate for ensuring the success and safety of the lumbar puncture procedure.

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While administering ear drops to a toddler, a nurse by pulls the auricle down and back. The mother asks, "Why are you pulling the ear that way?" Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the admission of a 9-year-old child who has acute rheumatic fever. When obtaining the client's history, it is appropriate for the nurse to ask the parent which of the following questions?

Correct Answer is A

Explanation

A nurse is caring for a toddler who is scheduled to have a lumbar puncture. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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