= Answer is... Choice B. Offer a pacifier for non-nutritive sucking.

Choice A rationale:

In the context of a newborn with a repaired gastroschisis receiving parenteral nutrition and continuous enteral feedings, instituting physical therapy may not directly contribute to the maintenance of normal growth and development concerning nutrition. While physical therapy plays a vital role in promoting motor development and rehabilitation in infants with various medical conditions, its immediate relevance to nutritional support in this scenario may be limited. Instead, the focus of care for this infant revolves around optimizing nutritional intake and supporting oral feeding skills, making physical therapy a less prioritized intervention at this stage.

Choice B rationale:

Offering a pacifier for non-nutritive sucking is a crucial action to include in the plan of care for a newborn receiving enteral nutrition, especially in the context of gastroschisis repair. Non-nutritive sucking serves several purposes beneficial for the infant's development and well-being. Firstly, it promotes the development of oral feeding skills, including suck-swallow coordination and oral motor strength, which are essential for transitioning to oral feeding and achieving nutritional milestones. Secondly, non-nutritive sucking provides comfort and helps infants self-regulate, contributing to their overall physiological and emotional stability. By offering a pacifier for non-nutritive sucking, the nurse supports the infant's oral motor development and enhances their ability to transition from enteral to oral feeding, ultimately promoting normal growth and development.

Choice C rationale:

Ensuring the placement of the enteral tube with an abdominal x-ray is an essential aspect of enteral nutrition administration; however, it may not directly contribute to the maintenance of normal growth and development in the same way as offering a pacifier for non-nutritive sucking does. While verifying enteral tube placement is crucial for preventing complications such as aspiration or malabsorption, continuous reliance on abdominal x-rays for tube placement confirmation poses risks associated with radiation exposure, especially in neonates. Therefore, while verifying tube placement is necessary, it should be balanced with the consideration of minimizing radiation exposure and utilizing alternative methods such as auscultation or pH testing when appropriate.

Choice D rationale:

Using sterile technique during feedings is a fundamental aspect of enteral nutrition administration to minimize the risk of infection and ensure patient safety. However, while maintaining sterility is essential, it may not directly address the specific goal of maintaining normal growth and development in the context of enteral nutrition. The question specifically emphasizes actions to support normal growth and development, which are more directly facilitated by interventions such as non-nutritive sucking to enhance oral feeding skills and self-regulation.

Choice D rationale
The nurse should instruct the mother to place the child in a quiet environment first. Kawasaki disease is an illness that can cause inflammation in the blood vessels and can lead to symptoms such as irritability and skin peeling. Placing the child in a quiet environment can help reduce stimulation and promote rest, which can help improve the child’s symptoms.
Choice A rationale
Applying lotion to hands and feet may help with the symptom of skin peeling, but it does not address the underlying issue of the child’s irritability or refusal to eat.
Choice B rationale
While it’s important for parents to rest when possible, this does not directly address the child’s symptoms.
Choice C rationale
Making a list of foods that the child likes could potentially help with the child’s refusal to eat, but it does not address the child’s irritability or skin peeling.

The correct answer is: C

Choice A reason: Comparing the child’s vital signs over the past three weeks could provide data on any changes in his physical health status. However, without additional context, this information alone may not be sufficient to determine the cause of his symptoms. Vital signs are typically within the following ranges for a healthy 10-year-old: temperature 97.8°F to 99.1°F (36.5°C to 37.3°C), pulse 70 to 110 beats per minute, respirations 17 to 22 breaths per minute, and blood pressure 90/60 mmHg to 120/80 mmHg.

Choice B reason: Counseling the parents to pay more attention to the child might be helpful if the child’s symptoms are due to emotional neglect or lack of parental involvement. However, this intervention assumes that the parents are not attentive without evidence and does not directly address the child’s reported symptoms.

Choice C reason: Asking the boy to describe a typical day at school is a non-invasive way to gather more information about potential stressors or issues that could be contributing to his symptoms. This approach can help identify if the symptoms are related to school environment, bullying, academic pressure, or other psychosocial factors.

Choice D reason: Conducting a complete neurological assessment would be appropriate if there were specific indications of neurological issues. Since the boy’s symptoms are non-specific and could be related to a variety of causes, including stress or anxiety, a neurological assessment might not be the most immediate step without further evidence suggesting a neurological cause.

Step 1: Calculate the total dose of diazepam for this child by multiplying the child’s weight (30 kg) by the prescribed dose (0.3 mg/kg). This calculation gives a total dose of 9 mg (30 kg × 0.3 mg/kg = 9 mg).

Step 2: Divide the total dose (9 mg) by the concentration of the medication (5 mg/mL) to determine the volume to be administered. This calculation gives a volume of 1.8 mL (9 mg ÷ 5 mg/mL = 1.8 mL).

Choice A rationale
Juvenile idiopathic arthritis (JIA) is a chronic condition that can cause joint damage and pain. Physical therapy is an essential part of managing JIA, and it often includes a variety of exercises to improve strength, flexibility, and overall joint health. One of the recommended physical activities for JIA patients is exercising in a swimming pool. Water-based exercises, also known as hydrotherapy, are beneficial because the buoyancy, resistance, and warmth of water can help reduce joint stress, increase muscle strength, and improve range of motion.
Choice B rationale
While regular exercise is important for adolescents with JIA, starting a training program that involves weight lifting and running might not be the best option. These activities can put excessive strain on the joints and potentially exacerbate symptoms. It’s crucial to choose low-impact exercises that won’t put too much stress on the joints.
Choice C rationale
Passive range of motion exercises can be beneficial for maintaining joint mobility in JIA patients. However, these exercises alone may not be sufficient for strengthening and mobilizing the joints and surrounding muscles. A comprehensive physical therapy regimen, including a combination of strengthening, stretching, and aerobic exercises, is typically recommended.
Choice D rationale
Splinting can be used in JIA management to help maintain bone and joint alignment and prevent deformities. However, splinting is typically used as an adjunct to other treatments and not as the primary method of encouraging joint mobilization and muscle strengthening. Therefore, while splinting can be beneficial, it should not be the only strategy implemented for physical therapy.

Choice A rationale
Enalapril is an angiotensin-converting enzyme (ACE) inhibitor commonly used in the treatment of heart failure. It works by widening blood vessels, which reduces the workload of the heart and helps keep heart failure from getting worse. In the given scenario, there is no specific indication to hold Enalapril based on the infant’s vital signs.
Choice B rationale
Digoxin is a medication that can help the heart beat stronger with a more regular rhythm. However, it is important to monitor the patient’s heart rate when administering Digoxin, as it can lower the heart rate. In this case, the infant’s apical pulse is 88 beats/minute, which is lower than the normal range for an eight-month-old infant (normal range: 100-160 beats/minute). Therefore, the nurse should hold the Digoxin and inform the healthcare provider.
Choice C rationale
Furosemide is a diuretic that helps the kidneys get rid of extra fluid that may build up in the body. It is often used in the treatment of heart failure to relieve symptoms such as fluid retention. In the given scenario, there is no specific indication to hold Furosemide based on the infant’s vital signs.
Choice D rationale
Hydralazine is a medication used to treat high blood pressure. It works by relaxing and widening blood vessels so blood can flow more easily. In the given scenario, there is no specific indication to hold Hydralazine based on the infant’s vital signs.

Choice A rationale
Providing a urinal for urinary hesitancy may be helpful in some cases, but it does not address the immediate concern of severe testicular pain, redness, and swelling. These symptoms could indicate a serious condition such as testicular torsion, which requires immediate medical attention.
Choice B rationale
Severe testicular pain accompanied by redness and swelling of the scrotum could indicate a serious condition such as testicular torsion. Testicular torsion is a medical emergency that requires immediate intervention to restore blood flow and prevent loss of the testicle.
Therefore, the nurse should immediately report these findings to the healthcare provider.
Choice C rationale
While collecting a sterile urine sample for culture and sensitivity could be useful in diagnosing a urinary tract infection, it does not address the immediate concern of severe testicular pain.
These symptoms could indicate a serious condition such as testicular torsion, which requires immediate medical attention.
Choice D rationale
Obtaining a swab of secretions from the penis and urethra could be useful in diagnosing a sexually transmitted infection, but it does not address the immediate concern of severe testicular pain. These symptoms could indicate a serious condition such as testicular torsion, which requires immediate medical attention.

Choice A rationale
While physical therapy can be beneficial for many pediatric patients, it may not be the most appropriate intervention for a newborn who has had gastroschisis repair and is on parenteral nutrition and continuous enteral feedings. The focus at this stage should be on promoting normal growth and development, and physical therapy may not directly contribute to this goal.
Choice B rationale
Offering a pacifier for non-nutritive sucking can be an effective strategy to promote normal growth and development in infants who have had gastroschisis repair. Non-nutritive sucking can help stimulate the sucking reflex, which is important for feeding and growth. Therefore, the nurse should include this action in the plan of care.
Choice C rationale
Confirming the placement of the enteral tube with an abdominal x-ray is an important part of care for infants on continuous enteral feedings. However, this action is more related to ensuring the safety and effectiveness of the feeding process rather than promoting the infant’s normal growth and development.
Choice D rationale
Using sterile technique during feedings is a standard practice to prevent infection, especially in infants who are on parenteral nutrition and continuous enteral feedings. However, this action does not directly promote the infant’s normal growth and development.

Choice A rationale
The initial phase of treatment for a school-age child with left femoral osteomyelitis involves ensuring no weight-bearing on the affected extremity. This is crucial because weight bearing can exacerbate the condition and cause further damage to the bone. The child should be encouraged to rest and avoid activities that put pressure on the affected limb. This measure, combined with appropriate antibiotic therapy, helps to control the infection and prevent complications.
Choice B rationale
Administering topical antibiotic therapy daily is not typically the primary mode of treatment for osteomyelitis. Osteomyelitis is a deep bone infection, and topical antibiotics may not reach the site of infection effectively. Instead, systemic antibiotics are usually administered intravenously, especially in the initial phase of treatment.
Choice C rationale
Scheduling ice pack applications to the infected area is not a standard treatment for osteomyelitis. While ice packs can help reduce inflammation and pain in some conditions, they are not typically used in the management of osteomyelitis. The primary treatment for osteomyelitis is antibiotic therapy.
Choice D rationale
Providing a passive range of motion exercises is not typically part of the initial phase of treatment for osteomyelitis. While physical therapy and exercises can be beneficial in the recovery phase to restore function and mobility, they are not usually recommended in the initial phase when the infection is active and the bone is inflamed.

Choice A rationale
In an infant with aortic stenosis and bilateral fine crackles in both lung fields, hypotension and tachycardia are additional findings that the nurse should expect to observe. Aortic stenosis can lead to decreased cardiac output, which can result in hypotension. The body compensates for this by increasing the heart rate, leading to tachycardia.
Choice B rationale
Vigorous feeding and satiation are not typically associated with aortic stenosis. Infants with aortic stenosis may actually have difficulty feeding due to fatigue.
Choice C rationale
Fever is not a typical symptom of aortic stenosis. If an infant with aortic stenosis has a fever, it may indicate a concurrent infection.
Choice D rationale
Hemiplegia, or paralysis of one side of the body, is not a typical symptom of aortic stenosis. If an infant with aortic stenosis presents with hemiplegia, it may indicate a serious complication such as a stroke.