A nurse is assessing a 2-year-old male toddler in a pediatric clinic during a well-child checkup.
Exhibits
After reviewing the toddler’s current medical record, which of the following interventions should the nurse expect the provider to prescribe?
Protective environment
Blood transfusion
Iron supplementation
Antibiotic continuation
The Correct Answer is C
Choice A rationale: A protective environment is typically indicated for immunocompromised clients, such as those with neutropenia or undergoing chemotherapy, not for uncomplicated anemia. The toddler’s white blood cell count is within the normal range of 5,000 to 10,000/mm³, and no evidence of infection risk or severe immunodeficiency is present. Pallor and low hemoglobin are consistent with iron deficiency anemia, which does not require isolation precautions unless additional hematologic compromise is identified.
Choice B rationale: Blood transfusions are reserved for cases of severe anemia with hemodynamic instability, cardiac compromise, or hemoglobin levels below 7 g/dL. This toddler’s hemoglobin is 8.1 g/dL, which while low, does not meet transfusion threshold in a stable, asymptomatic pediatric patient. Transfusion carries risks like iron overload and alloimmunization, making it inappropriate for mild to moderate anemia. Instead, correction through dietary modification and iron supplementation is preferred for age-related iron-deficiency anemia.
Choice C rationale: Iron supplementation is the standard therapy for iron deficiency anemia, especially in toddlers consuming excessive cow’s milk, which lacks iron and can cause occult intestinal blood loss. Hemoglobin of 8.1 g/dL is below the normal pediatric range of 9.5 to 14 g/dL, confirming anemia. Iron replenishment stimulates erythropoiesis by enabling hemoglobin synthesis. Supplementation corrects deficiency over time and should be paired with dietary education to limit milk to <24 oz/day and include iron-rich foods.
Choice D rationale: Continuing antibiotics is unnecessary unless there is ongoing infection. The toddler has recently completed antibiotic therapy for otitis media, and current symptoms do not suggest infection recurrence. Vital signs are stable and the white blood cell count is within normal limits (5,000–10,000/mm³), indicating no acute bacterial process. Antibiotic overuse may disrupt gut flora, impair iron absorption, and contribute to resistant bacterial strains, which is contraindicated in this clinical scenario.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Counterpressure is a nonpharmacologic pain management technique that involves applying firm, steady pressure to the sacral area during contractions. It is particularly effective for back pain during labor, which is often caused by the occiput of the fetus pressing against the maternal sacrum. This physical pressure helps to distract the brain from the pain signals and can help to realign the fetal head. It provides direct relief by counteracting the pressure from the fetus.
Choice B rationale
Terbutaline is a tocolytic medication that is used to relax the smooth muscles of the uterus and inhibit contractions. Administering this medication would halt the progression of labor, which is not the goal in this situation. The client is in the latent phase of labor, and the primary goal is to manage the pain while allowing the labor process to continue naturally. Therefore, terbutaline is contraindicated as it would interfere with the normal course of labor.
Choice C rationale
A pudendal nerve block is a form of regional anesthesia that anesthetizes the pudendal nerve, providing pain relief to the perineum, vulva, and vagina. It is typically administered in the second stage of labor just before delivery or for an episiotomy repair, as it is not effective for the pain associated with uterine contractions. The client is in the latent phase of labor and experiencing back pain, so a pudendal block would not be an appropriate intervention at this time.
Choice D rationale
While a warm bath can be a useful comfort measure during labor, it is not the most effective intervention for severe back pain specifically caused by the fetal position. Counterpressure provides targeted, direct pressure to the source of the pain, offering more immediate and substantial relief. A warm bath may provide general relaxation and distraction, but it does not address the underlying mechanical cause of the pain as effectively as counterpressure.
Correct Answer is D
Explanation
Choice A rationale
Postterm pregnancy, defined as a gestation extending beyond 42 weeks, is not a contraindication for misoprostol. In fact, it is a common indication for labor induction, as the placenta may begin to deteriorate, increasing the risk of fetal distress and meconium aspiration. Misoprostol, a prostaglandin E1 analog, helps ripen the cervix and stimulate uterine contractions. This pharmacologic action is beneficial in initiating labor in postterm pregnancies.
Choice B rationale
Transverse fetal lie is an obstetrical position where the fetus is lying sideways across the uterus. This position poses a significant risk of complications during vaginal birth, including uterine rupture and umbilical cord prolapse. Therefore, any attempt to induce labor with a medication like misoprostol is contraindicated. Cesarean delivery is typically the preferred method of delivery in cases of persistent transverse lie to ensure a safe delivery for both mother and fetus.
Choice C rationale
Intrauterine growth restriction (IUGR) is a condition where a fetus is smaller than expected for gestational age. It is not a contraindication for misoprostol. Often, IUGR is an indication for labor induction to prevent further fetal compromise. Misoprostol is a commonly used medication for this purpose, as it helps to initiate cervical ripening and uterine contractions, which can lead to a successful vaginal delivery.
Choice D rationale
A history of a cesarean section is a significant contraindication for misoprostol because it substantially increases the risk of uterine rupture. Misoprostol causes potent uterine contractions that can place undue stress on the uterine scar from the previous surgery. The risk of rupture is a life-threatening complication for both the mother and the fetus. Therefore, other methods of labor induction or a planned repeat cesarean section are often considered. *.
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