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 B
Explanation
Choice A rationale
Tomato soup is highly acidic due to its tomato base, which can relax the lower esophageal sphincter (LES) and increase stomach acid production. This can lead to the reflux of gastric contents into the esophagus, exacerbating the symptoms of GERD. The client should avoid highly acidic foods to manage their condition effectively.
Choice B rationale
White fish is a lean protein that is generally low in fat. High-fat foods can delay stomach emptying and decrease the pressure of the lower esophageal sphincter, increasing the risk of acid reflux. Lean proteins like white fish are less likely to trigger symptoms and are therefore a suitable dietary choice for a client with GERD.
Choice C rationale
Hot cocoa contains both caffeine and fat, which are known to exacerbate GERD symptoms. Caffeine can relax the lower esophageal sphincter, allowing stomach acid to reflux. Additionally, the fat content can delay gastric emptying, increasing pressure on the LES and worsening acid reflux symptoms.
Choice D rationale
Decaffeinated coffee can still trigger GERD symptoms. Coffee, even without caffeine, is acidic and can stimulate the production of stomach acid. The oils and compounds in coffee can also relax the lower esophageal sphincter, increasing the likelihood of acid reflux and causing irritation to the esophageal lining.
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