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

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale

This 12-year-old child with cystic fibrosis and difficulty clearing secretions is the priority. Cystic fibrosis causes thick mucus to accumulate in the lungs, leading to airway obstruction. Inability to clear these secretions indicates a potential acute respiratory crisis, which can rapidly progress to respiratory failure. This is a life-threatening airway and breathing emergency requiring immediate assessment and intervention to prevent respiratory compromise.

Choice B rationale

A 3-year-old with an atrial septal defect and a heart rate of 120/min is a non-acute finding. A heart rate of 120/min is within the normal range for a toddler (90-140/min) and is a common physiological response in a child with a heart defect to maintain cardiac output. This child is stable and does not present with an immediate life-threatening condition.

Choice C rationale

A 2-year-old with diarrhea and abdominal pain is a non-acute finding. While these symptoms require attention, they are common in toddlers and do not typically represent an immediate life-threatening emergency unless accompanied by signs of severe dehydration or septic shock. Other children with respiratory issues take priority due to the higher potential for rapid decompensation.

Choice D rationale

A 5-year-old with type 1 diabetes mellitus and a blood sugar of 150 mg/dL is stable. A blood sugar of 150 mg/dL is within a safe, controlled range for a child with type 1 diabetes, which is typically 80-180 mg/dL. This child does not require immediate intervention as their blood glucose is not indicative of hypo- or hyperglycemia crises. .

A. Increased head circumference. B. Hypotonicity. C. Irritability. D. Decreased auditory startle response.

Correct Answer is C

Explanation

Choice A rationale

Increased head circumference is an unexpected finding in a newborn exposed to cocaine in utero. Cocaine is a potent vasoconstrictor, which reduces blood flow and oxygen to the developing fetus, potentially leading to intrauterine growth restriction, which would more likely result in a smaller head circumference, not a larger one. This is due to compromised fetal oxygenation and nutrient delivery.

Choice B rationale

Hypotonicity, or decreased muscle tone, is not a typical finding. Neonates exposed to cocaine in utero often exhibit hypertonicity and a rigid posture due to central nervous system excitability. This increased muscle tone is a common neurological manifestation resulting from the drug's stimulatory effects on the developing nervous system, leading to hyperirritability and tremors.

Choice C rationale

Irritability is a very common finding in a newborn exposed to cocaine throughout pregnancy. Cocaine is a potent central nervous system stimulant, and its effects on the developing fetal brain can lead to long-term neurological and behavioral issues. After birth, the neonate experiences withdrawal symptoms, resulting in excessive crying, high-pitched cries, tremors, and a state of hypervigilance.

Choice D rationale

A decreased auditory startle response is not an expected finding. Newborns exposed to cocaine often exhibit an increased and exaggerated startle response to various stimuli, including auditory cues. This hyperresponsiveness is a manifestation of the generalized central nervous system excitability caused by the chronic prenatal exposure to the potent sympathomimetic effects of cocaine on the brain. *.

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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?

Nursing Test Bank

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A nurse is receiving information about four children during change-of-shift report. Which of the following children should the nurse assess first?

Correct Answer is A

Explanation

A nurse is performing a physical assessment of a newborn whose mother used cocaine throughout the pregnancy. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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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?