A nurse is assessing the psychosocial development of a toddler.
The nurse should recognize that this stage is characterized by which of the following?

Choice A rationale:

Increasing the oxygen flow rate may help improve oxygen saturation, but it does not address the underlying issue of fluid overload and heart failure exacerbation.

Choice B rationale:

Administering an additional dose of furosemide may help reduce fluid overload, but it is not the most immediate action to improve the client’s respiratory status and comfort.

Choice C rationale:

Notifying the healthcare provider is important, but the nurse should first take immediate action to improve the client’s respiratory status and comfort.

Choice D rationale:

Repositioning the client to a high Fowler’s position is the most appropriate initial nursing action. This position helps improve lung expansion and reduces the work of breathing, providing immediate relief for the client experiencing dyspnea and respiratory distress.

The correct answers are Choices B, D, E, and F.

Choice A rationale:

Administering promethazine 50 mg intermittent IV bolus is not typically indicated for managing acute abdominal pain and suspected appendicitis. Promethazine is an antiemetic and antihistamine, but it does not address the underlying cause of the symptoms.

Choice B rationale:

Obtaining informed consent for surgery is crucial as the client’s symptoms and lab results (elevated WBC count and C- Reactive Protein) strongly suggest appendicitis. Surgery, specifically an appendectomy, is the definitive treatment for appendicitis.

Choice C rationale:

Administering acetaminophen 800 mg may help alleviate pain and reduce fever, but it does not address the underlying cause of the symptoms. It is important to manage the pain, but the primary focus should be on diagnosing and treating the appendicitis.

Choice D rationale:

Initiating IV antibiotics is essential in managing suspected appendicitis to prevent infection and complications such as perforation or abscess formation. Antibiotics help control the infection until surgical intervention can be performed.

Choice E rationale:

Maintaining NPO (nothing by mouth) status is important to prepare the client for potential surgery and to prevent exacerbation of symptoms. Keeping the client NPO helps reduce the risk of aspiration during anesthesia and surgery.

Choice F rationale:

Obtaining an abdominal ultrasound is important to confirm the diagnosis of appendicitis. Imaging studies such as ultrasound or CT scan can help visualize the appendix and assess for inflammation or other abnormalities.

Choice G rationale:

Administering enemas until clear is not appropriate in this scenario. Enemas are not indicated for managing acute abdominal pain and suspected appendicitis. They could potentially worsen the condition or mask important symptoms.