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A nurse is caring for a 2-year-old child who has pneumonia and a temperature of 39.4° C (103° F). Which of the following actions should the nurse take?

Give 500 mg acetaminophen PO every 2 hr.

Administer a 300-mg aspirin suppository.

Place the child in an ice bath.

Lower the temperature of the room.

Answer and Explanation

The Correct Answer is D

Choice A reason:

This is a high dose for a 2 year old child.

Choice B reason:

Aspirin is contraindicated for children with viral infections due to the risk of Reye's syndrome. It should not be administered.

Choice C reason:

Placing the child in an ice bath is an overly aggressive intervention and can lead to hypothermia. It is not recommended.

Choice D reason:

Lowering the temperature of the room is important in reducing external temperature to help cool the baby.

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Correct Answer is A

Explanation

Choice A reason:

At 18 months, a toddler should typically be saying more than four words. This finding may

indicate a potential delay in speech development, and it should be reported to the provider for further evaluation.

Choice B reason:

Building a tower of three blocks is an appropriate developmental milestone for an 18-month-old and does not warrant reporting.

Choice C reason:

Temper tantrums are a normal behavior for toddlers, as they are still developing emotional regulation skills. This finding does not require reporting unless it is severe or causing harm to the child.

Choice D reason:

Jumping in place with both feet is an appropriate developmental milestone for an 18-month-old and does not warrant reporting.

A. Administer naloxone intramuscularly. B. Check inside the child's mouth for bleeding. C. Give the child a drink of water. D. Place the child's head in a hyperextended position.

Correct Answer is B

Explanation

Choice A reason:

Administering naloxone is not indicated for a seizure. Naloxone is used to reverse opioid overdose, not treat seizures.

Choice B reason:

Checking inside the child's mouth for bleeding is important after a seizure to ensure there is no injury to the oral cavity.

Choice C reason:

Giving the child a drink of water immediately after a seizure is not a priority intervention. The child may not be able to swallow properly immediately after a seizure.

Choice D reason:

Placing the child's head in a hyperextended position is not a recommended intervention after a seizure. It is important to maintain the child in a safe position and provide appropriate care after the seizure has ended.

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A nurse is caring for a 2-year-old child who has pneumonia and a temperature of 39.4° C (103° F). Which of the following actions should the nurse take?

Nursing Test Bank

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