A nurse is caring for a newborn who has hydrocephalus.
Which of the following manifestations should the nurse expect to find?

The correct answer is A. Tugging on the affected ear lobe.

Choice A rationale

Tugging on the affected ear lobe is a common sign of otitis media in children. This behavior is often observed because the child is experiencing discomfort or pain in the ear, and tugging or pulling on the ear lobe is a way to express or alleviate that discomfort.

Choice B rationale

Erythema and edema of the affected ear are not typical findings in otitis media. These symptoms are more commonly associated with external ear infections, such as otitis externa.

Choice C rationale

Pain when manipulating the affected ear lobe is more indicative of otitis externa rather than otitis media. Otitis media involves the middle ear, and manipulation of the ear lobe does not typically cause pain.

Choice D rationale

Clear drainage from the affected ear is not a typical finding in otitis media. If there is drainage, it is usually purulent (pus-like) and indicates a more severe infection or a ruptured eardrum.

The correct answers are B. Assess the client’s airway patency,

C. Remove objects from the client’s bed, and D. Place the client in a side-lying position.

Choice A rationale

Restraining the client during a seizure is not recommended as it can cause injury. The focus should be on ensuring the client’s safety and preventing harm.

Choice B rationale

Assessing the client’s airway patency is crucial during a seizure to ensure that the client is breathing properly and that the airway is not obstructed.

Choice C rationale

Removing objects from the client’s bed helps prevent injury during a seizure. Objects in the bed can pose a risk of harm if the client hits them during the seizure.

Choice D rationale

Placing the client in a side-lying position helps maintain an open airway and reduces the risk of aspiration. This position allows any secretions to drain out of the mouth, preventing choking.

Choice E rationale

Placing a tongue depressor in the client’s mouth is not recommended and can cause injury. It is a common misconception that this prevents the client from swallowing their tongue, but it can actually cause more harm.