A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 min ago.

Which of the following findings is the nurse’s priority?

Answer and explanation.

The correct answer is choice A. A nontender, protruding abdomen is a normal finding for a 2year-old toddler. This is due to the immature development of the abdominal muscles and the relatively large size of the liver and kidneys in relation to the rest of the body.

Choice B is wrong because the head circumference should be equal to or less than the chest circumference by age 2. A head circumference that exceeds the chest circumference could indicate hydrocephalus or other neurological problems.

Choice C is wrong because the fontanels, or soft spots on the skull, should be closed by age 18 months. Palpable fontanels could indicate dehydration, malnutrition, or congenital disorders.

Choice D is wrong because the natural loss of deciduous teeth, or baby teeth, usually begins around age 6. Premature loss of teeth could indicate dental caries, trauma, or endocrine disorders.

The correct answer is choice A. “I can give you information about respite care if you are interested.” Respite care is a service that provides short-term inpatient care for terminally-ill patients at a professional care facility, such as a hospital, hospice inpatient care facility, or nursing home. It is meant to relieve caregiver stress and offer them rest and time away from caregiving duties. Respite care is covered by Medicare for up to five consecutive days and no more than one respite period in a single billing period.

The nurse should offer this option to the son who is experiencing sleep deprivation due to caring for his mother.

Choice B is wrong because it suggests that the son should rely on medication to cope with his situation, which may not be appropriate or effective.

Sleeping pills may have side effects or interactions with other drugs, and they do not address the underlying cause of the son’s stress and fatigue.

Choice C is wrong because it does not acknowledge the son’s need for support or assistance.

It may sound like an empty compliment or a dismissal of the son’s concerns.

The nurse should express empathy and compassion, but also provide information and resources that can help the son.

Choice D is wrong because it does not offer any solution or guidance to the son.

It may also sound like a cliché or a generalization that does not reflect the son’s unique experience.

The nurse should avoid making assumptions or judgments about the son’s feelings or situation, and instead focus on his needs and preferences.