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A nurse is caring for a toddler. Which of the following statements should the nurse use when preparing to obtain the child's vital signs?

A.

"I am going to listen to your heart."

B.

"Can I listen to your lungs?"

C.

"I am going to take your blood pressure now."

D.

"Can you stand very still while I feel how warm you are?"

Answer and Explanation

The Correct Answer is A

A. “I am going to listen to your heart.”: This is the correct answer. It is a clear, simple statement that informs the child about what is going to happen. It is important to use language that is appropriate for the child’s age and development.
B. “Can I listen to your lungs?”: While this is a polite way to ask for consent, it might confuse a toddler who may not understand what “lungs” are.
C. “I am going to take your blood pressure now.”: This statement might be too complex for a toddler to understand. It’s better to use simpler language.
D. “Can you stand very still while I feel how warm you are?”: This statement might be confusing for a toddler. It’s better to use clear and direct language.
 


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Related Questions

Correct Answer is D

Explanation

A. “Burp your baby more frequently during feedings”: While burping can help with minor feeding issues, it’s unlikely to resolve the issue of projectile vomiting after eating.

B. “Try switching to a different formula”: While this might be an option in some cases, it’s not the first step to take. Projectile vomiting can be a sign of a more serious condition, such as pyloric stenosis, which needs medical attention.

C. “Give your infant an oral rehydration solution”: While rehydration is important, especially if the baby is vomiting, it doesn’t address the underlying issue causing the vomiting.

D. “Bring your baby in to the clinic today”: This is the correct action. Projectile vomiting in an infant, especially when combined with increased hunger, is a concern and should be evaluated by a healthcare professional as soon as possible

Correct Answer is C

Explanation

A. Administer 0.9% sodium chloride IV solution: While hydration is important, it’s not the first step in managing a child with suspected epiglottitis.

B. Initiate IV antibiotics: Antibiotics are typically used in the treatment of epiglottitis, but they are not the first step. The first step should be to prevent the spread of the infection.

C. Place the child on droplet precautions: This is the correct answer. Epiglottitis is a potentially life-threatening condition caused by infection. Droplet precautions can help prevent the spread of the infection to others.

D. Assist with obtaining an x-ray of the child’s neck: While an x-ray can help confirm the diagnosis of epiglottitis, it’s not the first step. The first step should be to prevent the spread of the infection.

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