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A nurse is caring for an infant in a provider's office.

Medical History Provider Visit #1. Heart rate 144/min.

Axillary temperature 39.7° C (103.5°F). Respiratory rate 32/min.

Oxygen saturation 95% on room air. Provider Visit #2 (4 days later).

Axillary temperature 37.4° C (99.3° F). Heart rate 132/min.

Respiratory rate 28/min.

Oxygen saturation 97% on room air.

Which of the following actions should the nurse plan to take? Select the actions the nurse should plan to take.

Teach caregivers to change diapers when wet.

Have caregivers administer 16 oz of water after each diarrhea stool.

Cleanse the diaper area with soap and water.

Collect nasal drainage for culture and sensitivity.

Teach caregivers to apply talcum powder to creases.

Use a nasal aspirator after feedings.

Answer and Explanation

Correct Answer : A,G

A. Teach caregivers to change diapers when wet.
✅ Correct. Prevents skin breakdown and diaper dermatitis.

B. Have caregivers administer 16 oz of water after each diarrhea stool.
❌ Incorrect. Infants should not get plain water in such amounts. Risk of water intoxication & electrolyte imbalance. Oral rehydration solutions (ORS) or breast milk/formula are recommended instead.

C. Cleanse the diaper area with soap and water.
❌ Incorrect. Harsh soaps can irritate the skin. Best practice: gentle cleansing with warm water or mild wipes, and barrier ointment if needed.

D. Collect nasal drainage for culture and sensitivity.
❌ Incorrect. Only done if ordered and if infection is suspected. At follow-up (Visit #2), infant is afebrile and stable—no need for culture.

F. Teach caregivers to apply talcum powder to creases.
❌ Incorrect. Talcum powder is contraindicated in infants (risk of aspiration & respiratory issues). Barrier creams preferred.

G. Use a nasal aspirator after feedings.
✅ Correct. Safe and effective to clear nasal secretions and prevent aspiration or feeding difficulties.

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Correct Answer is D

Explanation

The correct answer is d. Modify the environment.

Rationale for each choice:

Choice a. Improve the client's communication skills.

Statement:While communication is important,it is not the priority for a child with hemiplegic cerebral palsy.
Rationale:Hemiplegic cerebral palsy primarily affects motor skills,not communication abilities.While some children with hemiplegic cerebral palsy may have speech difficulties,it is not the most pressing concern in this case.Addressing environmental barriers to promote mobility and independence takes precedence.

Choice b. Provide respite services for the parents.

Statement:Respite services can provide valuable support for parents,but they are not the priority in this case.
Rationale:The focus of the care plan should be on the child's immediate needs and safety.Modifying the environment to enhance the child's functional abilities is crucial for their development and well-being.

Choice c. Foster self-care activities.

Statement:Encouraging self-care is essential,but it requires a supportive environment.
Rationale:Before promoting self-care activities,the nurse must ensure the child has the necessary accommodations and modifications in place to facilitate independence.

Choice d. Modify the environment.

Statement:This is the priority goal for a child with hemiplegic cerebral palsy.
Rationale:Modifying the home environment can significantly improve the child's mobility,safety,and ability to participate in daily activities.Examples of modifications include:
- Installing grab bars in the bathroom
- Widening doorways
- Removing tripping hazards
- Providing adaptive equipment such as special chairs or utensils
- Ensuring adequatelighting

A. Allow for imaginative play with peers without supervision. B. Establish a reward system for positive behavior. C. Provide a ﬂexible schedule that adjusts to the child's interests. D. Allow for adjustment of rules to correlate with the child's behavior.

Correct Answer is B

Explanation

Behavioral approaches have the most evidence for treating symptoms of Autism
Spectrum Disorder (ASD)1.
Applied Behavior Analysis (ABA) is a notable behavioral treatment for people with ASD that encourages desired behaviors and discourages undesired behaviors to improve a variety of skills.
A reward system for positive behavior is an example of an ABA technique.
Choice A is not correct because allowing for imaginative play with peers without supervision is not a recommended intervention for a child with ASD.
Choice C is not correct because providing a ﬂexible schedule that adjusts to the child’s interests is not a recommended intervention for a child with ASD.
Choice D is not correct because allowing for adjustment of rules to correlate with the child’s behavior is not a recommended intervention for a child with ASD.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care?

Correct Answer is D

Explanation

A nurse in a special education program is planning care for a child who has an autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse is caring for a child who has been physically abused by a family member. Which of the following statements should the nurse say to the child?

A nurse is caring for a school-age child who has acute glomerulonephritis with peripheral edema and is producing 35 mL of urine per hour. The nurse should place the client on which of the following diets?

A nurse is planning care for a client who ingested a large amount of acetylsalicylic acid. Which of the following actions should the nurse take?

A nurse is caring for a newborn whose mother voices concerns about sudden infant death syndrome (SIDS). The nurse should include which of the following statements in a discussion with the mother?

A nurse is collecting data from an adolescent. Which of the following should the nurse identify as the greatest risk for suicide?

A nurse is planning care for an infant who has spina bifida and is to undergo surgical closure of the myelomeningocele sac. Which of the following interventions should the nurse include in the plan of care?

A school nurse conducting a screening for pediculosis capitis identifies several children who require treatment. Which of the following instructions should the nurse give the children's parents?

A nurse is caring for a 10-month-old infant who is in a cast for developmental dysplasia of the hip (DDH). Which of the following strategies should the nurse implement to promote the infant's growth and development?