A nurse is planning care for a 4-year-old child who has leukemia and is receiving chemotherapy. The child has an absolute neutrophil count of 140/mm³. Which of the following interventions should the nurse include in the plan?
Administer the varicella vaccine to the child.
Increase the child's intake of fresh fruit.
Avoid taking the child's temperature rectally.
Restrict bathing to every other day.
The Correct Answer is C
Choice A reason: Administering the varicella vaccine to a child with leukemia and a low neutrophil count is not recommended because live vaccines are contraindicated due to the child's compromised immune system.
Choice B reason: Increasing the child's intake of fresh fruit is not advisable in this case because fresh fruits may carry bacteria that can cause infection in a child with a low neutrophil count.
Choice C reason: Avoiding rectal temperature measurements is important to prevent potential injury and infection in a child with a low neutrophil count, as their immune system is weakened.
Choice D reason: Restricting bathing to every other day is not necessary unless the child's skin is extremely sensitive due to chemotherapy. Regular bathing helps maintain hygiene and comfort.
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Related Questions
Correct Answer is A
Explanation
Choice A reason: Clearing the area of hard objects is crucial to prevent injury during a seizure. It helps to ensure that the child does not hit or get hurt by any objects in the vicinity while experiencing convulsions.
Choice B reason: Minimizing movement of the limbs is not recommended as it can cause injury to the child. Instead, the child should be allowed to move freely without restraint to avoid causing harm to their joints or muscles.
Choice C reason: Inserting a tongue blade between the teeth is an outdated and dangerous practice. It can cause injury to the child's mouth or teeth and may lead to choking if the tongue blade breaks.
Choice D reason: Placing the child in a prone position is not advised as it can obstruct the airway. The child should be placed on their side in the recovery position to keep the airway clear and allow fluids to drain from the mouth.
Correct Answer is A
Explanation
Choice A reason: Irregular bluish pigmentation on the sacral area could indicate a Mongolian spot, which is common and usually harmless, but it could also suggest other conditions that may require further evaluation. Reporting this finding is important for proper assessment and documentation.
Choice B reason: Slow, rhythmic movements of the lower extremities are normal in newborns and are known as primitive reflexes. These movements are expected and do not typically require reporting unless they are absent or abnormal.
Choice C reason: An anterior fontanel size of 3 cm (1.2 in) is within the normal range for a newborn. The fontanel should be soft and flat, and changes in size or tension should be monitored over time.
Choice D reason: Enlarged breasts in newborns are also common due to maternal hormones and usually resolve without intervention. It is not a finding that typically requires immediate reporting unless there is redness, swelling, or discharge.
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