A nurse is preparing to administer required immunizations to a toddler during a well-child visit. The parent asks the nurse how many baby aspirins he should administer if the toddler develops a fever. Which of the following responses should the nurse make?

"You should follow the label directions based on your child's weight."

"You should avoid administering aspirin to your child."

"Your child will require an antibiotic if she develops a fever."

"Your child can have two baby aspirins every 4 hours."

Answer and Explanation

The Correct Answer is B

A. "You should follow the label directions based on your child's weight.": While dosing medications based on weight is generally appropriate, aspirin is not recommended for children or adolescents due to the risk of Reye’s syndrome, a rare but serious condition affecting the liver and brain after viral infections.

B. "You should avoid administering aspirin to your child.": This is the safest and most accurate response. Aspirin should not be given to children under 18, particularly following viral illnesses or immunizations, because of the association with Reye’s syndrome. Acetaminophen or ibuprofen are preferred for fever management in toddlers.

C. "Your child will require an antibiotic if she develops a fever.": Fever after immunization is usually a benign, self-limited response. Antibiotics are not indicated unless there is evidence of a bacterial infection. Providing this information could cause unnecessary concern or inappropriate antibiotic use.

D. "Your child can have two baby aspirins every 4 hours.": Recommending aspirin in a toddler is unsafe due to the risk of Reye’s syndrome. Providing a specific dose encourages potentially harmful practice and is contraindicated in pediatric care.

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Correct Answer is C

Explanation

A. Cleanse the perineal area from back to front: Perineal hygiene after delivery should be performed from front to back to prevent transfer of gastrointestinal flora, such as Escherichia coli, to the episiotomy site or urinary tract. Cleansing from back to front increases the risk of wound contamination and postpartum infection.

B. Wash the perineal area with povidone-iodine twice daily: Routine use of antiseptic solutions such as povidone-iodine is not recommended for standard episiotomy care. These solutions can irritate healing tissue and disrupt normal skin flora. Gentle cleansing with warm water using a peri-bottle after voiding or defecation is typically advised.

C. Change the perineal pad with each void: Lochia provides a moist environment that can promote bacterial growth and increase infection risk at the episiotomy site. Changing the perineal pad frequently, especially after each void, helps maintain dryness, reduce bacterial proliferation, and support wound healing.

D. Wipe the perineal area with a soft towel: The perineal area should be gently patted dry rather than wiped to avoid mechanical trauma to the sutured episiotomy site. Wiping can place tension on the sutures and disrupt tissue approximation during the early stages of healing.

A. Airborne B. Droplet C. Contact D. Protective environment

Correct Answer is B

Explanation

A. Airborne: Airborne precautions are used for infections transmitted via small droplet nuclei that remain suspended in the air, such as tuberculosis, measles, or varicella. Mononucleosis, caused by the Epstein-Barr virus, is not transmitted via airborne particles, so airborne precautions are unnecessary.

B. Droplet: Mononucleosis is primarily transmitted through saliva and close respiratory contact, such as kissing or sharing utensils. Droplet precautions—including wearing a mask when within close contact and practicing hand hygiene—help prevent the spread of infectious respiratory secretions to others in the healthcare setting.

C. Contact: Contact precautions are indicated for infections transmitted by direct or indirect contact with contaminated surfaces, such as MRSA or Clostridioides difficile. Since mononucleosis is spread via respiratory droplets and saliva, contact precautions alone are insufficient.

D. Protective environment: Protective environment precautions are used to protect immunocompromised clients from exposure to environmental pathogens. They are not necessary for clients with mononucleosis, as the concern is preventing transmission from the infected client, not protecting them from infection.

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A nurse is preparing to administer required immunizations to a toddler during a well-child visit. The parent asks the nurse how many baby aspirins he should administer if the toddler develops a fever. Which of the following responses should the nurse make?

Nursing Test Bank

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