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 D

Explanation

A. 2+ deep tendon reflex: A reflex rating of 2+ is normal and indicates adequate neuromuscular function. In a client receiving magnesium sulfate, this suggests that magnesium levels are within the therapeutic range and are not causing toxicity.

B. Facial flushing: Facial flushing is a common side effect of magnesium sulfate due to vasodilation. While uncomfortable, it is not dangerous and typically does not require intervention unless accompanied by other signs of toxicity.

C. Respiratory rate 13/min: A respiratory rate above 12/min is generally considered within normal limits for adults. Magnesium toxicity becomes concerning when the respiratory rate drops below 12/min, indicating central nervous system depression.

D. Urine output 20 mL/hr: Magnesium sulfate is excreted primarily by the kidneys, and low urine output (<30 mL/hr) increases the risk of magnesium accumulation and toxicity. Reporting this finding allows the provider to adjust the infusion rate or evaluate renal function to prevent serious complications.

A. Children whose parents have college degrees B. Children who were born after 38 weeks of gestation C. Children whose parents are married D. Children who live in crowded homes

Correct Answer is D

Explanation

A. Children whose parents have college degrees: Higher parental education is generally associated with increased knowledge of child development and stress-coping strategies. While education alone does not eliminate risk, it is not considered a major risk factor for physical abuse.

B. Children who were born after 38 weeks of gestation: Full-term birth is associated with generally healthier outcomes and fewer complications compared with preterm birth. Birth after 38 weeks does not increase the risk for physical abuse.

C. Children whose parents are married: Being raised by married parents is not a risk factor for abuse. Stable family structures can provide protective effects, although abuse can occur in any family regardless of marital status.

D. Children who live in crowded homes: Overcrowding can increase parental stress, reduce privacy, and create chaotic living conditions, all of which are associated with a higher risk of physical abuse. Children in such environments are more vulnerable due to environmental stressors that can exacerbate caregiver frustration and risk behaviors.

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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

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is D

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