Which of the following findings should the nurse report to the health care provider immediately? (select all that apply)

Loss of appetite

Platelet count

Developmental regression

Absolute neutrophil count

Hemoglobin

Answer and Explanation

Correct Answer : C,D

Choice A reason: Loss of appetite is not an urgent finding, as it may be caused by various factors, such as nausea, pain, or stress. The nurse should monitor the child's fluid and calorie intake and encourage oral hydration and nutrition. However, loss of appetite does not require immediate reporting to the health care provider.

Choice B reason: Platelet count is not an urgent finding, as it is not given in the text. The nurse should check the child's laboratory results and compare them with the normal ranges for preschoolers. A normal platelet count for children is 150,000 to 450,000 per microliter of blood¹. A low platelet count (thrombocytopenia) may indicate bleeding disorders, infections, or bone marrow problems. A high platelet count (thrombocytosis) may indicate inflammation, infection, or cancer. The nurse should report any abnormal platelet count to the health care provider, but it is not an immediate concern.

Choice C reason: Developmental regression is an urgent finding, as it may indicate a serious neurological problem, such as a brain tumor, infection, or injury. Developmental regression is the loss of previously acquired skills or milestones, such as language, motor, or social skills. The nurse should assess the child's developmental level and report any signs of regression to the health care provider as soon as possible.

Choice D reason: Absolute neutrophil count is an urgent finding, as it may indicate a severe infection or a compromised immune system. Neutrophils are a type of white blood cell that fight bacterial infections. The absolute neutrophil count is the number of neutrophils in a microliter of blood. A normal absolute neutrophil count for children is 1,500 to 8,000 per microliter of blood². A low absolute neutrophil count (neutropenia) may increase the risk of infection and sepsis. A high absolute neutrophil count (neutrophilia) may indicate an acute infection or inflammation. The nurse should report any abnormal absolute neutrophil count to the health care provider immediately.

Choice E reason: Hemoglobin is not an urgent finding, as it is not given in the text. The nurse should check the child's laboratory results and compare them with the normal ranges for preschoolers. Hemoglobin is a protein in red blood cells that carries oxygen. A normal hemoglobin level for children is 11.5 to 15.5 grams per deciliter of blood³. A low hemoglobin level (anemia) may indicate blood loss, iron deficiency, or bone marrow problems. A high hemoglobin level (polycythemia) may indicate dehydration, lung disease, or heart disease. The nurse should report any abnormal hemoglobin level to the health care provider, but it is not an immediate concern.

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Correct Answer is C

Explanation

Choice A reason: Promising not to tell anyone about the abuse is not a helpful statement, as it implies that the abuse is a secret that should be hidden. This may make the child feel ashamed, guilty, or isolated. The nurse has a duty to report the abuse to the proper authorities and to protect the child from further harm.

Choice B reason: Blaming the family for the abuse is not a helpful statement, as it may cause the child to feel conflicted, angry, or fearful. The child may still love the family member who abused them, or may depend on them for their basic needs. The nurse should avoid making judgments or accusations, and instead focus on the child's feelings and safety.

Choice C reason: Reassuring the child that the abuse is not their fault is a helpful statement, as it may help the child cope with the trauma and reduce the feelings of self-blame, guilt, or shame. The nurse should validate the child's emotions and let them know that they are not responsible for the abuse or for stopping it.

Choice D reason: Suggesting to discuss the abuse with the family is not a helpful statement, as it may put the child in danger or cause them more distress. The child may not feel comfortable or safe to talk about the abuse with the family member who abused them, or with other family members who may not believe them or support them. The nurse should respect the child's privacy and boundaries, and only involve the family with the child's consent and under professional guidance.

A. Maintain the infant in the supine position. B. Limit visitors to immediate family members. C. Initiate contact precautions. D. Provide a latex-free environment.

Correct Answer is D

Explanation

Choice A reason: Maintaining the infant in the supine position is not an appropriate intervention, as it can increase the pressure on the myelomeningocele sac and cause further damage to the spinal cord. The nurse should position the infant prone or side-lying, with the head turned to one side and the hips flexed.

Choice B reason: Limiting visitors to immediate family members is not a necessary intervention, as the infant does not have an infectious condition that requires isolation. The nurse should encourage the parents and other family members to visit and bond with the infant, and provide emotional support and education.

Choice C reason: Initiating contact precautions is not a required intervention, as the infant does not have a contagious condition that poses a risk of transmission to others. The nurse should follow standard precautions, such as washing hands, wearing gloves, and disposing of contaminated materials properly.

Choice D reason: Providing a latex-free environment is an essential intervention, as the infant has a high risk of developing a latex allergy due to the frequent exposure to latex products during surgery and other procedures. The nurse should avoid using latex gloves, catheters, syringes, bandages, or other items that contain latex, and use alternative materials instead. The nurse should also label the infant's chart, crib, and door with a latex allergy alert.

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Which of the following findings should the nurse report to the health care provider immediately? (select all that apply)

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

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?

Correct Answer is D

Explanation

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