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Rationale for Correct Choices:

• Consult the child life specialist for guidance: A child life specialist can help the parent navigate the difficult conversation with their adolescent, providing strategies for addressing sensitive topics like metastasis and death.
• Reinforce teaching to the parent regarding the adolescent's potential emotional responses: Educating the parent on common emotional responses helps them prepare for and better support their adolescent through this challenging time.

Rationale for Incorrect Choices:

• Encourage the parent to hide their emotions from their adolescent: Hiding emotions can create barriers to trust and communication, which can make the adolescent feel isolated or confused.
• Instruct the parent to withhold the test results from their adolescent: Withholding important information can prevent the adolescent from understanding their condition and making informed decisions about their care.
• Discourage the parent from discussing the possibility of death with their adolescent: Avoiding discussions about death can prevent the adolescent from processing their emotions and understanding the reality of their situation.
• Collaborate with the RN to initiate a referral for admission to hospice care: Hospice care should only be considered after emotional support and clear communication have been established, not prematurely without addressing emotional needs first.

Rationale for Correct Choices:

• Increased Intracranial Pressure: The infant's symptoms (irritability, vomiting, bulging anterior fontanel, and tense fontanel) suggest increased intracranial pressure, a potential complication of hydrocephalus and ventriculoperitoneal shunt malfunction.
• Measure head circumference: Measuring head circumference is essential in assessing for increased intracranial pressure, as it can help identify changes in the volume of the head due to fluid buildup.
• Insert nasogastric tube: Inserting a nasogastric tube is often necessary to manage vomiting and ensure adequate hydration and nutrition, especially when the infant is unable to feed properly due to increased intracranial pressure.
• Behavioural changes: Monitoring for changes in behaviour, such as lethargy or decreased responsiveness, is critical in assessing the progression of increased intracranial pressure.
• Pupillary response: Pupillary response is an important parameter to monitor because changes in the size, shape, and reactivity of the pupils can indicate increased intracranial pressure or brainstem involvement.

Rationale for Incorrect Choices:

• Paralytic ileus: While the infant is having stool issues, the primary symptoms of irritability, vomiting, and bulging fontanel are more indicative of increased intracranial pressure. Paralytic ileus is generally associated with absent bowel sounds and abdominal distension.
• Otitis media: Otitis media typically presents with fever, ear pain, and irritability, but the infant’s bulging fontanel, vomiting, and irritability are more suggestive of intracranial pressure. Otitis media does not cause neurological symptoms like a tense fontanel.
• Peritonitis: Peritonitis usually presents with abdominal distension, guarding, or signs of sepsis, which are not evident here. The infant’s symptoms point more towards neurological issues related to the ventriculoperitoneal shunt or increased intracranial pressure.
• Prepare the infant for myringotomy: Myringotomy is performed for severe ear infections with fluid accumulation behind the eardrum (otitis media), but the infant's presentation suggests a neurological issue, not an ear infection.
• Place the child in an infant seat: Placing the infant in an infant seat may provide temporary comfort but does not address the underlying neurological issue, and this action does not help manage the potential condition.
• Plan to assist with the administration of intravenous antibiotics: While infection (e.g., shunt infection leading to hydrocephalus) is a possibility, the immediate nursing actions focus on confirming and managing the elevated ICP.
• Bowel sounds: Monitoring bowel sounds is more relevant to gastrointestinal conditions, such as paralytic ileus or peritonitis, which are not the primary concern here.
• Tympanic perforation relates to an ear condition and is not a relevant parameter for monitoring increased intracranial pressure.
• Abdominal distension: Abdominal distension is usually associated with gastrointestinal problems like peritonitis or paralytic ileus. However, the infant’s clinical presentation (neurological symptoms) suggests increased intracranial pressure.

• Steatorrhea: Steatorrhea (fatty stools) is a common symptom of cystic fibrosis due to pancreatic insufficiency. It is not directly related to the current acute infection (Streptococcus pneumonia).
• Barrel chest: A barrel chest is a chronic sign of cystic fibrosis caused by long-standing lung disease and airway obstruction. It is not related to the acute infection (Streptococcus pneumonia) but reflects the long-term effects of cystic fibrosis.
• Hemoptysis 300 mL: Hemoptysis, 300 mL, is a significant and concerning sign of potential worsening condition. While blood-streaked sputum was initially noted, a large volume like 300 mL indicates significant bleeding from the lungs.
• WBC count 17,000/mm³: The initial WBC count was 22,000/mm3, indicating an active bacterial infection. A decrease to 17,000/mm3, while still elevated, suggests that the body's inflammatory response is potentially improving and that the infection IS responding to treatment.
• Oxygen saturation 95% on 1 L oxygen via nasal cannula: The oxygen saturation has improved (from 92% to 95%) with a reduction in the amount of supplemental oxygen, indicating that the patient’s respiratory status is improving.
• Respiratory rate 32/min: The respiratory rate has decreased slightly from 36/min to 32/min, indicating that the patient’s breathing is becoming more stable as the condition improves. However, respiratory rate should still be closely monitored as part of overall progress.

Rationale for Correct Choice:

• Ceftriaxone: The child has an allergy to cephalosporins, which includes ceftriaxone. Since ceftriaxone is a cephalosporin antibiotic, it would be crucial for the nurse to clarify this prescription to avoid an allergic reaction.
• Medication allergy: The child’s medical history includes an allergy to cephalosporins, and ceftriaxone is a cephalosporin. Administering ceftriaxone to a child with this allergy could lead to an anaphylactic reaction or other serious adverse effects.

Rationale for Incorrect Choices:

• Ondansetron: Ondansetron is an antiemetic used for vomiting, and there is no evidence in the child’s history to suggest that this medication is contraindicated. The prescription for ondansetron does not require clarification based on the child's condition.
• Methylprednisolone: Methylprednisolone is a corticosteroid used to reduce inflammation. While it’s important to monitor the child for potential side effects, there is no indication that this medication would be contraindicated based on the child's condition.
• Budesonide: Budesonide is a corticosteroid inhaler commonly used for asthma or wheezing. There is no indication that this medication should be clarified as it’s appropriate for the child’s symptoms of wheezing and pneumonia.
• Albuterol nebulizer solution: Albuterol is a bronchodilator used to treat wheezing and bronchospasm. There is no indication that this medication needs clarification, as it is appropriate for the child’s respiratory symptoms.
• Vital signs: While the child’s vital signs show an elevated heart rate and respiratory rate, they do not provide a reason to clarify a medication prescription. These vital signs are likely a result of the infection and fever rather than an issue that affects medication choices.
• WBC count: The WBC count is mildly elevated, which is consistent with infection, but there is no reason to question medication orders based solely on this result. It does not affect the choice of antibiotics or other prescribed treatments.
• Scheduled chest x-ray: The scheduled chest x-ray is a part of the diagnostic process and does not impact the prescription of medications. It does not need to be clarified with respect to the medications ordered.
• Sodium level: The sodium level is within the normal range, so there is no need to clarify medication prescriptions based on this finding. It does not influence medication choices directly.

• Maintain infant in supine position: Given the infant's respiratory distress, including labored breathing, retractions, and nasal flaring, placing the infant in a supine position could worsen respiratory difficulties. The infant should be kept upright or in a semi-Fowler’s position to promote optimal breathing.
• Prepare the infant for a chest x-ray: A chest x-ray is crucial to assess the infant’s respiratory status and potential cardiac issues to identify any underlying causes of the symptoms, such as pneumonia, wheezing, cough, and labored breathing.
• Maintain infant on continuous pulse oximetry: Continuous pulse oximetry is essential for monitoring the infant's oxygen saturation levels. The infant is already on supplemental oxygen, and continuous monitoring will ensure that the oxygen levels are maintained and help identify any worsening of the respiratory condition.
• Monitor intake and output: Given the infant's poor feeding (consuming only half a bottle in the past 24 hours), monitoring intake and output is crucial to assess hydration status and nutritional needs. Decreased intake and output can indicate dehydration or worsening of the infant's condition.
• Initiate a peripheral IV line: Due to the infant’s poor feeding and the possibility of dehydration, establishing a peripheral IV line will allow for proper hydration and the administration of fluids or medications, as necessary, for the infant’s condition.
• Offer small, frequent feedings: Offering small, frequent feedings is appropriate for an infant with respiratory distress and decreased appetite. This can reduce the risk of aspiration and help ensure the infant receives adequate nutrition despite the difficulty with feeding.

A. This area is over the cheek and facial soft tissue. Cephalohematomas do not occur here, as they are confined to the skull bones under the periosteum.

B. This point is positioned over the parietal area of the skull, the typical site for cephalohematoma formation due to birth trauma. Cephalohematoma is a subperiosteal hemorrhage confined to the surface of the skull, most commonly over the parietal bone, and does not cross suture lines. Palpating this area helps determine whether the lesion has resolved or calcified.

C. This region is the lower abdominal or pelvic area, which is not relevant for assessing cranial birth trauma like cephalohematoma.