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This statement is incorrect because adding Polycose to the baby's bottles can increase the osmolality of the formula and cause dehydration. Polycose is a glucose polymer that can be used to supplement calories for infants who are underweight, but not for those with heart failure.

This statement is incorrect because feeding the baby on a schedule every 4 hours can cause overfeeding and increase the workload of the heart. Infants with heart failure should be fed on demand, when they show signs of hunger, and not by the clock.

This statement is incorrect because limiting the baby's crying to 15 minutes prior to each feeding can cause stress and anxiety for both the baby and the parent. Crying is a normal way for infants to communicate their needs and emotions, and it should not be restricted. Instead, the parent should try to soothe the baby and reduce environmental stimuli that can trigger crying.

This statement does not indicate a risk for rheumatic carditis, but rather a possible respiratory infection or asthma. Rheumatic carditis is an inflammatory condition of the heart valves that can result from untreated streptococcal pharyngitis.

This statement does not indicate a risk for rheumatic carditis, but rather a sign of heart failure. Dyspnea, tachypnea, and hypoxia are common manifestations of heart failure in children with congenital heart defects.

This statement does not indicate a risk for rheumatic carditis, but rather a normal finding for a client who has an IV access. A peripheral saline lock is used to administer fluids and medications as needed, and it should be monitored for signs of infection, infiltration, or phlebitis.

This statement is incorrect because administering iron at bedtime can cause gastrointestinal upset and interfere with the child's sleep. Iron should be given between meals or one hour before meals for better absorption.

This statement is incorrect because administering iron at mealtimes can reduce iron absorption. Iron can bind with certain substances in food, such as calcium, phytates, and tannins, and make it less available for the body.

This statement is incorrect because giving iron with milk can decrease iron absorption. Milk contains calcium, which can interfere with iron absorption. Milk can also cause nausea and vomiting when taken with iron.

This statement is incorrect because coarctation of the aorta is a condition where the aorta, the main artery that carries blood from the heart to the body, is narrowed. This causes increased pressure in the upper body and decreased pressure in the lower body, reducing the blood flow to the kidneys and other organs.

This statement is incorrect because tricuspid atresia is a condition where the tricuspid valve, which separates the right atrium and the right ventricle, is missing or abnormally developed. This prevents blood from flowing from the right atrium to the right ventricle, decreasing the blood flow to the lungs and causing cyanosis.

This statement is incorrect because tetralogy of Fallot is a condition that involves four defects: a large ventricular septal defect, pulmonary stenosis, overriding aorta, and right ventricular hypertrophy. These defects cause blood to bypass the lungs and mix with oxygen-poor blood in the aorta, decreasing the blood flow to the lungs and causing cyanosis.

Increased appetite is not a common finding in children with brain tumors. On the contrary, they may have decreased appetite, nausea, vomiting, or weight loss due to increased intracranial pressure or tumor location.

Negative Babinski reflex is a normal finding in children over 2 years old and adults. It means that the toes curl downward when the sole of the foot is stimulated. A positive Babinski reflex, which means that the big toe moves upward and the other toes fan outward, is a sign of damage to the corticospinal tract, which may be caused by a brain tumor.

Tachycardia, or rapid heart rate, is not a specific finding for brain tumors. It may be caused by many factors, such as fever, pain, anxiety, dehydration, or medications. However, some brain tumors may affect the autonomic nervous system, which regulates the heart rate, and cause bradycardia, or slow heart rate.

Tracheoesophageal fistula is a congenital anomaly that results from an abnormal connection between the trachea and the esophagus. It causes respiratory distress, choking, coughing, and cyanosis during feeding, and increased risk of aspiration pneumonia.

Inguinal hernia is a protrusion of abdominal organs through the inguinal canal into the scrotum or labia. It causes a bulge in the groin area that may increase in size with crying or straining. It may also cause pain, vomiting, and impaired blood flow to the herniated tissue.

Hypertrophic pyloric stenosis is a narrowing of the pyloric sphincter due to hypertrophy of the surrounding muscle. It causes projectile vomiting, dehydration, weight loss, and a palpable olive-shaped mass in the upper right quadrant.

Gastrointestinal system is not the primary system affected by Kawasaki disease, although some children may have symptoms such as diarrhea, vomiting, or abdominal pain. These are not specific to Kawasaki disease and may be caused by other conditions.

Respiratory system is not the primary system affected by Kawasaki disease, although some children may have symptoms such as cough, rhinorrhea, or wheezing. These are not specific to Kawasaki disease and may be caused by other conditions.

Integumentary system is not the primary system affected by Kawasaki disease, although some children may have symptoms such as rash, peeling of the skin, red eyes, red lips, and red tongue. These are not specific to Kawasaki disease and may be caused by other conditions.

Droplet precaution is not indicated for a child who has leukemia and a critically low platelet count, unless the child has a respiratory infection that is transmitted by droplets. Droplet precaution involves wearing a mask when within 3 feet of the child, and placing the child in a private room or with a roommate who has the same infection.

Neutropenic precaution is indicated for a child who has leukemia and a critically low neutrophil count, as it reduces the risk of infection and sepsis. Neutropenic precaution involves placing the child in a private room with positive pressure airflow, wearing gloves, gown, and mask when entering the room, and restricting visitors who are ill or immunocompromised.

Contact precaution is not indicated for a child who has leukemia and a critically low platelet count, unless the child has a skin or wound infection that is transmitted by direct or indirect contact. Contact precaution involves wearing gloves and gown when entering the room, and placing the child in a private room or with a roommate who has the same infection.

Acidic odors are not a sign of a perforated appendix, but rather a possible indication of gastroesophageal reflux disease (GERD), which is a condition that causes stomach acid to flow back into the esophagus¹.

Narrow fever is not a term that is commonly used in medicine. Fever is a general sign of infection or inflammation, and it can be present in both acute appendicitis and perforated appendix. However, fever alone is not a reliable indicator of the severity or location of the problem³.

Rigid abdomen is a sign of peritonitis, which is a possible consequence of a perforated appendix. Peritonitis causes the abdominal muscles to contract and become stiff, making the abdomen hard and tender to touch². However, rigidity can also occur in other conditions that cause intra-abdominal inflammation, such as pancreatitis or cholecystitis⁴.

Choice E reason: Nausea is a common symptom of acute appendicitis, but it is not specific to a perforated appendix. Nausea can be caused by irritation of the stomach or the nerves that control vomiting. It can also occur in other gastrointestinal disorders, such as gastritis or gastroenteritis⁵.

Determining if the child is having pain is important, but it is not the immediate priority. Pain assessment will help in managing the child’s comfort and can provide additional information about the condition. However, in the case of Wilms tumor, which is a common kidney cancer in children, the priority is to prevent any action that could potentially cause tumor spillage or spread.

Scheduling the child for an abdominal ultrasound is a necessary diagnostic step, but it is not the immediate priority. The ultrasound will help in assessing the size and extent of the tumor, but the first action should be to ensure that the tumor is not disturbed.

Obtaining a urine specimen for analysis is important for diagnosing the cause of the hematuria (blood in the urine), which is a common symptom of Wilms tumor. However, this is not the immediate priority compared to preventing potential harm to the child by avoiding pressure on the abdominal area.

This test will not indicate if your child has rheumatic fever, as it does not measure the inflammation or damage to the heart, joints, or other organs that rheumatic fever can cause. Rheumatic fever is diagnosed based on the presence of two major or one major and two minor criteria, as well as evidence of a preceding streptococcal infection.

This test will not indicate if your child has a therapeutic blood level of an aminoglycoside, as it does not measure the concentration of this type of antibiotic in the blood. Aminoglycosides are used to treat serious infections caused by gram-negative bacteria, and their blood levels need to be monitored to prevent toxicity and ensure efficacy.

This test will not confirm if your child has immunity to streptococcal bacteria, as it does not measure the level of protective antibodies that can prevent future infections. ASO antibodies are not protective, but rather indicate a past or present exposure to streptococcal bacteria.

This test will not indicate if your child has rheumatic fever, as it does not measure the inflammation or damage to the heart, joints, or other organs that rheumatic fever can cause. Rheumatic fever is diagnosed based on the presence of two major or one major and two minor criteria, as well as evidence of a preceding streptococcal infection.

This test will not indicate if your child has a therapeutic blood level of an aminoglycoside, as it does not measure the concentration of this type of antibiotic in the blood. Aminoglycosides are used to treat serious infections caused by gram-negative bacteria, and their blood levels need to be monitored to prevent toxicity and ensure efficacy.

This test will not confirm if your child has immunity to streptococcal bacteria, as it does not measure the level of protective antibodies that can prevent future infections. ASO antibodies are not protective, but rather indicate a past or present exposure to streptococcal bacteria.

Headaches are not a specific finding for rhabdomyosarcoma of the nasopharynx, as they can be caused by many other conditions. Headaches may occur if the tumor compresses the cranial nerves or the brain, but this is not a common manifestation.

Bleeding is not a specific finding for rhabdomyosarcoma of the nasopharynx, as it can be caused by many other conditions. Bleeding may occur if the tumor erodes the blood vessels or the mucosa, but this is not a common manifestation.

Tearing is not a specific finding for rhabdomyosarcoma of the nasopharynx, as it can be caused by many other conditions. Tearing may occur if the tumor affects the lacrimal duct or the eye, but this is not a common manifestation.

Assessing the client's erythematous rash is an important action for the nurse to take, but it is not the priority. The rash is one of the minor criteria for diagnosing acute rheumatic fever, and it may not be present in all cases. The rash is usually non-pruritic and migratory, and it appears on the trunk and extremities.

Identifying the degree of parental anxiety related to the diagnosis is an appropriate action for the nurse to take, but it is not the priority. The nurse should provide emotional support and education to the parents, and address their concerns and questions. However, this is not the most urgent action.

Using a pain-rating tool to determine the severity of the joint pain is an important action for the nurse to take, but it is not the priority. The joint pain is one of the major criteria for diagnosing acute rheumatic fever, and it is usually severe and migratory, affecting the large joints such as the knees, ankles, elbows, or wrists. The nurse should assess the pain level and provide analgesics and anti-inflammatory medications as prescribed.

Wrist restraints are not appropriate for infants who have undergone cleft lip and palate repair because they do not prevent the infant from reaching their mouth with their fingers or objects. Wrist restraints are more suitable for older children or adults who need to avoid pulling out tubes or catheters³.

Jacket restraints are not indicated for infants who have undergone cleft lip and palate repair because they do not restrict the movement of the arms or hands. Jacket restraints are more useful for children who need to be secured to a bed or chair to prevent falls or injuries³.

Mummy restraints are not recommended for infants who have undergone cleft lip and palate repair because they immobilize the entire body and can cause respiratory distress, overheating, or skin breakdown. Mummy restraints are only used for short procedures that require minimal movement, such as venipuncture or lumbar puncture³.

Recurrent epigastric pain is not a complication of peptic ulcer disease, but rather a common symptom of it. Peptic ulcer disease is the erosion of the mucosal lining of the stomach or duodenum, which can cause pain, burning, or discomfort in the upper abdomen.

Hyperactive bowel sounds are not a complication of peptic ulcer disease, but rather a normal finding in a child who has not eaten for a while. Hyperactive bowel sounds indicate increased peristalsis, which can be caused by hunger, stress, or infection.

Melena stool is a complication of peptic ulcer disease, as it indicates bleeding from the ulcer. Melena stool is black and tarry, and it has a foul odor. It means that the blood has passed through the entire digestive tract, and has been altered by the intestinal bacteria and enzymes.

Ridged abdomen is not an expected finding for an infant who has pyloric stenosis, as it indicates abdominal rigidity or guarding, which can be a sign of peritonitis or bowel obstruction. Pyloric stenosis is a narrowing of the pyloric sphincter, which causes gastric outlet obstruction and delayed gastric emptying.

Red currant jelly stools are not an expected finding for an infant who has pyloric stenosis, as they indicate blood and mucus in the stools, which can be a sign of intussusception or necrotizing enterocolitis. Pyloric stenosis does not affect the lower gastrointestinal tract, and the infant may have constipation or dehydration due to vomiting.

Distended neck veins are not an expected finding for an infant who has pyloric stenosis, as they indicate increased central venous pressure, which can be a sign of heart failure or superior vena cava syndrome. Pyloric stenosis does not affect the cardiovascular system, and the infant may have sunken fontanels or poor skin turgor due to dehydration.

Aspirin is also used to treat Kawasaki disease, as it reduces the fever, pain, and inflammation. However, it is not the first-line treatment, and it is given after IVIG to prevent thrombosis and platelet aggregation. Aspirin is given at a high dose during the acute phase, and then at a low dose until the inflammation subsides.

Penicillin is not indicated for Kawasaki disease, as it is an antibiotic that treats bacterial infections. Kawasaki disease is not caused by bacteria, but by an unknown trigger that activates the immune system and causes systemic vasculitis.

Acetaminophen is not effective for Kawasaki disease, as it does not reduce the inflammation or the risk of complications. Acetaminophen may be used to treat mild pain or fever, but it is not the main treatment. Moreover, acetaminophen may mask the fever and delay the diagnosis of Kawasaki disease.

Feeding the baby formula rather than breast milk is not necessary for gastroesophageal reflux, as breast milk is easier to digest and less likely to cause reflux than formula. The parent should continue to breastfeed the baby, unless there is a medical reason to switch to formula. The parent should also avoid overfeeding the baby, and burp the baby frequently during and after feedings.

Positioning the baby lying on his stomach is not recommended for gastroesophageal reflux, as it can increase the risk of aspiration, suffocation, and sudden infant death syndrome (SIDS). The parent should place the baby on his back to sleep, and elevate the head of the crib or bassinet by 30 degrees to reduce the reflux.

Thickening the baby's formula with honey is not advised for gastroesophageal reflux, as honey can cause botulism, a serious and potentially fatal illness, in infants under one year of age. The parent should not add any thickening agents to the formula, unless prescribed by the provider. Some studies suggest that thickening the formula with rice cereal may reduce the reflux, but the evidence is inconclusive and the practice may have adverse effects, such as increased caloric intake, constipation, or food allergies.

Pyloric stenosis is not a manifestation of inadequate motility of part of the intestine, but rather a hypertrophy of the pyloric muscle, which causes gastric outlet obstruction and delayed gastric emptying. Pyloric stenosis typically presents with projectile vomiting, dehydration, weight loss, and a palpable olive-shaped mass in the abdomen.

Encopresis is not a manifestation of inadequate motility of part of the intestine, but rather a condition in which a child over 4 years of age involuntarily passes stool, usually due to chronic constipation and fecal impaction. Encopresis typically presents with soiling of the underwear, abdominal pain, low self-esteem, and behavioral problems.

Enterocolitis is not a manifestation of inadequate motility of part of the intestine, but rather an inflammation of the mucosa of the small and large intestines, which can be caused by various infections, allergies, or ischemia. Enterocolitis typically presents with diarrhea, fever, abdominal pain, and dehydration.

Blood pressure is not the most reliable indicator of fluid loss, as it can be affected by many other factors, such as cardiac output, vascular resistance, and blood volume. Blood pressure may not change significantly until the fluid loss is severe and the compensatory mechanisms are overwhelmed.

Respiratory rate is not the most reliable indicator of fluid loss, as it can be affected by many other factors, such as oxygen demand, carbon dioxide levels, acid-base balance, and respiratory infections. Respiratory rate may increase as a result of fluid loss, but it is not a specific or sensitive sign.

Skin integrity is not the most reliable indicator of fluid loss, as it can be affected by many other factors, such as age, nutrition, hydration, and skin diseases. Skin integrity may deteriorate as a result of fluid loss, but it is not a quantitative or objective measure.

A high heart rate can be a sign of dehydration as the body tries to compensate for the decreased volume of blood. However, it’s important to note that a heart rate of 130/min is quite high for a 3-year-old child, even considering that children generally have higher heart rates than adults.

Urine specific gravity is a measure of the concentration of solutes in the urine. A lower value (closer to 1.000) indicates more dilute urine, which can be a sign of effective rehydration. A urine specific gravity of 1.015 is within the normal range.However, many factors can affect urine composition, so doctors cannot specify low, acceptable, or high values of dehydration based solely on this measure.

Respiratory rate 24/min is not an indication of effective oral rehydration therapy, as it is within the normal range for a 3-year-old child, which is 20 to 30/min. Respiratory rate measures the number of breaths per minute, and it may increase with dehydration, fever, pain, anxiety, or other conditions.

Wheat is not a suitable food choice for a child who has celiac disease, as it contains gluten, a protein that triggers an immune response and damages the small intestine in people with celiac disease. Wheat is found in many breads, cereals, pastas, and baked goods, and it should be avoided by the child.

Barley is not a suitable food choice for a child who has celiac disease, as it contains gluten, a protein that triggers an immune response and damages the small intestine in people with celiac disease. Barley is found in some soups, stews, beers, and malt products, and it should be avoided by the child.

Rye is not a suitable food choice for a child who has celiac disease, as it contains gluten, a protein that triggers an immune response and damages the small intestine in people with celiac disease. Rye is found in some breads, crackers, cereals, and whiskey, and it should be avoided by the child.

A child recovering from a ruptured appendix is not a suitable roommate for a child who has leukemia, as a ruptured appendix can cause peritonitis, which is a serious infection of the abdominal cavity, and it can be a source of bacteria or fungi that can spread to the child who has leukemia. A child who has leukemia has a compromised immune system and is susceptible to infections.

A child who has nephrotic syndrome is not a suitable roommate for a child who has leukemia, as nephrotic syndrome can cause edema, proteinuria, hypoalbuminemia, and hyperlipidemia, and it can be associated with infections, allergies, or autoimmune disorders that can affect the child who has leukemia. A child who has leukemia has a reduced number of blood cells and is prone to bleeding, anemia, and infections.

A child who has cystic fibrosis is not a suitable roommate for a child who has leukemia, as cystic fibrosis is a genetic disorder that affects the lungs, pancreas, liver, and intestines, and it can cause chronic respiratory infections, malabsorption, and diabetes, which can compromise the health of the child who has leukemia. A child who has leukemia has a weakened immune system and is vulnerable to infections.

0.5 mL/kg/hr is not an indication of corrected fluid imbalance, as it is below the normal range for a 6-month-old infant, which is 2 to 4 mL/kg/hr. A low urinary output may indicate dehydration, renal failure, or obstruction.

2 mL/kg/hr is not an indication of corrected fluid imbalance, as it is at the lower end of the normal range for a 6-month-old infant, which is 2 to 4 mL/kg/hr. A normal urinary output does not necessarily mean that the fluid balance is restored, as the infant may still have signs of dehydration, such as sunken fontanels, poor skin turgor, or dry mucous membranes.

75 mL/kg/hr is not an indication of corrected fluid imbalance, as it is too high for a 6-month-old infant, and it may indicate overhydration, diuresis, or diabetes insipidus. A very high urinary output may cause electrolyte imbalance, hypotension, or cerebral edema.