Correct Answer: D

Rationale: Severe skin breakdown in the diaper area is a significant finding indicating a potential health issue that needs immediate attention. It may be a sign of a skin condition, such as a diaper rash, which can cause discomfort and pain for the infant. Addressing this concern promptly is crucial to prevent further complications and ensure the baby's well-being. The other choices may also be important in assessing the overall situation of the family, but in terms of immediate care for the infant, the severe skin breakdown takes priority.

Correct Answer: B

Rationale: Administering the scheduled dose is appropriate in this scenario. The nurse obtained an apical heart rate of 128 bpm, which is within the expected range for a 2-year-old child.
Therefore, there is no immediate concern to withhold the scheduled dose of digoxin. Determining the pulse deficit is not necessary as the heart rate is appropriate. Calculating the safe dose range is not needed as the current dose is within the therapeutic range. Reviewing the serum digoxin level may be indicated later for monitoring but is not urgent based on the heart rate assessment. Administering the scheduled dose of digoxin is the correct action at this time.

Correct Answer: B

Rationale: Increased urine output is a reliable indicator that hydration status is improving. While alertness and playfulness are positive signs, increased urine output directly reflects improved hydration. Stable vital signs are important but may not directly indicate hydration status.
Tolerating small amounts of oral fluids is a good sign but may not be as direct an indicator as increased urine output.

Correct Answer: B

Rationale: The correct answer is B. Infants should not be given cow's milk before 1 year of age as it can interfere with iron absorption and lead to anemia.
Choice A is incorrect as avoiding sugary water is actually a good practice.
Choice C is unrelated to iron-deficiency anemia.
Choice D, not liking peaches or pears, is also not directly related to iron-deficiency anemia.

Correct Answer: C

Rationale: Children with von Willebrand disease have a deficiency in a clotting protein, putting them at risk of bleeding episodes. The priority nursing intervention for a child with von Willebrand disease is to guard against bleeding injuries to prevent excessive bleeding or hemorrhage.

Choices A, B, and D are not the priority interventions for von Willebrand disease. While reducing exposure to infection is important for any hospitalized child, it is not the priority for von Willebrand disease. Eliminating contact with cold objects is more relevant for conditions like Raynaud's disease. Reducing contact with other children is not a specific priority related to managing von Willebrand disease.