Correct Answer: C

Rationale: During a tonic-clonic seizure, the priority nursing responsibility is to protect the child from self-injury. Applying restraints (
Choice
A) can cause harm by restricting movement during the seizure. While administering oxygen (
Choice
B) may be necessary, it is not the immediate priority during an active seizure. Inserting a plastic airway (
Choice
D) is contraindicated as it can lead to injury and is not recommended during a seizure. Protecting the child from self-injury (
Choice
C) is crucial to prevent harm from uncontrolled movements and potential falls, ensuring the safety of the child.

Correct Answer: D

Rationale: The correct answer is D. Congenital hypothyroidism in infants often leads to lethargy and difficulty staying awake due to low thyroid hormone levels. Assessing the child's ability to stay awake is crucial in identifying signs of hypothyroidism.

Choices A, B, and C are incorrect because above-normal growth, being active and playful, and having healthy-looking skin are not typical manifestations of congenital hypothyroidism. Instead, infants with hypothyroidism may exhibit poor weight gain, decreased activity, and dry, pale skin.

Correct Answer: B

Rationale: The correct answer is B: Put on gloves because standard precautions are required. Standard precautions, which include wearing gloves, are crucial in preventing the transmission of infections during immunization.
Choice A is incorrect because the immediate action should be to address the lack of gloves.
Choice C is incorrect as gloves are necessary for infection control.
Choice D is incorrect as gloves should be worn as a standard preventive measure, regardless of the child's appearance.

Correct Answer: B

Rationale: Using a doll to demonstrate the procedure is the most appropriate preoperative teaching method for a 2-year-old child. It helps them understand what to expect in a non-threatening way by providing a visual representation of the upcoming surgery. Explaining the procedure in simple terms may be too abstract for a child of this age, as they may not fully comprehend verbal explanations. Showing pictures of the hospital environment may not be as effective as using a doll, as it may not provide a concrete understanding of the actual procedure. Allowing the child to play with medical equipment is unsafe and does not adequately prepare them for the surgery, as it may lead to misunderstandings or fear regarding the equipment's actual use during the surgery.

Correct Answer: C

Rationale: The correct answer is C because using echolalia (repeating words or phrases) is not typical for a 2-year-old and may indicate the need for further evaluation.

Choices A, B, and D are within the expected developmental skills for a 2-year-old. While a 2-year-old may not be able to stand on one foot for an extended period, it is not a concerning developmental milestone at this age. Building a tower of 7 blocks and coloring outside the lines of a picture are both age-appropriate activities that demonstrate fine motor skills and creativity, respectively. However, echolalia at this age could be a sign of an underlying communication or developmental issue that warrants further assessment and monitoring.