A 2-year-old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?

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: C

Rationale: When assessing a child with acute glomerulonephritis (AGN), a common trigger to expect in the nursing history is a recent strep throat infection. AGN can be triggered by a streptococcal infection, leading to the deposition of immune complexes in the glomeruli. This finding is crucial as it helps identify a potential cause for the development of AGN in the child. Choices A, B, and D are incorrect as high blood cholesterol levels, increased thirst and urination, and recent DPT immunization are not directly associated with triggering acute glomerulonephritis in children.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Explaining the association between drinking soda and dental caries. This is the most appropriate response because sweetened soda is a major contributor to dental caries, especially in young children. By discussing this with the mother, the nurse can educate her about the negative impact of soda on her child's oral health, including tooth decay and cavities. Option A) Encouraging 2-word phrases in speech development for a 2-year-old is not the most relevant response to the situation described. While speech development is important, addressing the soda consumption issue takes precedence due to its immediate health implications. Option C) Discussing the link between drinking soda and childhood obesity is also important, but given the child's current age and behavior, focusing on dental health is more urgent in this case. Option D) Emphasizing the importance of toddlers sleeping 10 hours a night, although essential for overall well-being, is not directly related to the child's soda consumption and its associated health risks. In an educational context, it is crucial for pediatric nurses to provide anticipatory guidance to parents regarding common childhood health issues. By addressing the impact of sweetened soda on dental health in this case, the nurse can empower the mother to make informed decisions to promote her child's overall well-being. This scenario highlights the significance of preventive care and parental education in pediatric nursing practice.

Correct Answer: D

Rationale: It is crucial for the nurse to educate the mother that giving pain medication around the clock helps manage pain effectively and improves the child's quality of life. This approach ensures a more consistent level of pain relief and prevents the pain from becoming severe, which can be more challenging to manage. Choices A, B, and C do not address the importance of consistent pain management and may not provide adequate relief for the child's condition.