A 4-year-old child with a history of frequent ear infections is brought to the clinic by the parents who are concerned about the child's hearing. What is the nurse's priority action?

Correct Answer: B

Rationale: The nurse's priority action should be to inspect the child's ears for drainage. This immediate assessment can provide valuable information about the presence of infection or fluid accumulation, which can directly impact the child's hearing. By identifying any signs of drainage, the nurse can promptly address any current issues affecting the child's ear health and hearing abilities.

Correct Answer: C

Rationale: In the case of a 2-year-old child admitted with severe dehydration due to gastroenteritis, the assessment finding that indicates the child's condition is improving is option C) Increased urine output. This is because increased urine output signifies that the kidneys are functioning well and able to concentrate urine, which is a positive sign of hydration status improving. Option A) Decreased heart rate is not a reliable indicator of improvement in dehydration as it can be a sign of cardiac compromise in severe cases. Option B) Sunken fontanelle is a sign of dehydration and would not indicate improvement. Option D) Dry mucous membranes are also a sign of dehydration and would not indicate improvement. Educationally, it is crucial for pediatric nurses to understand the signs and symptoms of dehydration in children and how to assess for improvement in their condition. Increased urine output is a key indicator of hydration status in pediatric patients and plays a vital role in monitoring their response to treatment. Nurses should prioritize assessing and monitoring urine output in dehydrated children to gauge their progress accurately.

Correct Answer: B

Rationale: Administering the scheduled dose is appropriate in this scenario as the heart rate of 128 bpm falls within the acceptable range for a two-year-old child with heart failure. It indicates that the child may benefit from the therapeutic effects of digoxin. Monitoring the heart rate closely after administration is essential to ensure the medication's effectiveness and safety.

Correct Answer: C

Rationale: Weighing the child daily is crucial in managing a child with acute glomerulonephritis as it helps in monitoring fluid retention, which is a key concern in this condition. Daily weight monitoring allows healthcare providers to assess changes in fluid status and adjust treatment accordingly. It is an essential component of the care plan to ensure the child's health status is closely monitored during the management of acute glomerulonephritis.

Correct Answer: D

Rationale: In this scenario, option D, "Demonstrates startle reflex," requires further evaluation by the nurse when assessing a 6-month-old infant. The startle reflex, also known as the Moro reflex, is typically present in newborns but should diminish or disappear by 3-4 months of age. Its persistence at 6 months could indicate a developmental delay or neurological issue that warrants further investigation by the nurse and healthcare team. Option A, "Has doubled birth weight," is a normal developmental milestone for a 6-month-old infant, indicating appropriate growth and nutrition. Option B, "Turn head to locate sound," is a typical auditory milestone for a 6-month-old infant, demonstrating developing sensory abilities. Option C, "Plays peek-a-boo," is a social and cognitive milestone that is expected around 6-8 months of age, showing engagement and interaction with the environment. In a pediatric nursing context, understanding developmental milestones is crucial for early identification of any delays or abnormalities. Nurses need to assess infants holistically to ensure they are meeting these milestones, as deviations can indicate underlying health issues or developmental concerns that require prompt intervention. Regular assessments help nurses provide appropriate care and support to promote optimal growth and development in pediatric patients.