A 4-year-old hospitalized with failure to thrive (FTT) has orders for daily weights, strict I&O, and calorie counts. Which action by the nurse is a concern?

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Weighing the child every morning after breakfast. This is a concern because weighing the child after breakfast can lead to inaccurate weight measurements. Weight should ideally be measured in a consistent manner, such as in the morning before any food or drink intake, and with the child in a similar state each time to ensure accuracy. Option B) Weighing the child with only undergarments on is actually a correct practice to standardize the weight measurement process and remove any potential inconsistencies due to clothing weight. Option C) Sitting with the child while she eats her meals is a supportive action to encourage adequate intake, which is beneficial in managing failure to thrive. Option D) Weighing the child after she has been fed is incorrect as weight measurements should be taken before any food intake to ensure consistency and accuracy. Educationally, understanding the importance of standardized procedures in healthcare practices, such as weight measurements, is crucial for accurate assessment and monitoring of pediatric patients with conditions like failure to thrive. It highlights the significance of following specific protocols to obtain reliable data for effective clinical decision-making.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) seizure. Abrupt withdrawal of baclofen, a muscle relaxant commonly used to manage spasticity, can lead to an increase in excitatory neurotransmitters in the central nervous system. This sudden imbalance can trigger seizures due to the sudden removal of the inhibitory effects of baclofen on the nervous system. Option A) depression is incorrect because although mood changes can occur with baclofen withdrawal, the most pressing concern is the risk of seizures. Option B) drowsiness is incorrect as withdrawal of baclofen is more likely to cause hyperexcitability rather than sedation. Option C) headache is incorrect as it is not a common symptom of baclofen withdrawal compared to the severe consequence of seizures. Educationally, understanding the potential consequences of abruptly stopping medications like baclofen is crucial for healthcare providers caring for pediatric patients. It highlights the importance of gradual tapering of medications to prevent adverse effects and underscores the significance of patient education regarding the risks associated with sudden discontinuation of prescribed medications. This knowledge is essential for nurses, nurse practitioners, and other healthcare professionals working in pediatric settings to ensure safe and effective patient care.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) tachypnea. Tachypnea is an increased respiratory rate, which is commonly seen in patients with asthma during an acute exacerbation. This rapid breathing is a compensatory mechanism the body uses to try to improve oxygenation. Option A) Biots respiration is characterized by irregular breathing patterns with periods of apnea. This is not typically associated with asthma. Option B) Chaney Stokes respiration is a pattern of breathing characterized by alternating periods of deep, rapid breathing followed by periods of apnea. This is not a typical finding in asthma. Option D) Bradypnea is a decreased respiratory rate, which is not consistent with the presentation of a patient with asthma experiencing difficulty breathing. Educationally, understanding the different respiratory patterns and their significance is crucial for nurses caring for pediatric patients with respiratory conditions like asthma. Recognizing tachypnea in a patient with asthma can prompt appropriate interventions and timely management to improve outcomes.

Correct Answer: D

Rationale: The correct instruction to prevent SIDS is to give the infant a pacifier at bedtime. The use of a pacifier while the infant is sleeping is associated with a decreased risk of SIDS. Other recommended preventive measures include placing the infant on their back to sleep, using a firm mattress in the crib, and avoiding soft bedding or pillows.

Correct Answer: C

Rationale: The nurse should inform the parent that the child will need pulmonary function tests every 12 to 24 months to assess lung function and response to treatment. These tests help evaluate the presence of lung disease, monitor disease progression, and assess the effectiveness of the current therapeutic regimen in managing asthma.