A 4-year-old weighing 15 kg produces 150 mL of urine in 10 hours. What should the nurse do?

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Record the urine output in the chart. The rationale behind this is that the child's urine output of 150 mL in 10 hours falls within the expected range for a 4-year-old weighing 15 kg. By recording this urine output in the chart, the nurse is documenting the child's renal function, which is crucial for monitoring overall health status. Option A) Notify the physician; urine output is too low is incorrect because the urine output is actually within the normal range for a child of this age and weight. There is no indication of renal impairment based on this information alone. Option B) Encourage increased oral intake is not necessary in this case as the child's urine output is normal. Increasing oral intake without a clinical indication could lead to overhydration, which can be harmful. Option D) Administer IV fluids to rehydrate is not warranted as there is no indication of dehydration based on the urine output provided. Administering IV fluids without a valid reason can lead to fluid overload and potential complications. From an educational standpoint, understanding normal pediatric urine output parameters is essential for nurses caring for pediatric patients. By accurately assessing and documenting urine output, nurses can detect early signs of renal dysfunction or dehydration. This question highlights the importance of critical thinking and clinical judgment in pediatric nursing practice.

Correct Answer: A

Rationale: In the context of refeeding syndrome, the major changes that may occur typically affect electrolytes. Refeeding syndrome is a potentially fatal condition that can occur when an individual who is malnourished or starved undergoes rapid reinstitution of feeding. When food is reintroduced, there is an increase in insulin secretion, leading to a shift of electrolytes (especially phosphorus, potassium, and magnesium) into cells for energy metabolism and storage. This shift can result in severe electrolyte imbalances, particularly hypophosphatemia, which can lead to cardiac arrhythmias, respiratory failure, seizures, and even death. Option A is correct because electrolyte imbalances are the hallmark of refeeding syndrome. Options B, C, and D are incorrect because while serum proteins, hormones, and liver enzymes may also be affected during refeeding syndrome, electrolyte disturbances are the most significant and life-threatening consequences. Educationally, understanding the pathophysiology of refeeding syndrome is crucial for healthcare providers working with malnourished individuals, especially in pediatric patients who may be more vulnerable. Proper monitoring, gradual reintroduction of nutrition, and close observation for signs of electrolyte imbalances are essential in preventing and managing refeeding syndrome in pediatric patients.

Correct Answer: D

Rationale: In pediatric pharmacology, understanding the appropriate drug dosages for children is crucial due to their unique physiological characteristics. The correct answer to the question is option D) 100. In the first minutes of birth, a newborn's heart rate can be as high as 100 beats per minute. This is considered a normal physiological response as the newborn transitions from intrauterine to extrauterine life. It is important for nurses and healthcare providers to be aware of these normal vital signs in the immediate postnatal period to ensure the newborn's well-being. Options A) 50, B) 60, and C) 80 are incorrect because they fall below the normal range of heart rate for a newborn in the first minutes after birth. A heart rate of 50, 60, or 80 beats per minute would be considered bradycardia in a newborn and may indicate a need for medical intervention. Understanding the normal vital signs in newborns is essential for early identification of any potential issues and prompt intervention if necessary. Educationally, this question highlights the importance of knowing normal pediatric vital signs, especially in the immediate postnatal period. Nurses and healthcare providers must be able to quickly assess and interpret vital signs in newborns to provide appropriate care and support. This knowledge is essential for passing the NCLEX exam and for ensuring safe and effective clinical practice in pediatric settings.

Correct Answer: C

Rationale: In infants and young children, it is normal for the anterior fontanel to remain open up to about 18-24 months of age. The fontanel serves an important function in allowing the skull to grow and expand as the brain grows rapidly during infancy. Therefore, the presence of an open fontanel in a 2-year-old child is a normal finding and does not warrant any immediate concern or action. It does not indicate abuse, the need to notify the doctor, or inquire about a family history of Tay-Sachs disease.

Correct Answer: B

Rationale: Playing in sand at the park can increase the risk of lead poisoning in children because sand can be contaminated with lead particles from various sources such as old paint, industrial pollution, or leaded gasoline residues. When children play in sand, they may accidentally ingest the contaminated particles while handling or playing with the sand. This ingestion can lead to lead poisoning, as even small amounts of lead can be harmful to children's health. Therefore, playing in sand at the park poses a higher risk of lead exposure compared to the other activities listed.