Correct Answer: C

Rationale: The correct clinical manifestation that a nurse is likely to observe in a child with suspected intussusception is abdominal distension. Intussusception is a medical emergency where a part of the intestine folds into itself, causing obstruction. Abdominal distension is a common symptom due to the obstruction and the build-up of gases and fluids. While currant jelly stools (Choice B) are a classic sign of intussusception, they are typically seen in later stages of the condition and may not be present during the initial assessment. Projectile vomiting (Choice A) is more commonly associated with conditions like pyloric stenosis. Constipation (Choice D) is not a typical manifestation of intussusception; the condition usually presents with severe colicky abdominal pain and possible passage of blood and mucus in stools.

Correct Answer: A

Rationale: The passage of a normal brown stool in a child with intussusception could indicate spontaneous reduction of the intussusception. This change in the patient's condition is significant, requiring prompt notification of the practitioner for further evaluation and management. While measuring abdominal girth (Choice B) is important for assessing abdominal distention, it is not the priority when a potential spontaneous reduction may have occurred. Auscultating for bowel sounds (Choice C) and taking vital signs, including blood pressure (Choice D), are routine nursing assessments but do not address the immediate need to inform the practitioner of a possible change in the patient's condition that necessitates urgent attention.

Correct Answer: D

Rationale: When counseling a couple about the possibility of having a child with a genetic abnormality, it is vital for the nurse to present information in a nondirective manner. This approach empowers the couple to make decisions based on their values and preferences, respecting their autonomy. Gathering information from three generations (Choice A) may not be necessary and might overwhelm the couple with unnecessary data. Informing the family about the need for a wide range of information (Choice B) is not as critical as supporting their decision-making process through a nondirective approach. While maintaining confidentiality (Choice C) is crucial, it is not the most important aspect compared to ensuring the couple can make informed choices that align with their beliefs and wishes.

Correct Answer: A

Rationale: Monitoring liver function tests regularly is crucial when a child with JIA is on methotrexate due to the potential hepatotoxicity associated with this medication. Methotrexate can lead to liver damage, hence monitoring helps in early detection and intervention. Encouraging regular exercise (Choice B) is generally good for children with JIA to maintain joint mobility and muscle strength, but it is not directly related to methotrexate therapy. Providing high-calorie snacks (Choice C) is not a priority consideration for a child on methotrexate. Encouraging frequent handwashing (Choice D) is important for infection control, but it is not specifically associated with methotrexate therapy in a child with JIA.

Correct Answer: A

Rationale: The priority nursing intervention for a child with acute lymphoblastic leukemia (ALL) receiving chemotherapy is to prevent infection. Chemotherapy compromises the child's immune system, increasing susceptibility to infections. Preventing infection is crucial to avoid potential complications such as sepsis, which can be life-threatening. Administering chemotherapy is essential for treating ALL but preventing infection takes precedence due to the increased risk of infections associated with chemotherapy-induced immunosuppression. Providing nutritional support is important for overall health but preventing infections is more critical in this context. Monitoring fluid intake is significant, but the priority is to prevent infections that can have severe consequences in an immunocompromised child.