A nurse is caring for a 15-month-old child in a clinic. Which of the following actions should the nurse take? (See the chart for additional client information.)

Correct Answer: A

Rationale: In this scenario, the correct action for the nurse to take is to administer the DTaP vaccine to the 15-month-old child. The DTaP vaccine is typically recommended for children at this age to protect against diphtheria, tetanus, and pertussis. Administering this vaccine aligns with the standard immunization schedule for pediatric patients. Option B, administering the rotavirus vaccine, is not the most appropriate action in this case as the child's age indicates that they have likely already received the rotavirus vaccine earlier in infancy. Rotavirus vaccination is typically given in multiple doses during infancy. Option C, holding immunizations until the fever subsides, is not recommended as mild illnesses like low-grade fevers do not contraindicate routine vaccinations. It is important to educate parents that mild illnesses should not delay vaccinations unless the child is significantly unwell. Option D, administering the hepatitis A vaccine, is not the priority at this age unless specifically indicated based on the child's medical history or risk factors. Hepatitis A vaccination is not typically administered at 15 months as part of the routine immunization schedule. Educationally, this question emphasizes the importance of understanding the recommended immunization schedule for pediatric patients and the rationale behind each vaccine. It highlights the nurse's role in providing evidence-based care and promoting preventive health measures for children. By selecting the correct answer, the nurse demonstrates competency in pediatric vaccine administration and adherence to best practices in pediatric care.

Correct Answer: D

Rationale: In caring for a child with cystic fibrosis, addressing the finding of increased cough with thick mucus is the priority for the nurse. This is because thick mucus in the airways is a hallmark of cystic fibrosis, leading to airway obstruction, decreased lung function, and increased risk of respiratory infections. By addressing this symptom, the nurse can help improve the child's respiratory status and overall quality of life. Difficulty in gaining weight is a common issue in cystic fibrosis due to malabsorption, but addressing respiratory symptoms takes precedence as it directly impacts the child's breathing and oxygenation. Loose, fatty stools are characteristic of cystic fibrosis due to pancreatic insufficiency, but they are not immediately life-threatening compared to respiratory complications. Educationally, understanding the priority of addressing respiratory symptoms in cystic fibrosis is crucial for nurses caring for pediatric patients with this condition. By grasping the significance of managing respiratory manifestations promptly, nurses can enhance patient outcomes and provide holistic care to children with cystic fibrosis.

Correct Answer: A

Rationale: Rationale: The correct answer is A) Increase the child's calorie intake. In cystic fibrosis, a child has increased energy needs due to the malabsorption of nutrients and increased work of breathing. Therefore, it is crucial to encourage parents to increase the child's calorie intake to meet their energy demands and promote growth and development. Adequate nutrition also supports the immune system, helps maintain a healthy weight, and improves overall health outcomes in children with cystic fibrosis. Option B) Administer oxygen therapy regularly is incorrect because oxygen therapy is not a routine treatment for cystic fibrosis. Oxygen therapy is typically used in respiratory conditions where there is a deficiency in oxygen saturation, which is not a primary feature of cystic fibrosis. Option C) Limit physical activity is incorrect because regular physical activity is important for overall health and well-being, including in children with cystic fibrosis. Exercise can help improve lung function, cardiovascular health, and overall quality of life in these children. Option D) Provide small, frequent meals is incorrect because while it is beneficial to provide easy-to-digest, small, and frequent meals for some children with cystic fibrosis who may have pancreatic insufficiency, the primary focus should be on increasing the overall calorie intake to meet the child's energy needs. Educational Context: Understanding the specific care needs of children with cystic fibrosis is essential for nurses caring for pediatric patients with this condition. By emphasizing the importance of increasing the child's calorie intake, nurses can help parents optimize their child's nutritional status and overall health outcomes. Providing comprehensive education to parents can empower them to actively participate in the management of their child's cystic fibrosis and promote better health outcomes for the child.

Correct Answer: C

Rationale: In caring for a child with a seizure disorder, option C, which is placing a soft object under the child's head, is the correct intervention. This is important because it helps to prevent injury to the child during the seizure episode by providing cushioning and support for the head. Placing a soft object under the head can also help maintain proper alignment of the airway, which is crucial for adequate oxygenation during the seizure. Options A, B, and D are incorrect interventions for a child having a seizure. Inserting an oral airway during a seizure (option A) can potentially cause injury to the child's mouth or teeth due to involuntary jaw clenching. Turning the child onto their back (option B) can lead to airway obstruction or aspiration if the child vomits. Restraining the child (option D) during a seizure may increase the risk of injury and is not recommended as it can also lead to increased agitation and potential harm. In an educational context, understanding the appropriate interventions during a seizure in a child with a seizure disorder is crucial for nurses caring for pediatric patients. Proper training and knowledge in managing seizures can help prevent complications and ensure the safety and well-being of the child during such episodes. It is essential for healthcare providers to stay updated on best practices and guidelines for managing pediatric patients with seizure disorders to deliver safe and effective care.

Correct Answer: D

Rationale: In caring for a child with a history of developmental delay, it is crucial for nurses to consider a holistic approach to their assessment. The correct answer, option D (All of the above), is the most appropriate choice in this scenario. Developmental delays can stem from a variety of causes, including neurological disorders, genetic factors, and environmental influences. By selecting option D, the nurse acknowledges the multifactorial nature of developmental delays and demonstrates an understanding of the need to assess the child comprehensively. Option A (Neurological disorder) is a common cause of developmental delays in children. Conditions such as cerebral palsy, epilepsy, or brain malformations can impact a child's development. While neurological disorders are significant contributors, they do not represent the sole cause of developmental delays. Therefore, choosing only option A would overlook other potential factors. Option B (Genetic disorder) highlights the role of genetic influences in a child's development. Genetic conditions like Down syndrome, Fragile X syndrome, or other chromosomal abnormalities can lead to developmental delays. While genetic factors play a crucial role, focusing solely on genetics may limit the nurse's assessment scope and overlook other crucial aspects contributing to the child's condition. Option C (Environmental factors) emphasizes the impact of the child's surroundings on their development. Environmental factors such as exposure to toxins, poor nutrition, lack of stimulation, or socioeconomic challenges can all influence a child's developmental trajectory. While environmental factors are significant, they do not act in isolation and often interact with genetic and neurological factors to shape a child's development. In an educational context, understanding the diverse causes of developmental delays is vital for nurses working in pediatric care. By recognizing the complex interplay of neurological, genetic, and environmental factors, nurses can provide comprehensive care tailored to each child's unique needs. This question reinforces the importance of a thorough assessment process and highlights the need for a holistic approach when caring for children with developmental delays.