A nurse on the pediatric unit is observing the developmental skills of several 2-year-old children in the playroom. Which child should the nurse continue to evaluate?

Correct Answer: C

Rationale: The correct answer is C. Using echolalia, which is the repetition of words or phrases, is not typical for a 2-year-old child and may indicate the need for further evaluation. Choices A, B, and D are all within the expected developmental skills for a 2-year-old. While most 2-year-olds may not be able to stand on one foot, it is not a cause for concern at this age. Building a tower of 7 blocks and coloring outside the lines of a picture are both appropriate for a 2-year-old's developmental skills.

Correct Answer: B

Rationale: The priority nursing intervention for a child with acute lymphoblastic leukemia (ALL) is preventing infection due to their compromised immune system. Children undergoing treatment for ALL are highly susceptible to infections, making infection prevention crucial for the child's well-being and treatment success. Administering antibiotics, though important in specific cases, is not the priority in this scenario. Providing nutritional support and managing pain are significant aspects of care but take a back seat to infection prevention in this situation.

Correct Answer: A

Rationale: The priority nursing action after a tracheostomy surgery is to suction the tracheostomy tube. Suctioning helps maintain a clear airway and prevent complications such as airway obstruction or respiratory distress. While monitoring respiratory status is important, suctioning takes precedence immediately post-surgery to ensure adequate air exchange. Changing the tracheostomy dressing and ensuring tracheostomy ties are secure are also essential tasks but are secondary to the critical need for airway maintenance through suctioning.

Correct Answer: B

Rationale: In caring for a 2-year-old child with hemophilia, it is essential to prioritize safety and prevent bleeding episodes. The correct answer, using a soft toothbrush for oral care (Option B), is crucial because children with hemophilia are at risk for bleeding gums and oral mucosa. A soft toothbrush helps prevent trauma and subsequent bleeding during oral hygiene practices. Encouraging participation in contact sports (Option A) is contraindicated in hemophilia due to the high risk of injury and potential for serious bleeding episodes. Administering nonsteroidal anti-inflammatory drugs (Option C) is also not recommended as they can increase the risk of bleeding in children with hemophilia. Similarly, administering aspirin for pain (Option D) should be avoided as it can further impair the blood clotting process in these patients. Educationally, this question highlights the importance of understanding the specific care needs of children with hemophilia. It emphasizes the need for nurses to be knowledgeable about appropriate interventions to prevent complications and promote the well-being of pediatric patients with this condition. By choosing the correct option, nurses can provide safe and effective care to children with hemophilia, promoting positive health outcomes.

Correct Answer: B

Rationale: The priority nursing intervention for a child with juvenile idiopathic arthritis (JIA) is to administer nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs help manage pain and inflammation associated with JIA, making them crucial in providing relief to the child. Encouraging a diet high in protein (Choice A) may be beneficial for overall health but is not the priority in managing JIA symptoms. Applying heat to affected joints (Choice C) can provide comfort but does not address the underlying inflammation. Providing range-of-motion exercises (Choice D) is important for maintaining joint mobility but is not the priority intervention when managing acute symptoms of JIA.