Based on developmental norms for a 5-year-old child, at what apical pulse did the nurse decide to withhold a scheduled dose of digoxin (Lanoxin) elixir and notify the health care provider?

Correct Answer: C

Rationale: For a 5-year-old child, an apical pulse below 90 beats/min is a reason to withhold digoxin. Digoxin is a medication commonly used to treat heart conditions, and its administration is based on heart rate parameters. A pulse rate below 90 beats/min indicates bradycardia. In pediatric patients, bradycardia below this threshold may be a sign of toxicity or potential adverse effects of digoxin, necessitating withholding the medication and informing the healthcare provider. Choices A, B, and D are incorrect as they represent pulse rates above the threshold for withholding digoxin in a 5-year-old child.

Correct Answer: A

Rationale: The correct answer is A: Teaching proper care procedures. In this scenario, focusing on teaching the mother proper care procedures is crucial as she is the nurturer in the family and will likely be the primary caregiver for the child. This will empower her to provide appropriate care and support for her daughter during the recovery process. Choices B, C, and D are not the most appropriate activities for the mother in this situation. Dealing with insurance coverage, determining treatment success, and transmitting information to family members are important but not as directly relevant to the immediate care needs of the child's broken arm.

Correct Answer: C

Rationale: Asking about the gestational age is crucial in determining the stage of labor and assessing potential complications. This information helps in understanding the progress of labor and making appropriate decisions regarding the management of the delivery process. Choices A, B, and D are not as pertinent at this point in providing immediate care or assessing the situation compared to knowing the gestational age.

Correct Answer: B

Rationale: The correct answer is to offer a pacifier to the infant before administering tube feeding. Offering a pacifier helps stimulate the sucking reflex, preparing the infant for feeding and promoting digestion and comfort. Irrigating the tube with water (Choice A) is not typically the first action before tube feeding and may not be necessary. Slowly instilling formula (Choice C) should only be done after the infant is prepared for feeding. Placing the infant in the Trendelenburg position (Choice D) is not necessary and may not be recommended for tube feeding.

Correct Answer: D

Rationale: In this scenario, option D is the correct choice. The nurse should reassure the parent that while the catheterization procedure may be uncomfortable for the infant, it is necessary for obtaining a sterile urine specimen and that there should not be any damaging long-term psychological effects on the baby. It is essential for the nurse to provide this reassurance to alleviate the parent's fears and ensure the procedure is carried out effectively. Option A is incorrect because obtaining a "clean catch" specimen may not always be feasible or reliable for obtaining a sterile urine sample in infants. Option B is also incorrect as the priority in this situation is the medical necessity of obtaining a sterile specimen rather than the parent's fears. Option C, although acknowledging the concern, does not address the reassurance aspect needed to support the parent through the procedure. Educationally, it is important for pediatric nurses to understand how to communicate effectively with parents and address their concerns regarding medical procedures for their children. Providing clear explanations, reassurance, and empathy are key components of pediatric nursing care when dealing with anxious parents.