The nurse is assessing a 4-year-old child who is brought to the clinic for a routine checkup. The child's parent reports that the child has been more irritable and less active over the past week. The nurse notes a petechial rash on the child's trunk and extremities. What should the nurse do first?

Correct Answer: D

Rationale: Petechial rash can be a sign of a serious condition like meningitis, and the healthcare provider should be notified immediately.

Correct Answer: A

Rationale: The correct instruction for the nurse to provide to the parents is to wash the child's bed linens and clothing in hot soapy water. This is essential to eliminate head lice as they can survive on bedding and clothing. It is also important to wash any other items that the child may have used or come into contact with, such as brushes and combs, to prevent reinfestation. Rewashing the child's hair following an isolation period is not necessary, and taking the child to a hair salon for a shampoo and shorter haircut is not a recommended treatment for head lice.

Correct Answer: B

Rationale: In a sickle cell crisis, pain management is a priority to alleviate the child's suffering. Administering the prescribed pain medication is crucial to address the severe pain experienced by the child. Warm compresses, fluid intake, and oxygen saturation monitoring are important interventions but should follow the priority of pain management in this situation.

Correct Answer: B

Rationale: Mixing formula with rice cereal is beneficial for infants with GERD as it thickens the feed, helping to reduce the risk of reflux. This can aid in promoting adequate nutrition and minimizing symptoms associated with GERD in infants.

Correct Answer: B

Rationale: Notifying the healthcare provider is crucial when an infant scheduled for intussusception reduction passes a soft-formed brown stool as it may indicate spontaneous reduction of the intussusception. The healthcare provider needs to be informed to assess if the procedure is still necessary or if further evaluation is required.

Correct Answer: C

Rationale: Administering prescribed pain medication at the first sign of pain is crucial in managing sickle cell anemia-related pain effectively. Prompt administration helps prevent the pain from escalating and becoming severe, enhancing the child's comfort and quality of life. Cold compresses, rest, and diet modifications may play supportive roles but are not as directly impactful in addressing acute pain episodes associated with sickle cell anemia.

Correct Answer: A

Rationale: Administering a bronchodilator is the initial priority as it helps open the child's airways, reducing the wheezing and shortness of breath. This intervention aims to provide immediate relief and improve the child's respiratory distress.

Correct Answer: D

Rationale: Positioning the infant on the stomach occasionally when awake and active can help prevent flat spots on the head.

Correct Answer: B

Rationale: In children with gastroenteritis, assessing hydration status is essential as they are at risk of dehydration from vomiting and diarrhea. Monitoring hydration helps prevent complications and guides appropriate interventions to maintain the child's fluid balance.