Which of the following would the nurse identify as the initial priority for a child with acute lymphocytic leukemia?

Correct Answer: A

Rationale: The correct answer is A) Instituting infection control precautions. In a child with acute lymphocytic leukemia, the initial priority is to prevent infection due to the child's compromised immune system. Children with leukemia are at high risk for infection due to their decreased white blood cell count from both the disease process and treatment. Instituting infection control precautions, such as hand hygiene, limiting visitors, and avoiding exposure to sick individuals, is crucial in protecting the child from potential life-threatening infections. Option B) Encouraging adequate intake of iron-rich foods is not the priority in this scenario because iron intake is not the immediate concern for a child with acute lymphocytic leukemia. Option C) Assisting with coping with chronic illness is important but not the initial priority when the child's health is at immediate risk. Option D) Administering medications via IM injections is not the priority as infection control measures take precedence in a child with leukemia. In an educational context, it is essential for nurses to prioritize interventions based on the immediate needs of the patient. Understanding the unique healthcare needs of children with leukemia and recognizing the importance of infection prevention can significantly impact patient outcomes. Nurses must be well-versed in recognizing and addressing priority interventions to provide safe and effective care to pediatric patients with complex medical conditions like acute lymphocytic leukemia.

Correct Answer: D

Rationale: In the context of an infant with gastroesophageal reflux (GER), the inappropriate nursing diagnosis is D) Altered oral mucous membranes. This is because GER primarily affects the gastrointestinal system, leading to the regurgitation of stomach contents into the esophagus. While infants with GER may experience symptoms like spitting up and irritability, it does not directly impact the oral mucous membranes. Option A) Fluid volume deficit is a relevant nursing diagnosis for an infant with GER due to the potential loss of fluids through frequent regurgitation. Option B) Risk for aspiration is also appropriate as regurgitated stomach contents can be aspirated into the lungs, leading to respiratory complications. Option C) Altered nutrition: less than body requirements is relevant as the regurgitation can impact the infant's ability to adequately intake and retain nutrients. Educationally, understanding the rationale behind each nursing diagnosis is crucial for providing effective care to infants with GER. By differentiating between appropriate and inappropriate diagnoses, nurses can tailor their interventions to address the specific needs of the infant, promoting better outcomes and quality of care.

Correct Answer: C

Rationale: In a term neonate, sole creases being spread over the entire foot (Option C) is the correct answer. This indicates normal foot development and maturation in a newborn. It is essential for the nurse to recognize this as part of the physical assessment to ensure proper growth and development. Option A, stating the creases are absent near the heels, is incorrect as sole creases should be present throughout the sole of the foot in a healthy newborn. Option B, mentioning creases under the heels only, is incorrect as it does not reflect the typical distribution of sole creases in a term neonate. Option D, stating creases are evident only towards the transverse arch, is incorrect as sole creases should extend over the entire foot, not just towards a specific area. Understanding normal neonatal physical assessments, such as sole crease distribution, is crucial for nurses caring for newborns. It helps in early identification of any abnormalities or developmental issues that may require further evaluation or intervention. By knowing what to expect in a healthy newborn, nurses can provide appropriate care and support to promote optimal growth and development.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Shortening the nursing time. The rationale behind this is that as infants grow and develop, they start to become more efficient at feeding and may nurse for shorter durations. This indicates that the infant is becoming more adept at extracting milk and may be ready to transition to other feeding methods. Option A) Taking solid foods well is incorrect because introducing solid foods is a separate developmental milestone from weaning from breastfeeding. Option B) Sleeping through the night is unrelated to the readiness to wean from breastfeeding. Option D) Eating on a regular schedule is also not a sign of readiness to wean from breastfeeding as it pertains more to establishing feeding routines rather than weaning specifically. From an educational perspective, it is crucial for nurses and caregivers to understand the signs of readiness to wean from breastfeeding to ensure a smooth transition for both the infant and the mother. By recognizing these signs, caregivers can support the infant's transition to other feeding methods at an appropriate developmental stage, promoting healthy growth and development.

Correct Answer: B

Rationale: The correct answer is B) Four months. At four months of age, infants typically exhibit the developmental skills mentioned in the question stem. Staring at objects, bringing hands to the mouth, vocalizing with cooing and gargling sounds, and bearing some weight when held in a standing position are all characteristics of a four-month-old infant's developmental milestones. Option A) Two months is incorrect because by two months, infants are not typically able to sustain weight when held in a standing position or exhibit the range of skills described in the question. Option C) Six months is incorrect as infants at this age usually demonstrate more advanced skills such as rolling over, sitting with support, and babbling consonant sounds, beyond what was described in the question. Option D) Eight months is incorrect as by this age, infants generally display even more advanced skills such as crawling, pulling themselves to stand, and responding to their name, which go beyond the developmental markers mentioned in the question. From an educational perspective, understanding typical developmental milestones is crucial for nurses caring for pediatric patients. Recognizing age-appropriate behaviors and skills helps nurses assess growth and development, identify potential delays or issues, and provide appropriate care and support to infants and their families. By knowing these milestones, nurses can tailor their interventions and education to support optimal development and well-being in pediatric patients.