While examining a 2-year-old child, the nurse in charge sees that the anterior fontanel is open. The nurse should:

Correct Answer: C

Rationale: In infants and young children, it is normal for the anterior fontanel to remain open up to about 18-24 months of age. The fontanel serves an important function in allowing the skull to grow and expand as the brain grows rapidly during infancy. Therefore, the presence of an open fontanel in a 2-year-old child is a normal finding and does not warrant any immediate concern or action. It does not indicate abuse, the need to notify the doctor, or inquire about a family history of Tay-Sachs disease.

Correct Answer: A

Rationale: For 12-year-old Caroline with recurring nephrotic syndrome, body image should be a prime consideration when planning ongoing nursing care. Nephrotic syndrome can cause physical changes such as weight gain, swelling, and changes in appearance due to the disease process and treatment side effects like corticosteroids. These physical changes can impact a child's self-esteem and body image, especially during the sensitive pre-adolescent period. As a result, addressing Caroline's body image concerns through open communication, providing support, promoting self-acceptance, and involving her in decision-making regarding her care can significantly impact her emotional well-being and overall quality of life.

Correct Answer: B

Rationale: Type 2 diabetes mellitus (DM) most likely results from heterogeneous risk factors, such as obesity, unhealthy diet, sedentary lifestyle, genetic predisposition, and other lifestyle factors. By addressing these risk factors through lifestyle modifications, such as maintaining a healthy diet and regular exercise, the development of Type 2 DM can often be prevented or delayed. On the other hand, Type 1 diabetes is primarily an autoimmune condition where the body mistakenly attacks insulin-producing cells in the pancreas, and it is not preventable. Gestational diabetes occurs during pregnancy and is influenced by hormonal changes during pregnancy and other factors, making it less preventable through lifestyle changes alone. Thus, Type 2 diabetes is the type that is most preventable through lifestyle modifications.

Correct Answer: C

Rationale: Idiopathic thrombocytopenic purpura (ITP) is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Steroids are often prescribed to help increase platelet production in patients with ITP. Therefore, the nurse should monitor the child for signs of bleeding, such as petechiae, ecchymosis, gum bleeding, and other unusual bleeding manifestations. Monitoring for bleeding is crucial to assess the effectiveness of the steroid treatment and to prevent complications associated with ITP.

Correct Answer: C

Rationale: The most appropriate intervention to decrease cardiac demands and minimize cardiac workload in children with heart disease is to schedule care to provide uninterrupted rest periods. By allowing the child to rest without interruptions, their heart will not have to work as hard, promoting better overall cardiac function. This intervention focuses on promoting rest and recovery, which is crucial for children with heart disease to maintain optimal cardiac health. Feeding the infant over long periods may not necessarily decrease cardiac demands, and allowing the infant to have her way to avoid conflict is not related to cardiac workload. Developing and implementing a consistent care plan is important but may not directly decrease cardiac demands as effectively as scheduling care for uninterrupted rest periods.