Correct Answer: B

Rationale: Maintain a saline-lock: While maintaining a saline lock is important for ensuring vascular access in case of emergency, it is not the priority action in caring for a child with acute glomerulonephritis. Monitoring daily weight is crucial in acute glomerulonephritis, as it helps assess fluid balance and detect early signs of fluid retention or worsening kidney function, which are key concerns in this condition. This makes it a priority action. Place the child on a no-salt-added diet: Dietary modifications, including reducing salt intake, may be recommended for managing acute glomerulonephritis. However, it is not the priority action at this stage. Parental education is important for long-term management and understanding of the condition, but it is not the most immediate priority in the acute phase of the illness.

Correct Answer: B

Rationale: Increase in appetite: Otitis media, an infection or inflammation of the middle ear, typically causes discomfort and pain in infants. As a result, they may experience a decrease in appetite rather than an increase. Tugging on the affected ear lobe: Tugging or pulling on the affected ear lobe is a common sign of ear pain in infants with otitis media. It occurs because the pain from the middle ear extends to the outer ear canal. Erythema and edema of the affected auricle: Otitis media primarily affects the middle ear, so erythema (redness) and edema (swelling) are not typically observed on the outer ear (auricle). Instead, these symptoms are more commonly seen in external ear infections, such as otitis externa. Bluish-green discharge from the ear canal: Bluish-green discharge from the ear canal is not a typical finding in otitis media. It may suggest a secondary bacterial infection or another underlying condition, but it is not a characteristic feature of otitis media.

Correct Answer: A

Rationale: Move the child into a side-lying position: This action is crucial during a seizure with vomiting to prevent aspiration. Placing the child on their side helps ensure that any vomit can easily exit the mouth and reduces the risk of choking or aspiration into the lungs. Place a pillow under the child's head: While providing comfort is important, it is not the priority during a seizure with vomiting. Placing a pillow under the child's head might elevate the head slightly, but it doesn't address the risk of aspiration, which is the primary concern. Time the seizure: Timing the seizure is important for documentation and to monitor the duration of the seizure. However, it is not the priority during the active phase of the seizure, especially when vomiting is occurring. Remove the child's eyeglasses: Removing the child's eyeglasses is not a priority during a seizure with vomiting. While it's important to prevent injury, particularly to the eyes, during a seizure, the immediate concern is addressing the risk of aspiration caused by vomiting.

Correct Answer: B

Rationale: Measuring the child's chest circumference: Measuring the chest circumference may not directly aid in the assessment of Wilm's tumor. While it's important for assessing respiratory conditions or monitoring growth, it's not a primary assessment for Wilm's tumor, which primarily affects the abdomen. Palpating the child's abdomen: This is an essential action in assessing for Wilm's tumor. The nurse should carefully palpate the abdomen to check for any masses, swelling, or tenderness, as these could be indicative of the tumor. Measuring the child's occipitofrontal circumference: This measurement pertains to the head circumference and is not directly related to the assessment of Wilm's tumor. While it's important for monitoring head growth and development, it's not a priority when assessing for Wilm's tumor. Placing the child in an upright position: Placing the child in an upright position may be necessary for certain assessments or procedures, but it's not directly related to assessing for Wilm's tumor. The focus should primarily be on abdominal assessment and palpation to detect any signs of the tumor.

Correct Answer: B

Rationale: Left side: Placing the infant on the left side after feeding is not typically recommended for managing gastroesophageal reflux. This position may not provide optimal support for digestion and may not effectively reduce reflux symptoms. Upright: This is the correct answer. Placing the infant in an upright position after feeding can help reduce gastroesophageal reflux. Gravity helps keep stomach contents down, preventing them from flowing back up into the esophagus. Holding the infant upright on the caregiver's shoulder or in a baby carrier can be effective in minimizing reflux symptoms. Right side: Placing the infant on the right side after feeding is not typically recommended for managing gastroesophageal reflux. Similar to the left side, this position may not provide optimal support for digestion and may not effectively reduce reflux symptoms. Prone: Placing the infant in a prone (face-down) position after feeding is not recommended due to the risk of sudden infant death syndrome (SIDS). Prone positioning is associated with an increased risk of SIDS, and current guidelines advise against placing infants to sleep or rest on their stomachs. Additionally, a prone position may not effectively reduce gastroesophageal reflux and may pose other risks to the infant's health and safety.