Correct Answer: A,B,C,D

Rationale: The correct answer includes instructions on pain management (
A), monitoring for signs of dehydration and need for adequate nutrition (
A), reporting of mild ear pain or foul breath (
B), dietary restrictions (
C), and reassurance about scab formation (
D). Pain control is crucial post-tonsillectomy to ensure adequate intake of fluids and prevent dehydration (
A). Monitoring for ear pain or foul breath is important as they may indicate secondary issues post-surgery (
B). Dietary restrictions help prevent injury to the surgical site (
C). Informing about scab formation reassures the parent about normal healing process (
D). Other choices are incorrect as they do not address essential post-operative care aspects.

Correct Answer: A

Rationale: The correct answer is A: Inability to pick up crackers with thumb and forefinger. This finding is of most concern because it indicates a potential delay in fine motor skills development, specifically the pincer grasp, which is typically achieved by 9 months. This milestone is important for self-feeding and coordination. Referral to Early Intervention is warranted to assess and support the child's developmental progress.



Choices B, C, and D are less concerning as they are within the range of normal development for a 9-month-old. Playing with a toy for only a few minutes is typical at this age due to short attention spans. Crawling on all fours and inability to pull self to a standing position are age-appropriate gross motor skills for a 9-month-old.

Correct Answer: A

Rationale: The correct answer is A. The 12-month-old with a weak cry, pale complexion, decreased breath sounds, retractions, and an oxygen saturation of 93% should be prioritized. Infants have a higher risk of respiratory distress, especially with signs of retractions and decreased breath sounds. The weak cry and pale complexion suggest significant distress. The oxygen saturation of 93% indicates hypoxemia. Prioritizing this child ensures prompt intervention to prevent respiratory failure.


Choice B is incorrect as the 5-year-old's condition, though concerning, is less urgent compared to the 12-month-old.
Choice C is incorrect as the 16-year-old's symptoms, while indicating respiratory distress, are less critical than the 12-month-old's.
Choice D is incorrect as the 9-year-old's symptoms, though serious, do not indicate as severe distress as the 12-month-old. Prioritizing based on age, severity of symptoms, and risk of deterioration is crucial in the

Correct Answer: A,B,C

Rationale:
Correct
Answer: A, B, C


Rationale:
A: Managing pain is crucial post-tonsillectomy to ensure the child can eat and drink, preventing dehydration.
B: Reporting mild ear pain or bad breath is important as they can be signs of complications that need medical attention.
C: Instructing to eat soft foods and avoid crunchy ones helps prevent irritation to the surgical site, aiding in healing.

Incorrect choices:
D: Monitoring scabs on the tonsils is essential to detect any signs of infection or bleeding, so this instruction is incorrect.
E:
F:
G:

Summary:
The correct instructions focus on pain management, monitoring for complications, and dietary restrictions for optimal healing post-tonsillectomy. Monitoring scabs and incorrect eating instructions are potential pitfalls to avoid.

Correct Answer: B

Rationale: The correct answer is B: Inability to raise head when in prone position. At one month old, infants should be able to raise their heads briefly when lying on their stomach. This is an important milestone for neck muscle strength and control. The nurse should report this finding to the provider as it may indicate developmental delays or medical issues.

Choices A, C, and D are typical developmental milestones for infants at one month old and are not cause for immediate concern. Sitting without support and bringing objects to the mouth typically develop around 6 months, and picking up objects with fingers develops around 9 months.