A nurse is assessing a 3-year-old child and suspects the child may have a developmental delay. Which of the following actions is a priority for the nurse to take?
Refer the child to social work for early intervention.
Educate the parents on the developmental delays their child is diagnosed with.
Provide the parents with pamphlets for support groups for children with developmental delays.
Discuss the assessment findings with the primary care provider.
The Correct Answer is D
Choice A rationale
Referring the child to social work for early intervention is important, but it is not the immediate priority. The nurse should first discuss the assessment findings with the primary care provider to confirm the diagnosis and plan the next steps.
Choice B rationale
Educating the parents on the developmental delays their child is diagnosed with is essential, but it should come after a confirmed diagnosis and a comprehensive plan is in place. The primary care provider should be involved in this process.
Choice C rationale
Providing the parents with pamphlets for support groups is supportive but not the immediate priority. The nurse should first ensure that the primary care provider is aware of the assessment findings to confirm the diagnosis and plan appropriate interventions.
Choice D rationale
Discussing the assessment findings with the primary care provider is the priority action. This ensures that the child receives a thorough evaluation and appropriate interventions are planned based on a confirmed diagnosis.
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Correct Answer is A
Explanation
ChoiceA rationale
Theapexoftheheart(apicalpulse)isthepreferredsiteforassessingtheheartrateininfants.It is located at the point of maximal impulse (PMI) and provides the most accuratemeasurementof theheartrateinthisagegroup.
ChoiceB rationale
The brachial artery is not the preferred site for assessing the heart rate in infants. While it canbeused forbloodpressuremeasurement,itisnotasaccurateastheapicalpulseforheartrateassessment.
ChoiceCrationale
Theradialarteryisnottypicallyusedforassessingthe heartrateininfants.Itismorecommonlyusedinolderchildren andadults.
ChoiceD rationale
Thecarotidarteryisnotrecommendedforassessingtheheartrateininfantsduetotheriskofcompressingtheairwayandcausingdiscomfort.
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale
The Measles, Mumps, and Rubella (MMR) vaccine is recommended for children at 12-15 months of age. This vaccine protects against three serious diseases: measles, mumps, and rubella. Measles can cause severe respiratory illness and encephalitis, mumps can lead to meningitis and hearing loss, and rubella can cause congenital rubella syndrome in unborn babies if a pregnant woman is infected.
Choice B rationale
The Rotavirus (RV) vaccine is typically given to infants at 2, 4, and sometimes 6 months of age. It is not recommended for children older than 8 months.
Choice C rationale
The Human Papillomavirus (HPV) vaccine is recommended for preteens starting at age 11 or 12. It is not given to 1-year-old children.
Choice D rationale
The Varicella (VAR) vaccine is recommended for children at 12-15 months of age to protect against chickenpox, which can cause severe skin infections, pneumonia, and encephalitis.
Choice E rationale
The Diphtheria, Tetanus, and Acellular Pertussis (DTaP) vaccine is part of the routine immunization schedule for children, with doses given at 2, 4, 6, and 15-18 months of age. This vaccine protects against three serious diseases: diphtheria, which can cause breathing problems and heart failure; tetanus, which can cause muscle stiffness and lockjaw; and pertussis (whooping cough), which can cause severe coughing spells and pneumonia.