A nurse is assessing a toddler at a well-child visit.
At what point in the physical examination should the nurse examine the child's tympanic membrane?
At the beginning.
Before auscultating the chest and abdomen.
Before examining the head and neck.
At the end.
The Correct Answer is D
Choice A rationale
Examining the tympanic membrane at the beginning may cause distress to the child and make the rest of the exam difficult.
Choice B rationale
Before auscultating the chest and abdomen, the child needs to be calm and cooperative, which might not be the case if their ear is examined first.
Choice C rationale
Examining the tympanic membrane before the head and neck could lead to increased anxiety and uncooperativeness in the child during the rest of the exam.
Choice D rationale
Examining the tympanic membrane at the end allows for a more accurate and complete examination without causing the child to become distressed early in the process.
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Correct Answer is C
Explanation
Choice A rationale
Playing might cause irregular breathing patterns due to excitement or activity, making it hard to get an accurate respiratory rate.
Choice B rationale
Crying can alter the normal breathing rate and pattern, resulting in an inaccurate assessment of respirations.
Choice C rationale
Sleeping provides the most accurate assessment of respirations, as the infant’s breathing will be at its natural, resting rate.
Choice D rationale
Laughing, similar to crying, causes irregular breathing patterns due to physical exertion and emotions, affecting accuracy.
Correct Answer is B
Explanation
Choice A rationale
A front-facing car seat for an infant does not provide adequate protection in the event of a collision. Infants should always be in a rear-facing car seat to support their head, neck, and spine.
Choice B rationale
Using an infant model car seat designed specifically for the car ensures that the seat meets safety standards and is appropriate for the child's size and developmental needs, providing optimal protection.
Choice C rationale
Being able to fit a hand between the baby and the car seat harness indicates the harness is too loose. The harness should be snug enough that only one or two fingers can fit between the strap and the baby's chest to provide secure restraint.
Choice D rationale
A rear-facing car seat should not be placed in the front passenger seat due to the risk of injury from airbags. The safest position for a rear-facing car seat is in the back seat, away from active airbags.