A nurse is caring for a toddler who is having difficulty sleeping during hospitalization.
Which of the following actions should the nurse take to promote sleep?
Encourage play exercises in the evening.
Turn off the room light.
Provide bedtime rituals.
Explain the source of the toddler's fears.
The Correct Answer is C
Choice A rationale
Encouraging play exercises in the evening can lead to overstimulation, which can make it harder for the toddler to fall asleep. Physical activity should generally be done earlier in the day to help with sleep later on.
Choice B rationale
Turning off the room light can create a dark environment conducive to sleep, but it doesn’t address the need for a calming routine, which is essential for young children’s sleep. Some children also feel safer with a nightlight.
Choice C rationale
Providing bedtime rituals can help signal to the toddler that it is time to wind down and sleep. Consistent rituals, such as reading a story or singing a lullaby, provide a sense of security and comfort.
Choice D rationale
Explaining the source of the toddler’s fears may be beyond the cognitive ability of a toddler and does not directly promote sleep. It’s better to provide comfort and reassurance through routine.
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Correct Answer is C
Explanation
Choice A rationale
An APGAR score of 5 indicates significant distress and poor adjustment to extrauterine life, which is not consistent with the provided description of the infant's condition.
Choice B rationale
An APGAR score of 6 suggests moderate difficulty with extrauterine adaptation, which is still not entirely consistent with the overall assessment of the infant.
Choice C rationale
An APGAR score of 7 aligns with the described observations of the newborn: pink trunk and head, bluish extremities, active movement, heart rate of 130/min, and a response to
suctioning, which suggest the infant is in reasonably good condition with some minor issues that need monitoring.
Choice D rationale
An APGAR score of 8 would indicate that the newborn is in very good condition with only slight adjustments needed, which does not fully match the infant's description with the noted
issues like a weak cry and bluish extremities.
Correct Answer is ["A","B","C","D"]
Explanation
Choice A rationale
Inspection is always the first step in an abdominal assessment. It involves visually examining the abdomen for any abnormalities such as distention, masses, or scars.
Choice B rationale
Auscultation follows inspection and involves listening to bowel sounds with a stethoscope. This helps to assess the presence and frequency of peristalsis.
Choice C rationale
Deep palpation is performed after superficial palpation to identify any deep-seated abnormalities or pain. It helps in assessing the size, shape, consistency, and mobility of abdominal organs.
Choice D rationale
Superficial palpation is performed before deep palpation to detect any tenderness, muscle resistance, or superficial masses. It is done gently to avoid causing discomfort to the child.