A nurse is planning care for a 4-year-old child who requires isolation and airborne precautions.
Which of the following activities should the nurse plan for this child?
Constructing a model airplane.
Putting together a large-piece puzzle.
Playing in the hallway.
Watching a video game in the playroom.
The Correct Answer is B
Choice A rationale
Constructing a model airplane may require smaller parts and more intricate work, not ideal for a 4-year-old child.
Choice B rationale
Putting together a large-piece puzzle is suitable for fine motor skills development and can be done while in isolation.
Choice C rationale
Playing in the hallway would expose the child to other areas and people, defeating the purpose of airborne precautions.
Choice D rationale
Watching a video game in the playroom is not feasible as it would require leaving the isolation area.
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Correct Answer is D
Explanation
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.
Correct Answer is B
Explanation
Choice A rationale
Acrocyanosis is a common and typically benign condition in newborns, characterized by bluish discoloration of the hands and feet. It is not an immediate priority.
Choice B rationale
Respiratory distress is the priority assessment for a newborn immediately following a cesarean delivery. Ensuring the newborn has a patent airway and is breathing effectively is crucial for their survival and immediate well-being.
Choice C rationale
Hypothermia is a concern for newborns, but respiratory distress takes precedence as an immediate life-threatening condition.
Choice D rationale
Accidental lacerations can occur during a cesarean delivery, but they are usually not life-threatening and can be addressed after ensuring the newborn's respiratory status is stable. .