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 C
Explanation
Choice A rationale
The absence of creases on the plantar surface is typical of a preterm infant, not a term infant. Term infants usually have some creases.
Choice B rationale
Abundant lanugo is more common in preterm infants, while term infants may have some but not extensive lanugo.
Choice C rationale
A flexed position at rest is expected in a term neonate, as it indicates good muscle tone and neuromuscular development.
Choice D rationale
The pinna of the ear remaining folded is more indicative of a preterm infant, as term infants typically have fully formed and firmer ear cartilage.
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.