Author Question: A parent brings a 2-year-old child to the clinic, reporting that the child has an ear infection. ... (Read 138 times)

MGLQZ · **on:** Jun 28, 2018

A parent brings a 2-year-old child to the clinic, reporting that the child has an ear infection. Which assessment information leads the nurse to suspect a diagnosis of bacterial otitis media? (Select all that apply.)

A.
Acute otalgia
B.
Dull, throbbing pain
C.
Fever of 104 F (40 C)
D.
High-pitched crying
E.
Poor feeding
F.
Rubbing the ear

Question 2

A nurse is assessing a 6-month-old baby with volvulus. The infant's vital signs are as follows: pulse: 118 beats/minute; blood pressure: 78/54 mm Hg; respirations: 42 breaths/minute. What action by the nurse is most appropriate?

A.
Assess the infant's abdomen and skin.
B.
Document the findings in the baby's chart.
C.
Increase the rate of IV fluid administration.
D.
Notify the health-care provider immediately.

orangecrush · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: A, C, E, F
Manifestations of acute otitis media include otalgia, irritability, otorrhea, fever that may be high, poor feeding, rubbing or pulling at the ear, bulging tympanic membrane, enlarged lymph glands, and visualization of purulent material during an otoscopic exam.

Answer to Question 2

ANS: B
These vital signs are appropriate for a 6-month-old baby. The nurse should document the findings in the patient's chart. A full assessment is completed, but specific assessments are not needed based on these vital signs. The IV rate does not need adjustment, and there is no need to inform the provider.