Pediatric nursing · practice question

A 2-year-old toddler in the emergency department is being evaluated for dehydration from vomiting and diarrhea. Assessment data include pulling at ears and crying with tugging on the right ear. Which finding requires the nurse to intervene immediately?

Multiple choiceMediumnclex-rn-bsnnclex-validatednclex-2026pediatric-nursing

Routine data unchanged from the prior assessment.A comfort request with unchanged vital signs and no new symptoms.The new finding that pulling at ears and crying with tugging on the right ear.A stable, long-standing finding that matches the expected care plan.

Answer and explanation

Correct answer

C. The new finding that pulling at ears and crying with tugging on the right ear.

Why

Follow-up items test whether the nurse recognizes cues that are new, acute, or inconsistent with stability and need prompt nursing action.

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A 2-year-old toddler in the emergency department is being evaluated for dehydration from vomiting and diarrhea. Assessment data include pulling at ears and crying with tugging on the right ear. Which finding requires the nurse to intervene immediately?

Correct answer

Why

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