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Pediatric nursing · practice question

A 6-month-old infant in the pediatric clinic is being evaluated for febrile illness in a toddler. Assessment data include pulling at ears and crying with tugging on the right ear. Which finding requires the nurse to intervene immediately?

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Answer and explanation

Correct answer

A. 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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