1. You are caring for a newborn with a myelomeningocele who is awaiting surgical closure of the defect. Which assessment finding is of most concern?

2. The nurse is administering IV fluids to a 3-year-old client. Which action by the nurse would warrant intervention by the charge nurse?

3. The 8-year-old client diagnosed with a vaso-occlusive sickle cell crisis is complaining of a severe headache. Which intervention should the nurse implement first?

4. You have obtained this assessment information about a 3-year-old who has just returned to the pediatric unit after having a tonsillectomy. Which finding requires the most immediate follow-up?