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When should a mother introduce solid foods to her 4-month-old infant? The mother states that her mother suggests putting rice cereal in the baby's bottle. The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?
- A. Stops rooting when hungry
- B. Opens mouth when food is offered
- C. Awakens once for nighttime feedings
- D. Gives up a bottle for a cup
Correct Answer: B
Rationale: Introducing solid foods when the child opens their mouth for food is important to ensure readiness for solids. This behavior indicates the infant's interest and readiness for new textures and flavors, promoting safe and successful introduction to solid foods. The other choices are not indicative of the infant's readiness for solid foods: A - stopping rooting is a reflex action, C - awakening for nighttime feedings is a normal behavior, and D - transitioning from a bottle to a cup is a developmental milestone unrelated to solid food introduction.
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A child with pertussis is receiving azithromycin (Zithromax Injection) IV. Which intervention is most important for the nurse to include in the child's plan of care?
- A. Obtain vital signs to monitor for fluid overload
- B. Change IV site dressing every 3 days and as needed
- C. Monitor for signs of facial swelling or urticaria
- D. Assess for abdominal pain and vomiting
Correct Answer: C
Rationale: When administering azithromycin IV, monitoring for signs of an allergic reaction, such as facial swelling or urticaria, is crucial. This helps in early detection of potential adverse reactions and ensures prompt intervention to prevent complications associated with the medication. The other options are not directly related to the administration of azithromycin IV in this scenario. Monitoring for fluid overload would be more relevant for fluid administration, changing IV site dressing is important but not the priority in this case, and assessing for abdominal pain and vomiting may be important but not as critical as monitoring for signs of an allergic reaction.
Which assessment finding should the healthcare provider identify as most concerning in a child with acute glomerulonephritis?
- A. Hypertension.
- B. Gross hematuria.
- C. Proteinuria.
- D. Periorbital edema.
Correct Answer: A
Rationale: In a child with acute glomerulonephritis, hypertension is the most concerning assessment finding as it can indicate worsening renal function. Hypertension is a common complication of glomerulonephritis and can lead to further kidney damage if not managed promptly. Monitoring and controlling blood pressure is crucial in these cases to prevent complications and preserve renal function. Gross hematuria, proteinuria, and periorbital edema are also common findings in acute glomerulonephritis but hypertension poses a higher risk for renal damage if left uncontrolled.
A 3-year-old child is admitted to the hospital with a diagnosis of pneumonia. The nurse notes that the child has a fever and is breathing rapidly. What is the nurse's priority action?
- A. Administer antipyretic medication
- B. Obtain a chest X-ray
- C. Start the child on oxygen therapy
- D. Notify the healthcare provider
Correct Answer: C
Rationale: In a child with pneumonia who is breathing rapidly, the priority action for the nurse is to start the child on oxygen therapy. This intervention is essential to ensure adequate oxygenation, which is crucial in managing respiratory distress and preventing complications associated with hypoxia. Administering antipyretic medication (Choice A) may help reduce the fever but does not address the immediate need for oxygen therapy. Obtaining a chest X-ray (Choice B) is important for diagnosis but providing oxygen is more urgent. Notifying the healthcare provider (Choice D) can be done after initiating oxygen therapy to update on the patient's condition.
When reviewing developmental changes with the parents of a 6-month-old infant, what information should the practical nurse reinforce?
- A. Encourage the infant to self-feed finger foods.
- B. Teach the parents strategies to help the infant sit up.
- C. Provide a developmentally safe environment for the infant.
- D. Explain that an increased appetite typically occurs in the next 6 months.
Correct Answer: C
Rationale: The correct answer is C because providing a developmentally safe environment for a 6-month-old infant is crucial as they begin to explore their surroundings more actively. This includes ensuring that the environment is free of hazards and that the infant is supervised to prevent accidents. Choice A is incorrect because self-feeding finger foods may not be developmentally appropriate for a 6-month-old infant. Choice B is incorrect as most infants are able to sit up with support around 6 months of age without the need for specific teaching strategies. Choice D is also incorrect as while appetite changes can occur, explaining a specific increase in appetite over the next 6 months is not a primary focus when discussing developmental changes with parents of a 6-month-old.
A 10-year-old child is admitted to the hospital with a diagnosis of acute glomerulonephritis. The nurse notes that the child has edema and elevated blood pressure. What is the nurse's priority action?
- A. Administer antihypertensive medication as prescribed
- B. Monitor the child's urine output
- C. Elevate the child's legs to reduce edema
- D. Restrict the child's fluid intake
Correct Answer: A
Rationale: In a child with acute glomerulonephritis presenting with edema and elevated blood pressure, the priority action for the nurse is to administer antihypertensive medication as prescribed. Managing blood pressure is essential to prevent further complications associated with the condition, such as worsening kidney function and cardiovascular strain. Monitoring urine output is important but not the priority over managing elevated blood pressure. Elevating the child's legs may help with edema but addressing the elevated blood pressure takes precedence. Fluid intake restriction may be necessary in some cases, but it is not the immediate priority when managing acute glomerulonephritis with edema and hypertension.