Nokea
A 6-month-old has had a pyloromyotomy to correct a pyloric stenosis. Three days after surgery, the parents have placed their infant in his own infant seat (see figure). The nurse should do which of the following?
- A. Reposition the infant to the left side.
- B. Ask the parents to put the infant back in his crib.
- C. Remind the parents that the infant cannot use a pacifier now.
- D. Tell the parents they have positioned their infant correctly.
Correct Answer: D
Rationale: An infant seat is appropriate for a 6-month-old post-pyloromyotomy, supporting recovery and comfort.
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A 9-month-old infant with eczema has lesions that are secondarily infected. Which of the following is most appropriate to help the parents best meet the needs of the child?
- A. Preventing siblings from being in close contact.
- B. Sending the child to day care as usual.
- C. Playing video games for several hours each evening.
- D. Playing with the child every day.
Correct Answer: D
Rationale: Playing with the child daily promotes emotional bonding and normal development, which is critical for a 9-month-old. Preventing sibling contact is unnecessary unless siblings are ill, day care may risk further infection, and video games are inappropriate for an infant.
The parent of a 9-month-old infant is concerned that the infant's front soft spot is still open. The nurse should tell the parent:
- A. I will measure your baby's head to see if it is a normal size.
- B. Your infant will need to be referred for more testing.
- C. You should contact your physician immediately.
- D. It is normal because this soft spot usually closes between 12 and 18 months.
Correct Answer: D
Rationale: The anterior fontanelle typically closes between 12-18 months, so this is normal.
A student with type 1 diabetes tells the nurse she is feeling light-headed. The student's blood sugar is 60 mg/dL. Using the 15-15 rule, the nurse should:
- A. Give 15 mL of juice and give another 15mL in 15 minutes.
- B. Give 15 g of carbohydrate and retest the blood sugar in 15 minutes.
- C. Give 15 g of carbohydrate and 15 g of protein.
- D. Give 15 oz of juice and retest in 15 minutes.
Correct Answer: B
Rationale: The 15-15 rule involves giving 15 g of fast-acting carbohydrate (e.g., 4 oz juice) and retesting after 15 minutes to correct hypoglycemia. Protein is not immediate, and incorrect volumes (15 mL or 15 oz) are ineffective.
The parent of a child with spastic cerebral palsy and a communication disorder tells the nurse, 'He seems so restless. I think he is in pain.' The nurse should:
- A. Assess the child for pain using the Faces, Legs, Activity, Cry, Consolability (FLACC) scale.
- B. Assess the child using the pediatric FACES scale.
- C. Administer the pain medication which is ordered to be given as needed and assess the response.
- D. Notify the primary care provider of the change in behavior.
Correct Answer: A
Rationale: The FLACC scale is appropriate for assessing pain in children with communication disorders, as it relies on observable behaviors rather than verbal reports.
The nurse mentions that a group meeting for mothers of mentally retarded children is to be held soon. 'Not retarded!' the child's mother angrily blazes, 'Exceptional.' When responding to this outburst, which of the following replies by the nurse would be most appropriate?
- A. Retarded' is the commonly used and accepted term.'
- B. I'm sorry if I offended you by my thoughtless remark.'
- C. No matter what it's called, the condition is still the same, isn't it?'
- D. I'd like to hear more of your thoughts and feelings on that.'
Correct Answer: D
Rationale: Inviting the mother to share her feelings promotes therapeutic communication and addresses her emotional response sensitively.