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A 9-week-old infant is scheduled for a cleft lip repair. What information is most important for the nurse to convey to the surgeon before transporting the infant to the surgical suite?
- A. Urine specific gravity is 1.011
- B. White blood cell count of 10,000/mm³
- C. Weight gain of 2 pounds (0.91 kg) since birth
- D. Red blood cell count of 2.3 x 10²/L
Correct Answer: D
Rationale: A low red blood cell count indicates anemia, a surgical risk requiring preoperative attention.
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The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. What additional finding should the nurse expect to observe?
- A. Hypotension and tachycardia
- B. Vigorous feeding and satiation
- C. Fever
- D. Hemiplegia
Correct Answer: A
Rationale: Aortic stenosis can reduce cardiac output, leading to hypotension, with tachycardia as a compensatory response.
The nurse is assessing the growth and development of a 3-year-old child. Which speech and language skills should the nurse identify as normal developmental milestones for this child?
- A. Recognizes most letters and numbers
- B. Uses 1-word sentences
- C. Speaks in simple sentences with four or more words
- D. Uses gestures with 1 to 2-word sentences .
Correct Answer: C
Rationale: Simple sentences with four or more words are expected for a 3-year-old's language development.
A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?
- A. The diaper area shows severe skin breakdown
- B. The mother states the baby is irritable during feedings
- C. The mother is a single parent and lives with her parents
- D. The infant's formula has been changed twice
Correct Answer: A
Rationale: Severe diaper dermatitis causes discomfort, impacting sleep and requiring immediate care.
Which snack choice by a school-aged child with gastroesophageal reflux indicates to the nurse that the child understands the dietary restrictions?
- A. Chocolate milkshake
- B. Sugar cookies
- C. Tacos
- D. Pizza
Correct Answer: B
Rationale: Sugar cookies are less likely to trigger GERD symptoms compared to high-fat or acidic foods.
A child has been prescribed loratadine 5 mg to be taken orally once a day. The bottle is labeled “Loratadine for Oral Suspension, USP 5 mg per 5 mL.â€. How many teaspoons should the nurse instruct the parent to give with each dose?
- A. 1
Correct Answer: A
Rationale: The prescribed 5 mg dose equals 5 mL (5 mg ÷ 5 mg/5 mL), or 1 teaspoon.