Nokea
A mother states that she thinks her 9-month-old 'is developing slowly.' When assessing the infant's development, the nurse is also concerned because the infant should be demonstrating which of the following characteristics?
- A. Vocalizing single syllables.
- B. Standing alone.
- C. Building a tower of two cubes.
- D. Drinking from a cup with little spilling.
Correct Answer: C
Rationale: Building a tower of two cubes is expected by 9 months; failure to do so suggests developmental delay.
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After the nurse teaches the mother of a child with atopic dermatitis how to bathe her child, which of the following statements by the mother indicates effective teaching?
- A. I let my child play in the tub for 30 minutes every night.
- B. I would loves the bubble bath I put in the tub.
- C. When my child gets out of the tub I just pat the skin dry.
- D. I make sure my child has a bath every night.
Correct Answer: C
Rationale: Patting the skin dry prevents irritation and maintains skin integrity in atopic dermatitis. Prolonged baths, bubble baths, and daily bathing can exacerbate dryness and irritation.
The nurse begins CPR on a 5-year-old unresponsive client. When the emergency response team arrives, the child continues to have no respiratory effort but has a heart rate of 50 with cyanotic legs. The team should next:
- A. Discontinue compressions but continue administering breaths with a bag-mask device.
- B. Establish an intravenous line with a large bore needle while preparing the defibrillator.
- C. Begin 2-person CPR at a ratio of 2 breaths to 15 compressions.
- D. Begin 2-person CPR at a ratio of 2 breaths to 30 compressions.
Correct Answer: C
Rationale: For a 5-year-old with a heart rate of 50 (bradycardia) and no respiratory effort, 2-person CPR with a ratio of 2 breaths to 15 compressions is appropriate to optimize oxygenation and circulation.
When positioning a neonate with an unrepaired myelomeningocele, which of the following positions is most appropriate?
- A. Supine with the hips at 90-degree flexion.
- B. Right side-lying position with the knees flexed.
- C. Prone with hips in abduction.
- D. Supine in semi-Fowler's position with chest and abdomen elevated.
Correct Answer: C
Rationale: The prone position protects the myelomeningocele sac from pressure and rupture before surgical repair, with hips in abduction to maintain alignment and prevent strain on the defect.
A 12-year-old with asthma wants to exercise. Which of the following activities should the nurse suggest to improve her breathing?
- A. Soccer.
- B. Swimming.
- C. Track.
- D. Gymnastics.
Correct Answer: B
Rationale: Swimming is recommended for children with asthma because the warm, humid environment reduces airway irritation and bronchoconstriction. It also promotes controlled breathing, improving respiratory function.
A nurse evaluates discharge teaching as successful when the parents of a school-age child with a ventriculoperitoneal shunt insertion identify which sign as signaling a blocked shunt?
- A. Decreased urine output with stable intake.
- B. Tense fontanel and increased head circumference.
- C. Elevated temperature and reddened incisional site.
- D. Irritability and increasing difficulty with eating.
Correct Answer: D
Rationale: Irritability and difficulty eating are early signs of shunt blockage due to increased intracranial pressure, which parents should recognize for timely intervention.