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A nurse in the healthcare provider's office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant's response is normal if which finding is noted?
- A. The fingers curl tightly, and the toes curl forward.
- B. The toes flare, and the big toe is dorsiflexed.
- C. There is extension of the extremities on the side to which the head is turned, with flexion on the opposite side.
- D. The infant turns to the side that is touched.
Correct Answer: B
Rationale: To elicit the Babinski reflex, the nurse strokes the lateral sole of the foot from the heel to across the base of the toes. In the expected response, the toes flare, and the big toe dorsiflexes. The Babinski reflex disappears at 12 months of age. Turning to the side that is touched is the expected response when the rooting reflex is elicited. Tight curling of the fingers and forward curling of the toes is the expected response when the grasp reflex (palmar and plantar) is elicited. Extension of the extremities on the side to which the head is turned with flexion on the opposite side is the expected response when the tonic neck reflex is elicited.
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Intramuscular (IM) phytonadione (vitamin K) 0.5 mg is prescribed for a newborn. After the medication is prepared, in which anatomic site does the nurse administer it?
- A. Rectus femoris muscle
- B. Deltoid muscle
- C. Gluteal muscle
- D. Vastus lateralis muscle
Correct Answer: D
Rationale: Vitamin K is administered to newborn infants to help prevent hemorrhagic disease. The best site for intramuscular injection in infants is the vastus lateralis muscle. This site is preferred due to its location away from the sciatic nerve, femoral artery, and vein, reducing the risk of complications. The rectus femoris muscle may be used if necessary; however, it is less favorable than the vastus lateralis due to its proximity to vital structures, making injections there more hazardous. The deltoid muscle is not typically used for IM injections in newborns. The gluteal muscles should be avoided until the child has been walking for at least a year, as they are poorly developed and close to the sciatic nerve.
Which of the following vaccines are not part of the regular schedule of immunizations for children?
- A. DTaP
- B. MMR
- C. Hib
- D. Hepatitis A
Correct Answer: D
Rationale: Hepatitis A is not part of the standard childhood immunization schedule, unlike DTaP, MMR, and Hib, which are routinely administered.
A new mother who is breastfeeding her newborn calls the nurse at the pediatrician's office and reports that her infant is passing seedy, mustard-yellow stools. The nurse provides the mother with which information?
- A. To monitor the infant for infection and, if a fever develops, to contact the pediatrician
- B. That the stools should be solid and pale yellow to light brown
- C. That this is normal for breastfed infants
- D. To decrease the number of feedings by two per day
Correct Answer: C
Rationale: Breastfed infants pass very soft, seedy, mustard-yellow stools, which is considered normal. Formula-fed infants excrete stools that are more solid and pale yellow to light brown. It is essential for the mother to understand that seedy, mustard-yellow stools are expected in breastfed infants, indicating that there is no need for concern. Monitoring for infection as the first response without other symptoms can cause unnecessary anxiety. Decreasing the number of feedings without valid reasons can lead to inadequate nutrition for the newborn. Therefore, the correct advice for the nurse to provide in this scenario is that seedy, mustard-yellow stools are normal for breastfed infants, reassuring the mother and promoting proper understanding of newborn stool characteristics.
A new mother is being discharged from the maternity unit and provided with information about signs and symptoms to report to her health care provider. Which statement by the mother indicates a need for further information?
- A. I will call my nurse-midwife if I experience any redness, swelling, or tenderness in my legs.''
- B. My temperature needs to remain within a normal range.''
- C. Frequent urination and burning when I urinate are expected.''
- D. Feelings of pelvic fullness or pelvic pressure are a sign of a problem.''
Correct Answer: C
Rationale: The correct answer is 'Frequent urination and burning when I urinate are expected.' This statement by the mother indicates a need for further information because these symptoms are not normal and could indicate a urinary tract infection or another issue that needs medical attention. The other choices correctly reflect signs and symptoms that should be reported to the health care provider. Redness, swelling, or tenderness in the legs can indicate a blood clot, and feelings of pelvic fullness or pressure can be signs of a problem. Monitoring temperature is also important to ensure there is no infection or other complications postpartum.
Distribution of a drug to various tissues is dependent on the amount of cardiac output to each type of tissue. Which tissue would receive the highest amount of cardiac output and thus the highest amount of a drug?
- A. skin
- B. adipose tissue
- C. skeletal muscle
- D. myocardium
Correct Answer: D
Rationale: Highly perfused tissue includes all vital organs: the brain, heart, kidneys, adrenal glands, and liver. Choices 1, 2, and 3 are incorrect because the skin and adipose tissue are poorly perfused, while the skeletal muscle is better perfused.