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A nurse is caring for an infant who has a cleft palate and is having trouble bottle feeding. Which of the following actions should the nurse take?
- A. Select a bottle with a one-way flow valve.
- B. Choose a bottle with a narrow nipple.
- C. Burp the infant every 90 ml (3 oz).
- D. Use the football hold when feeding the child.
Correct Answer: A
Rationale: A one-way flow valve bottle controls milk flow, aiding infants with cleft palate. Narrow nipples, frequent burping, or football hold are less specific to feeding challenges.
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A nurse is caring for a child who has pertussis. Which of the following precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Airborne
- D. Protective
Correct Answer: A
Rationale: Pertussis spreads via respiratory droplets, requiring droplet precautions. Contact precautions are for direct contact diseases, airborne for smaller particles like TB, and protective precautions are for immunocompromised patients.
A nurse is collecting data from a 1-month-old infant who has just undergone a hernia repair. Which of the following findings should the nurse report to the provider?
- A. Axillary temperature 37.4° C (99.3° F)
- B. Apical pulse 155/min
- C. Respiratory rate 40/min
- D. Blood pressure 64/40 mm Hg
Correct Answer: D
Rationale: Blood pressure of 64/40 mm Hg is abnormally low, indicating potential shock or dehydration, requiring immediate reporting. Other findings are within normal ranges for a 1-month-old.
A nurse is caring for an adolescent who reports manifestations of an STI. Which of the following actions should the nurse take?
- A. Request that the adolescent sign a consent for treatment form prior to performing STI screening.
- B. Instruct the adolescent that a guardian must be present to provide consent for STI screening.
- C. Plan to notify the adolescent's guardian if the STI screening comes back positive.
- D. Obtain phone consent from the guardian of the adolescent prior to performing STI screening.
Correct Answer: A
Rationale: Adolescents can consent to STI screening in many jurisdictions, respecting their privacy. Guardian involvement may deter care, and notification breaches confidentiality unless required.
A nurse is caring for an adolescent client who has a terminal illness. Which of the following statements should the nurse make to the parent?
- A. I will administer pain medication on a schedule.
- B. I will limit visits from siblings who are under the age of 18.
- C. You should go home when your child needs to rest.
- D. You should allow your child to die at home.
Correct Answer: A
Rationale: Scheduled pain medication ensures comfort. Limiting sibling visits, dictating parental presence, or suggesting home death disregard family preferences and needs.
A nurse is caring for a preschooler who has diabetes mellitus and is pale, diaphoretic, and irritable. The child's blood glucose level is 52 mg/dL. Which of the following actions should the nurse take first?
- A. Give 1 tsp of peanut butter to the child.
- B. Recheck the child's blood glucose level.
- C. Administer 1 tbsp of sugar to the child.
- D. Document the incident in the child's record.
Correct Answer: C
Rationale: Administering sugar treats hypoglycemia quickly in a conscious child. Peanut butter is slow-acting, rechecking delays treatment, and documentation follows intervention.