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A nurse is collecting data from a 4-month-old infant at a well-child visit. For which of the following findings should the nurse notify the provider?
- A. Moves objects to mouth
- B. Anterior fontanel closed
- C. Rolls from back to abdomen
- D. Posterior fontanel closed
Correct Answer: B
Rationale: Anterior fontanel closure before 12-18 months may indicate abnormal development.
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A nurse is caring for a client who is in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
- A. Measure the duration of the seizure
- B. Restrain the client's arms and legs to prevent injury
- C. Lower the side rails of the bed when the seizure begins
- D. Insert an oral airway into the client's mouth
Correct Answer: A
Rationale: Measuring duration aids in assessing seizure severity and planning care.
The guardian of a 4-year-old child.
A nurse is collecting a health history from the guardian of a 4-year-old child. Which of the following statements by the guardian is the priority for the nurse to address?
- A. I have noticed that my child is withdrawn since we switched day care providers.
- B. My child continually asks me the same questions.
- C. My child still wets the bed at least two times per week.
- D. I have a difficult time getting my child to eat green vegetables.
Correct Answer: A
Rationale: Withdrawal may indicate emotional distress, a priority over typical developmental behaviors.
The client delivered a newborn by cesarean birth 1 day ago.
A nurse is caring for a client who delivered a newborn by cesarean birth 1 day ago. The client requests nonpharmacological interventions to manage pain when changing positions. Which of the following responses should the nurse make?
- A. You can apply counterpressure to your back with each position change.
- B. You should change positions as little as possible.
- C. You can splint the incision with a pillow when changing positions.
- D. You should use patterned-paced breathing when changing positions.
Correct Answer: C
Rationale: Splinting the incision with a pillow reduces pain during movement.
A nurse is reinforcing teaching about disease management with a client who has GERD. Which of the following statements should the nurse make?
- A. You should only drink 2 cups of coffee per day.
- B. You should elevate the head of the bed while sleeping.
- C. You should eat three large meals and two snacks per day.
- D. You should lay down for 1 hour following a meal.
- E. None
- F. None
Correct Answer: B
Rationale: Elevating the head of the bed reduces acid reflux during sleep, a key GERD management strategy.
A nurse is collecting data from a toddler during a well-child visit. Which of the following actions should the nurse take to prepare the toddler for a physical examination?
- A. Thoroughly explain each procedure to the toddler.
- B. Start the examination with routine immunizations.
- C. Allow the toddler to handle the equipment.
- D. Completely undress the toddler.
Correct Answer: C
Rationale: Allowing the toddler to handle equipment reduces fear and increases cooperation.