Nokea
A nurse is collecting data from an 8-month-old infant. Which of the following findings indicates expected growth and development?
- A. Inability to hold a bottle
- B. Uses palmar grasp
- C. Sits unsupported
- D. Forces tongue outward when it is touched
Correct Answer: C
Rationale: Sitting unsupported by 8 months is expected. Bottle holding occurs earlier, palmar grasp fades by this age, and tongue thrust typically resolves by 6 months.
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A nurse is preparing to obtain a blood pressure reading from a school-age child. Which of the following actions should the nurse take?
- A. Record the diastolic value as the first Korotkoff sound (K1).
- B. Release the cuff pressure at a rate of about 5 mm Hg/second.
- C. Position the child's arm at the level of the heart.
- D. Select a cuff with a bladder size that is approximately 20% of the child's upper arm circumference.
Correct Answer: C
Rationale: Positioning the arm at heart level ensures accuracy. Diastolic is K5, cuff release should be 2-3 mm Hg/second, and cuff size is ~40% of arm circumference.
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.
A nurse is reinforcing teaching with the parent of a 15-month-old toddler about nutritional guidelines. Which of the following statements by the parent indicates an understanding of the teaching?
- A. My child will be constipated if they drink more than 6 ounces of juice a day.
- B. My child's intake of calcium should average 500 milligrams every day.
- C. My child should consume 1,500 to 1,800 calories each day by the time they turn 2.
- D. My child's appetite will increase suddenly when they turn 18 months old.
Correct Answer: B
Rationale: A 15-month-old toddler needs about 500 milligrams of calcium per day to support bone growth and development. Excessive juice does not cause constipation but can reduce appetite for other foods. Toddlers need approximately 1,000 to 1,300 calories per day, so 1,500-1,800 calories is excessive. There is no specific age-related sudden appetite increase at 18 months.
A nurse is reinforcing teaching with the guardian of a 1-month-old infant who has a cleft lip and is bottle fed. Which of the following statements the guardian indicates that the teaching was effective?
- A. I will wait to burp my baby until after the feeding is finished.
- B. I will use a narrow-based nipple to feed my baby.
- C. I will hold my baby in an upright position during feedings.
- D. I will allow my baby's cheeks to remain relaxed during feeding.
Correct Answer: C
Rationale: Upright positioning prevents milk entering nasal passages in cleft lip infants. Delaying burping, narrow nipples, or relaxed cheeks are less effective.
A nurse is obtaining a sputum sample from a school-age child. Which of the following actions should the nurse take?
- A. Ask the child to cough deeply.
- B. Ask the child to clear their throat.
- C. Use wall suction to obtain the sample from the child's throat.
- D. Use a bulb syringe to obtain sputum from the child's mouth.
Correct Answer: A
Rationale: Asking the child to cough deeply helps obtain a sputum sample from the lower respiratory tract. Clearing the throat, wall suction, or bulb syringe are less effective or inappropriate methods.