Nokea
A nurse is reinforcing teaching about immunizations with the parents of a newborn. Which of the following statements should the nurse make?
- A. Your newborn will receive the first DTaP vaccine during the initial well-baby visit.
- B. Your newborn should receive an immunization for MMR at 6 months.
- C. Your newborn is scheduled to have a hepatitis B vaccine prior to discharge.
- D. Your newborn should receive the PCV vaccine two times prior to his first birthday.
Correct Answer: C
Rationale: Hepatitis B vaccine is recommended to be given within 24 hours of birth as the first dose of a series.
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A nurse is collecting data from a 5-month-old infant who has increased intracranial pressure (ICP) resulting from hydrocephalus. Which of the following manifestations should the nurse expect?
- A. Low-pitched cry
- B. Positive Babinski reflex
- C. Insomnia
- D. Bulging fontanel
Correct Answer: D
Rationale: A bulging fontanel is a key sign of increased ICP in infants. It occurs due to pressure within the skull causing the soft spot on the head to protrude.
A nurse is caring for a 2-month-old infant who is postoperative following repair of a cleft lip and palate. The surgeon prescribes restraints. The nurse should apply which of the following types of restraints to the infant?
- A. Wrist
- B. Mummy
- C. Elbow
- D. Jacket
Correct Answer: C
Rationale: Elbow restraints prevent the infant from bending their arms keeping them from touching their face and disrupting the surgical site.
A nurse is collecting data from a 1-year-old child who has Wilms' tumor. Which of the following findings should the nurse expect?
- A. Diarrhea
- B. Jaundice
- C. Swollen joints
- D. Abdominal mass
Correct Answer: D
Rationale: Wilms' tumor often presents as an asymptomatic abdominal mass.
A nurse is collecting data from a 4-year-old child. Which of the following findings should the nurse expect?"
- A. Heart rate 110/min
- B. Capillary refill greater than 3 seconds
- C. Weight gain of 0.9 kg (2 lb) in a year
- D. Respiratory rate 32/min
Correct Answer: A
Rationale: A heart rate of 110 beats per minute is within the normal range for a 4-year-old child. The typical heart rate for this age is between 80 to 120 beats per minute.
A nurse is planning care for a child who has epiglottitis. Which of the following actions should the nurse plan to take?
- A. Obtain a throat culture.
- B. Visualize the epiglottis using a tongue depressor.
- C. Initiate airborne precautions.
- D. Prepare the child for a neck X Ray and possible tracheostomy
Correct Answer: D
Rationale: A neck X-ray can help diagnose epiglottitis by showing the characteristic "thumb sign."