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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.
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A nurse is reinforcing teaching with the guardian of a 1-month-old infant who has colic. Which of the following instructions should the nurse include in the teaching?
- A. Offer a pacifier when your baby is fussy.
- B. You should offer water in between feedings.
- C. You should place a warm heating pad on your baby's abdomen.
- D. Allow your baby to cry for 5 minutes before responding.
Correct Answer: A
Rationale: A pacifier soothes colicky infants. Water risks intoxication, heating pads may burn, and delayed response increases distress in young infants.
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 parents of a preschooler who has recently started to stutter. Which of the following instructions should the nurse include?
- A. Critique your child's speech.
- B. Look away from your child when they start to stutter.
- C. Avoid completing your child's sentences.
- D. Tell your child to take a deep breath when they are stuttering.
Correct Answer: C
Rationale: Avoiding sentence completion reduces pressure and supports fluency. Critiquing, looking away, or suggesting deep breaths may increase anxiety and worsen stuttering.
A nurse is collecting data from a child who recently experienced a psychomotor seizure. Which of the following findings should the nurse expect?
- A. Hyperactivity
- B. Nystagmus
- C. Apnea
- D. Amnesia
Correct Answer: D
Rationale: Amnesia is common post-psychomotor seizure. Hyperactivity, nystagmus, or apnea are not typical postictal findings.
A nurse is collecting data from a 5-month-old infant who is postoperative following umbilical hernia repair. Which of the following measures should the nurse use to evaluate the infant's pain level?
- A. FLACC pain rating scale
- B. COMFORT pain rating scale
- C. FACES pain rating scale
- D. CRIES pain rating scale
Correct Answer: A
Rationale: FLACC is ideal for non-verbal infants post-surgery. COMFORT suits ICU settings, FACES is for older children, and CRIES is for neonates up to 6 months.