A nurse is reviewing the immunization schedule of an 11-month-old infant. What immunizations does the nurse expect the infant to have previously received?
- A. Pertussis, tetanus, polio, and measles
- B. Diphtheria, pertussis, tetanus, and polio
- C. Rubella, polio, tuberculosis, and pertussis
- D. Measles, mumps, rubella, and tuberculosis
Correct Answer: B
Rationale: The correct answer is B: Diphtheria, pertussis, tetanus, and polio. By 11 months of age, infants should have received doses of these vaccines as part of the immunization schedule. Choice A is incorrect because measles is usually given later in the schedule. Choice C is incorrect as rubella is usually given as part of the MMR vaccine, not individually, and tuberculosis is not routinely given as a vaccine in early infancy. Choice D is incorrect because mumps is not part of the recommended vaccines at 11 months of age.
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What clinical manifestation of tetralogy of Fallot should the nurse expect when caring for children with this diagnosis?
- A. Slow respirations
- B. Clubbing of fingers
- C. Decreased RBC counts
- D. Subcutaneous hemorrhages
Correct Answer: B
Rationale: The correct answer is B: Clubbing of fingers. Clubbing of fingers is a common manifestation in children with tetralogy of Fallot due to chronic hypoxia. This condition causes the fingertips and nails to enlarge, creating a bulbous or club-like appearance. Slow respirations (Choice A) are not a typical clinical manifestation of tetralogy of Fallot. Decreased RBC counts (Choice C) may be seen in conditions like anemia but are not specific to tetralogy of Fallot. Subcutaneous hemorrhages (Choice D) are not a characteristic clinical manifestation of tetralogy of Fallot.
What intervention best meets a major developmental need of a newborn in the immediate postoperative period?
- A. Giving a pacifier to the newborn
- B. Placing a mobile over the newborn's crib
- C. Providing the newborn with a soft, cuddly toy
- D. Warming the newborn's formula before feeding
Correct Answer: A
Rationale: The correct answer is giving a pacifier to the newborn. Sucking is a natural reflex and a source of comfort for newborns, especially postoperatively. Offering a pacifier can help meet their developmental needs by providing comfort and a soothing mechanism. Placing a mobile over the crib (choice B) may provide visual stimulation but does not directly address the newborn's developmental needs for comfort and self-soothing. Providing a soft, cuddly toy (choice C) may offer some comfort but may not be as effective in meeting the specific developmental need for sucking postoperatively. Warming the newborn's formula before feeding (choice D) relates more to feeding practices than directly addressing a major developmental need in the postoperative period.
A 2-year-old child with a diagnosis of autism spectrum disorder is being discharged. What should the nurse include in the discharge teaching?
- A. Maintain a structured routine
- B. Encourage social interaction
- C. Use positive reinforcement
- D. Use a communication board
Correct Answer: A
Rationale: The correct answer is to maintain a structured routine. Children with autism spectrum disorder benefit greatly from structured routines as they provide a sense of stability and predictability, which can help reduce anxiety and improve behavior. Encouraging social interaction (Choice B) is important but may need to be approached in a structured manner to prevent overwhelming the child. Positive reinforcement (Choice C) is also beneficial for behavior management but may not address the overall need for routine and predictability that is crucial for children with autism. Using a communication board (Choice D) may be helpful for facilitating communication, but establishing and maintaining a structured routine is fundamental for supporting the child's development and well-being in managing their autism spectrum disorder.
A parent tearfully tells a nurse, 'They think our child is developmentally delayed. We are thinking about investigating a preschool program for cognitively impaired children.' What is the nurse's most appropriate response?
- A. Praise the parent for the decision and encourage the plan.
- B. Ask for more specific information related to the developmental delays.
- C. Advise the parent to have the healthcare provider help choose an appropriate program.
- D. Explain that this may be a premature action and the developmental delays could disappear.
Correct Answer: B
Rationale: The most appropriate response for the nurse in this situation is to ask for more specific information related to the developmental delays. By seeking additional details, the nurse can better understand the situation, offer appropriate support, and provide guidance tailored to the child's specific needs. Praising the parent or encouraging the plan without understanding the full context may not be beneficial. Advising the parent to have the healthcare provider help choose a program assumes the parent has not already involved the healthcare provider, which may not be the case. Explaining that the developmental delays could disappear is not appropriate as it may give false hope or minimize the parent's concerns.
A group of students is reviewing information about the endocrine system in infants and children. The students demonstrate understanding of the information when they state:
- A. Endocrine glands begin developing during gestation.
- B. Endocrine glands are fully functional at birth.
- C. Infants may have difficulty regulating glucose and electrolytes.
- D. A child's endocrine system plays a significant role in growth and development.
Correct Answer: C
Rationale: The correct answer is C. Infants may have difficulty regulating glucose and electrolytes due to their immature endocrine systems. This can lead to issues such as hypoglycemia and electrolyte imbalances. Choice A is incorrect because endocrine glands actually begin developing early in gestation, not just in the third trimester. Choice B is incorrect as endocrine glands are not fully functional at birth; they continue to mature and develop after birth. Choice D is incorrect as a child's endocrine system has a significant impact on growth and development through the secretion of hormones that regulate various processes in the body, but it does not specifically address the difficulty in regulating glucose and electrolytes seen in infants.