A nurse notes that a 10-month-old infant has a larger head circumference than chest. The nurse interprets this as a normal finding because the head and chest circumference become equal at which age?
- A. 1 month
- B. 6 to 9 months
- C. 1 to 2 years
- D. to 3 years
Correct Answer: B
Rationale: It is considered normal for a baby's head circumference to be larger than their chest circumference during the first few months of life. Generally, a baby's head grows more rapidly than their chest, which causes the head circumference to be larger. By around 6 to 9 months of age, the head and chest circumference measurements typically become equal. This is part of the normal growth and development pattern in infants.
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The nurse should expect Mr. Gabatan to have some spasticity of the lower extremities. To prevent the development of contractures, careful consideration must be given to:
- A. Active exercise
- B. Use of tilt board
- C. Deep massage
- D. Proper positioning
Correct Answer: D
Rationale: Proper positioning is crucial in preventing the development of contractures in patients with spasticity of the lower extremities. Contractures can result from prolonged positioning in a way that shortens the muscle-tendon unit. By ensuring proper positioning, the nurse can help maintain the muscles and joints in a neutral and extended position, minimizing the risk of contractures. This may involve positioning supports such as pillows, splints, or footboards to keep the limbs in an optimal position.
At what age can most infants sit steadily unsupported?
- A. 4 months
- B. 6 months
- C. 8 months
- D. 10 months
Correct Answer: C
Rationale: Most infants can sit steadily unsupported at around 8 months of age. By this time, they have developed sufficient strength and control in their core muscles to sit up without support. It is important for parents to provide a safe environment for their infants to practice sitting up and to always supervise them during this milestone development.
Which nursing consideration is important when caring for a child with impetigo contagiosa?
- A. Apply topical corticosteroids to decrease inflammation.
- B. Carefully remove dressings so as not to dislodge undermined skin, crusts, and debris.
- C. Carefully wash hands and maintain cleanliness when caring for an infected child.
- D. Examine child under a Wood lamp for possible spread of lesions.
Correct Answer: C
Rationale: Carefully washing hands and maintaining cleanliness when caring for an infected child with impetigo contagiosa is important due to its highly contagious nature. Impetigo is a skin infection that is easily spread through direct contact with the lesions or with items contaminated by the infected person such as towels, clothing, or bedding. By washing hands and maintaining cleanliness, caregivers can help prevent the spread of infection to others and minimize the risk of re-infection to the child. This nursing consideration is crucial in managing impetigo and promoting the child's recovery.
After cancer chemotherapy, a client experiences nausea and vomiting. The nurse should highest priority to which intervention?
- A. Serving small portions bland food
- B. Encouraging rhythmic breathing exercises
- C. Administering metoclopramide (Reglan) and dexamethasone (Decadron) as prescribed
- D. Withholding fluids for the first 4 to 6 hours after chemotherapy administration
Correct Answer: C
Rationale: Administering metoclopramide (Reglan) and dexamethasone (Decadron) as prescribed should be the highest priority intervention for a client experiencing nausea and vomiting after cancer chemotherapy. Metoclopramide is a commonly used antiemetic medication that helps to reduce nausea and vomiting by enhancing gastric emptying and decreasing nausea. Dexamethasone, a corticosteroid, can also help alleviate inflammation that may contribute to the nausea and vomiting. By administering these medications as prescribed, the nurse can effectively address the client's symptoms and improve their comfort level. The other options, such as serving small portions bland food, encouraging rhythmic breathing exercises, and withholding fluids, are important interventions but should not take precedence over providing the prescribed antiemetic medications to manage the client's post-chemotherapy symptoms.
Which of the following organisms is the most common cause of urinary tract infection (UTI) in children?
- A. Klebsiella
- B. Staphylococcus
- C. Escherichia coli
- D. Pseudomonas
Correct Answer: C
Rationale: Escherichia coli (E. coli) is the most common cause of urinary tract infections (UTIs) in children. UTIs in children are most commonly caused by bacteria entering the urinary tract through the urethra. E. coli is a type of bacteria that naturally resides in the intestines but can cause infections when it enters the urinary tract. Children, especially girls, are more prone to UTIs due to shorter urethras that make it easier for bacteria to travel up to the bladder. Therefore, E. coli is the most likely culprit in causing UTIs in children.