Nokea
After observing a mother giving her 11-month-old ferrous sulfate followed by two ounces of orange juice, what should the nurse do next?
- A. Suggest placing the iron drops in the orange juice and feed the infant.
- B. Tell the mother to follow the iron drops with formula instead of orange juice.
- C. Instruct the mother to feed the infant nothing in the next 30 minutes after the iron.
- D. Give positive feedback about the way she administered the sulfate.
Correct Answer: D
Rationale: Providing positive feedback to the mother for correctly administering the iron supplements is essential as it reinforces proper medication administration practices. This encouragement can help build the mother's confidence and ensure that she continues to administer the supplements correctly in the future, promoting the infant's health and well-being. Choices A, B, and C are incorrect because there is no need to suggest altering the administration method, changing the liquid used, or restricting feeding immediately after administering the iron supplement. Giving positive feedback is the most appropriate action in this scenario to acknowledge the mother's correct administration technique.
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The nurse provides information about the human papillomavirus (HPV) vaccine to the mother of a 14-year-old adolescent who came to the clinic this morning complaining of menstrual cramping. Which explanation should the nurse provide to support administering the HPV vaccine to the adolescent at this visit?
- A. Use of protective barriers during sexual activity prevents most strains of HPV infection
- B. Most adolescents are not honest about being sexually active
- C. Not all strains of HPV will be covered if given at a later date
- D. Immunity must be established to prevent future HPV infection and the risk for cervical cancer
Correct Answer: D
Rationale: Administering the HPV vaccine at this visit is essential to establish immunity against HPV, thus reducing the risk of HPV infection and cervical cancer. Vaccination is a proactive measure to protect the adolescent's health in the future. Choice A is incorrect because although protective barriers can reduce the risk of HPV transmission, the vaccine provides broader protection. Choice B is incorrect as it makes a generalization about adolescent behavior that is not relevant to vaccination. Choice C is incorrect as it suggests that delaying vaccination would not impact coverage, which is inaccurate as earlier vaccination provides broader protection against HPV strains.
When reviewing developmental changes with the parents of a 6-month-old infant, what information should the practical nurse reinforce?
- A. Encourage the infant to self-feed finger foods.
- B. Teach the parents strategies to help the infant sit up.
- C. Provide a developmentally safe environment for the infant.
- D. Explain that an increased appetite typically occurs in the next 6 months.
Correct Answer: C
Rationale: The correct answer is C because providing a developmentally safe environment for a 6-month-old infant is crucial as they begin to explore their surroundings more actively. This includes ensuring that the environment is free of hazards and that the infant is supervised to prevent accidents. Choice A is incorrect because self-feeding finger foods may not be developmentally appropriate for a 6-month-old infant. Choice B is incorrect as most infants are able to sit up with support around 6 months of age without the need for specific teaching strategies. Choice D is also incorrect as while appetite changes can occur, explaining a specific increase in appetite over the next 6 months is not a primary focus when discussing developmental changes with parents of a 6-month-old.
When should a mother introduce solid foods to her 4-month-old infant? The mother states that her mother suggests putting rice cereal in the baby's bottle. The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?
- A. Stops rooting when hungry
- B. Opens mouth when food is offered
- C. Awakens once for nighttime feedings
- D. Gives up a bottle for a cup
Correct Answer: B
Rationale: Introducing solid foods when the child opens their mouth for food is important to ensure readiness for solids. This behavior indicates the infant's interest and readiness for new textures and flavors, promoting safe and successful introduction to solid foods. The other choices are not indicative of the infant's readiness for solid foods: A - stopping rooting is a reflex action, C - awakening for nighttime feedings is a normal behavior, and D - transitioning from a bottle to a cup is a developmental milestone unrelated to solid food introduction.
A 3-year-old child is admitted to the hospital with a diagnosis of pneumonia. The nurse notes that the child has a fever and is breathing rapidly. What is the nurse's priority action?
- A. Administer antipyretic medication
- B. Obtain a chest X-ray
- C. Start the child on oxygen therapy
- D. Notify the healthcare provider
Correct Answer: C
Rationale: In a child with pneumonia who is breathing rapidly, the priority action for the nurse is to start the child on oxygen therapy. This intervention is essential to ensure adequate oxygenation, which is crucial in managing respiratory distress and preventing complications associated with hypoxia. Administering antipyretic medication (Choice A) may help reduce the fever but does not address the immediate need for oxygen therapy. Obtaining a chest X-ray (Choice B) is important for diagnosis but providing oxygen is more urgent. Notifying the healthcare provider (Choice D) can be done after initiating oxygen therapy to update on the patient's condition.
While teaching a parenting class to new parents, the nurse describes the needs of infants and toddlers regarding discipline and limit setting. What is the most important reason for implementing such parenting behaviors?
- A. Children need help in developing social skills.
- B. This age group fears loss of self-control.
- C. They provide the child with a sense of security.
- D. Children must learn to deal with authority.
Correct Answer: C
Rationale: Implementing discipline and limit setting for infants and toddlers is primarily important as it provides them with a sense of security. This sense of security is crucial for their emotional and psychological development, helping them feel safe and supported as they explore the world around them. Choice A is incorrect because while developing social skills is important, the primary reason for discipline and limit setting in this context is to provide security. Choice B is incorrect as it does not address the main reason for implementing discipline and limit setting. Choice D is incorrect as the primary focus is not about dealing with authority at this early stage of development.