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An infant can move his head from side to side while following a moving object, can lift his head from a prone position 45 degrees off the examining table, smiles when encouraged, and makes cooing sounds. He cannot maintain a seated position. The most likely age of the infant is:
- A. 1 month
- B. 3 months
- C. 6 months
- D. 9 months
Correct Answer: B
Rationale: At 3 months, infants typically develop the ability to lift their heads 45 degrees in prone, follow objects with their eyes, smile responsively, and make cooing sounds. They are not yet able to sit independently.
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A client with diabetes mellitus has a prescription for 5 U-100 regular insulin and 25 U of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms?
- A. Hyperglycemia
- B. Hyperuricemia
- C. Hypoglycemia
- D. Hypochondria
Correct Answer: C
Rationale: The signs and symptoms of headache, sweating, tremor, pallor, and nervousness described in the client suggest hypoglycemia, which is caused by low blood sugar levels. Insulin is a medication used to lower blood sugar levels in individuals with diabetes. In this case, the client has taken a combination of regular insulin and NPH insulin before breakfast, which could have led to a rapid drop in blood sugar levels by the afternoon causing the symptoms described. It is important to treat hypoglycemia promptly by giving the client a fast-acting carbohydrate source, such as glucose tablets or juice, to raise their blood sugar back to a safe level.
When should the nurse expect breastfeeding-associated jaundice to first appear in a normal newborn?
- A. 0 to 12 hours
- B. 12 to 24 hours
- C. 2 to 4 days
- D. 4 to 5 days
Correct Answer: C
Rationale: Breastfeeding-associated jaundice typically first appears in a normal newborn between 2 to 4 days after birth. This type of jaundice is usually mild and is caused by insufficient milk intake, leading to decreased bilirubin elimination. It is important for healthcare providers to monitor the baby's weight and ensure adequate feeding to prevent or address breastfeeding-associated jaundice.
The nurse in the postoperative unit prepares to receive a client after a balloon angioplasty of the carotid artery. Which of the ff items of priority should the nurse keep at the bedside for such client?
- A. Blood pressure apparatus
- B. IV infusion stand
- C. Call bell
- D. Endotracheal intubation
Correct Answer: A
Rationale: Having a blood pressure apparatus at the bedside is a priority for a client following a balloon angioplasty of the carotid artery. Monitoring blood pressure closely is essential to assess for any signs of complications such as bleeding or thrombosis after the procedure. Rapid identification and management of any changes in blood pressure are crucial in the immediate postoperative period to ensure the client's safety and well-being. It allows the nurse to promptly intervene if there are any signs of complications, helping to prevent further harm to the client.
Which age group should the pediatric nurse recognize as being vulnerable to events that lessen their feeling of control and power?
- A. Infants
- B. Toddlers
- C. Preschoolers
- D. School-age children
Correct Answer: A
Rationale: Infants are the age group that the pediatric nurse should recognize as being vulnerable to events that lessen their feeling of control and power. Infants are entirely dependent on others for their care and are still developing their sense of self and autonomy. They are unable to communicate their needs effectively and rely on caregivers to interpret and respond to their cues. Any disruptions in routine or changes in their environment can make infants feel insecure and powerless. Therefore, the pediatric nurse should be particularly attentive to the emotional needs and sense of control of infants when providing care.
The MOST likely cause of a 4-year-old boy refusing to go to bed and remaining active is
- A. thyrotoxicosis
- B. ADHD
- C. behavioral insomnia of childhood
- D. sleep-onset association disorder
Correct Answer: C
Rationale: Behavioral insomnia involves resistance to bedtime routines.