Baby M is 5 months old. You notice that she now has the ability to grasp objects between her fingers and opposing thumb. This is known as:
- A. Parachute reflex
- B. Grasp reflex
- C. Pincer grasp
- D. Prehension
Correct Answer: C
Rationale: The correct answer is C: Pincer grasp. The pincer grasp is the ability to hold objects between the thumb and another finger, typically developed around 9-12 months. At 5 months, it is early for a pincer grasp to fully develop, but the beginning of this skill can be seen as early as 5 months. Choices A and B are incorrect as the parachute reflex is a protective response to falling and the grasp reflex is an automatic response to touch. Choice D, prehension, is a general term for the act of grasping or holding objects, but it does not specifically refer to holding objects between the thumb and fingers like the pincer grasp does.
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The nurse is assessing a child's capillary refill time. This can be accomplished by doing what?
- A. Inspect the chest
- B. Auscultate the heart
- C. Palpate the apical pulse
- D. Palpate the nail bed with pressure to produce a slight blanching
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 6-year-old child has patient-controlled analgesia (PCA) for pain management after orthopedic surgery. The parents are worried that their child will be in pain. What should your explanation to the parents include?
- A. The child will continue to sleep and be pain-free
- B. Parents cannot administer additional medication with the button
- C. The pump can deliver baseline and bolus dosages
- D. There is a high risk of overdose, so monitoring is done every 15 minutes
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is preparing a child for possible alopecia from chemotherapy. What information should the nurse give regarding alopecia?
- A. Hair usually regrows in two years.
- B. When hair regrows, it may have a slightly different color or texture.
- C. Expose your head to sunlight to minimize alopecia.
- D. Wearing hats and scarves are preferred to wearing a wig.
Correct Answer: B
Rationale: The correct answer is B. Hair loss from chemotherapy is usually temporary, and when it regrows, it may have a different color or texture. Sun exposure should be minimized, as the scalp may be more sensitive. Wearing hats and scarves can provide comfort and protection, but there is no preference over wearing a wig. Choice A is incorrect because hair regrowth after chemotherapy varies from person to person and usually occurs sooner than two years. Choice C is incorrect as sun exposure should be minimized to protect the sensitive scalp. Choice D is incorrect as the preference between wearing hats, scarves, or a wig is subjective and depends on the individual's comfort and preferences.
The nurse is discussing growth and development with a group of parents. What should the nurse say about developmental milestones?
- A. Increase in body size.
- B. Age-specific tasks that most children can do at a certain time.
- C. The direction of growth.
- D. Refers to the age group of children.
Correct Answer: B
Rationale: The correct answer is B: "Age-specific tasks that most children can do at a certain time." Developmental milestones are specific tasks or abilities that most children can achieve at a certain age range. Choices A, C, and D are incorrect because developmental milestones are not just about increase in body size, the direction of growth, or the age group of children. They are more focused on the expected tasks and skills children can accomplish at particular ages.
What is the appropriate site to administer an intramuscular (IM) vaccine to a newborn?
- A. The dorsal gluteal muscle
- B. The vastus lateralis muscle
- C. The ventral gluteal muscle
- D. The biceps muscle
Correct Answer: B
Rationale: The correct site to administer an intramuscular (IM) vaccine to a newborn is the vastus lateralis muscle. For newborns, the vastus lateralis is preferred over the dorsogluteal site because the dorsogluteal site has been associated with low antibody seroconversion rates, indicating a reduced immune response. The vastus lateralis is also recommended for IM injections in newborns, while the deltoid muscle is preferred for older infants and children. The ventral gluteal muscle and the biceps muscle are not appropriate sites for IM injections. Therefore, choice B is the correct answer.