During the 2-month well-child checkup, the nurse expects the infant to respond to sound in which manner?
- A. Respond to name
- B. React to loud noise with Moro reflex
- C. Turn his or her head to side when sound is at ear level
- D. Locate sound by turning his or her head in a curving arc
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The parent of an infant with colic tells the nurse, "All this baby does is scream at me; it is a constant worry." What is the nurse's best action?
- A. Encourage the parent to verbalize feelings.
- B. Encourage the parent not to worry so much.
- C. Assess the parent for other signs of inadequate parenting.
- D. Reassure the parent that colic rarely lasts past age 9 months.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
At which age should the nurse expect an infant to begin smiling in response to pleasurable stimuli?
- A. 1 month
- B. 2 months
- C. 3 months
- D. 4 months
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
An infant is diagnosed with a tracheoesophageal fistula. Which assessment finding should the nurse expect?
- A. Jaundice
- B. Hyperactive bowel sounds
- C. Absence of sucking, vomiting
- D. Coughing, with excessive secretion
Correct Answer: D
Rationale: Coughing with excessive secretion is a common sign of tracheoesophageal fistula. In this condition, the connection between the trachea and esophagus allows saliva and food to enter the airways, leading to coughing and excessive secretions. Choice A, jaundice, is not typically associated with tracheoesophageal fistula. Hyperactive bowel sounds (Choice B) are more likely seen in conditions like gastroenteritis. Absence of sucking and vomiting (Choice C) is not a typical finding related to tracheoesophageal fistula.
The nurse is caring for a patient from a culture unfamiliar to the local area. The best way for a culturally competent nurse to interact with the family is to:
- A. Explain that the child must now be cared for differently
- B. Speak in the language most used by the staff and encourage the family to learn it
- C. Be respectful and open-minded when discussing beliefs
- D. Insist that the family changes their beliefs
Correct Answer: C
Rationale: The best way for a culturally competent nurse to interact with a family from an unfamiliar culture is to be respectful and open-minded when discussing beliefs. This approach demonstrates cultural competence by honoring and valuing the family's beliefs and practices. Choice A is incorrect as it disregards the family's cultural practices without understanding them. Choice B is not the best approach as it focuses on language rather than respecting beliefs. Choice D is inappropriate as it goes against the principles of cultural competence by imposing beliefs on the family.
The nurse is preparing an airborne infection isolation room for a patient. Which communicable disease does the patient likely have?
- A. Varicella
- B. Pertussis
- C. Influenza
- D. Scarlet fever
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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