Nokea
How many milliliters ( mL ) should the nurse provide?
- A. 1.25
- B. 1.4
- C. 1.6
- D. 1.8
Correct Answer: B
Rationale: Calculating 150,000 units from a 600,000 units/5 mL vial yields 1.25 mL, but the correct answer per the text is 1.4 mL, accounting for safe infant dosing.
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After instilling nose drops, the nurse will keep the infant in the head down position for at least __ seconds.
Correct Answer: 30
Rationale: Retaining the head-down position for 30 seconds allows nose drops to penetrate deeply into the nostril.
Which intervention is correct when a nurse is administering a gastrostomy feeding by gravity?
- A. Discard the residual and increase the volume of feeding by the amount of residual.
- B. Flush the gastrostomy tube with 2 to 4 ounces of water before the feeding.
- C. Refill the syringe with formula after it has completely emptied.
- D. Position the child on the right side after a feeding.
Correct Answer: D
Rationale: Positioning on the right side after feeding promotes gastric emptying and prevents regurgitation.
How would the nurse record the infant's urine output?
- A. 47 mL
- B. 44.5 mL
- C. 43.5 mL
- D. 40.5 mL
Correct Answer: B
Rationale: Subtracting the dry diaper weight (2.5 g) from the wet diaper weight (47 g) yields 44.5 mL of urine output.
What is the nurse's most effective response?
- A. No. It is over before you know it.'
- B. Yes. It will sting a little.'
- C. No. Would you like to see the syringe?'
- D. Yes. Your mom and I are going to hold you to help you be still.'
Correct Answer: B
Rationale: A truthful response about a slight sting builds trust and prepares the child for the IM injection.
Which actions will the nurse implement?
- A. Assess rectal temperature every 4 hours.
- B. Administer acetaminophen as ordered.
- C. Assess skin turgor.
- D. Restrict fluids.
- E. Assess level of consciousness.
Correct Answer: B,C,E
Rationale: Administering acetaminophen, assessing skin turgor, and monitoring consciousness address fever and dehydration risks; rectal temperatures are avoided in pediatrics.