Nokea
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.
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Which intervention will the nurse implement when suctioning a tracheostomy?
- A. Suction for two to three breaths.
- B. Clear the catheter with water after suctioning for reuse.
- C. Apply suction for no more than 15 seconds.
- D. Establish a regular schedule for suctioning.
Correct Answer: C
Rationale: Limiting suction to 15 seconds prevents hypoxia and tissue damage during tracheostomy suctioning.
What factor does the nurse explain affects the infant's physiological response to medications?
- A. Faster metabolism in the liver
- B. Slower intestinal transit
- C. Immature kidney function
- D. Increased secretion of hydrochloric acid
Correct Answer: C
Rationale: Immature kidney function in infants under 1 year hinders effective drug excretion, affecting response.
Which strategy might the nurse use when administering oral medications to a young child who is reluctant?
- A. Mix the medication with chocolate milk.
- B. Tell the child that the medication is candy.
- C. Give the medication quickly if the child is crying.
- D. Offer the child fruit juice after the medication is swallowed.
Correct Answer: D
Rationale: Offering fruit juice after swallowing medication encourages cooperation without compromising nutrient intake.
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.
What emergency action should be implemented for airway obstruction in the infant?
- A. Six to 10 midsternal thrusts
- B. Five back blows followed by five chest thrusts
- C. Five chest thrusts followed by five back blows
- D. Abdominal thrusts until the object is expelled
Correct Answer: B
Rationale: Five back blows followed by five chest thrusts is the standard intervention for infant airway obstruction.