Nokea
In terms of gross motor development, what should the nurse expect an infant age 5 months to do?
- A. Sit erect without support
- B. Roll from the back to the abdomen
- C. Turn from the abdomen to the back
- D. Move from a prone to a sitting position
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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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.
At a well-child visit, parents ask the nurse how to know if a daycare facility is a good choice for their infant. Which observation should the nurse stress as especially important to consider when making the selection?
- A. Developmentally appropriate toys
- B. Nutritious snacks served to the children
- C. Handwashing by providers after diaper changes
- D. Certified caregivers for each of the age groups at the facility
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is caring for a very low-birth-weight (VLBW) infant with a peripheral intravenous infusion. What nursing considerations regarding infiltration should be included in planning IV care?
- A. Infiltration is not solely related to the activity level of VLBW infants.
- B. Continuous infusion pumps do not always stop automatically when infiltration occurs.
- C. Hypertonic solutions can cause severe tissue damage if infiltration occurs.
- D. The infusion site should be checked regularly to prevent infiltration-related complications.
Correct Answer: C
Rationale: Hypertonic solutions can damage tissues if they leak from the vein due to infiltration. It is crucial to monitor for this complication to prevent severe tissue damage. Infiltration is not solely related to the activity level of VLBW infants; it can occur due to various reasons such as vein condition, catheter placement, and fluid type. Continuous infusion pumps may not always detect infiltration, as they typically alarm for pressure changes but not all infiltration instances. Checking the infusion site regularly, preferably hourly, is essential to prevent complications like tissue damage from extravasations, fluid overload, and dehydration.
At what point in the hospitalization of the pediatric patient should discharge planning and teaching begin?
- A. Post-operatively
- B. Right when the patient is being discharged with the parents and support members present
- C. On the morning that the patient is scheduled to go home
- D. On admission
Correct Answer: D
Rationale: Discharge planning should begin on admission to ensure that all necessary teaching and preparations are completed in a timely manner. Starting discharge planning early allows for a comprehensive assessment of the patient's needs, coordination with the healthcare team, and adequate time for patient and family education. Choice A, post-operatively, is too late in the process and may lead to rushed planning. Choice B, right at discharge, may not allow enough time for thorough preparation. Choice C, on the morning of discharge, also does not provide sufficient time for effective planning and education.
The parents of a 2-month-old boy are concerned about spoiling their son by picking him up when he cries. What is the nurse's best response?
- A. Allow him to cry for no longer than 15 minutes and then pick him up
- B. Babies need comforting and cuddling. Meeting these needs will not spoil him
- C. Babies this young cry when they are hungry. Try feeding him when he cries
- D. If he isn't soiled or wet, leave him, and he'll cry himself to sleep
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.