In the newborn, into what muscle is intramuscular vitamin K administered?
- A. Deltoid
- B. Dorsogluteal
- C. Rectus femoris
- D. Vastus lateralis
Correct Answer: D
Rationale: In newborns, intramuscular vitamin K is traditionally administered into the vastus lateralis muscle. This site is preferred due to its large muscle mass and accessibility. The dorsogluteal site is not recommended for newborns due to the risk of injury to the sciatic nerve. The deltoid site is also not recommended for newborns. The rectus femoris muscle is not commonly used for intramuscular injections in newborns.
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The nurse is discussing development and play activities with the parent of a 2-month-old boy. Which statement by the parent would indicate a correct understanding of the teaching?
- A. I can give my baby a ball of yarn to pull apart or different textured fabrics to feel
- B. I can use a music box and soft mobiles as appropriate play activities for my baby
- C. I should introduce a cup and spoon or push-pull toys for my baby at this age
- D. I do not have to worry about appropriate play activities at this age
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Kimberly is having a checkup before starting kindergarten. The nurse asks her to do the "finger-to-nose test." What is the purpose of this test?
- A. Deep tendon reflexes
- B. Cerebellar function
- C. Sensory discrimination
- D. Ability to follow directions
Correct Answer: B
Rationale: The finger-to-nose test assesses cerebellar function, which is responsible for balance and coordination. The test evaluates how well the cerebellum controls motor functions and coordination. Choice A, deep tendon reflexes, is incorrect because this test does not assess reflexes but rather cerebellar function. Choice C, sensory discrimination, is incorrect as this test focuses on motor function rather than sensory abilities. Choice D, ability to follow directions, is incorrect since the test primarily assesses motor coordination and not cognitive skills related to following instructions.
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 interviewing the father of a 10-month-old girl. The child is playing on the floor when she notices an electrical outlet and reaches up to touch it. Her father says no firmly and moves her away from the outlet. The nurse should use this opportunity to teach the father what?
- A. That the child should be given a time-out
- B. That the child is old enough to understand the word no
- C. That the child will learn safety issues better if she is spanked
- D. That the child should already know that electrical outlets are dangerous
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
In teaching parents about appropriate pacifier selection, the nurse should recommend which characteristic?
- A. Easily grasped handle
- B. Detachable shield for cleaning
- C. Soft, pliable material
- D. Ribbon or string to secure to clothing
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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