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The health care team wishes to establish a policy regarding sleep positions for infants with gastroesophageal reflux (GER). The first step should be to search for:
- A. Policies from other hospitals.
- B. Data from retrospective studies.
- C. Published national standards.
- D. Expert opinions.
Correct Answer: C
Rationale: National standards provide evidence-based guidance for policy development.
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When teaching the mother of an infant who has undergone surgical repair of a cleft lip how to care for the suture line, the nurse demonstrates how to remove formula and drainage. Which of the following solutions should the nurse use?
- A. Mouthwash.
- B. Povidone-iodine (Betadine) solution.
- C. A mild antiseptic solution.
- D. Half-strength hydrogen peroxide.
Correct Answer: D
Rationale: Half-strength hydrogen peroxide is gentle and effective for cleaning the suture line without irritating the delicate tissue.
A 13-month-old has a febrile seizure one month after the administration of the chickenpox vaccine. The nurse should:
- A. Recognize that the events are unrelated.
- B. Report the event through the Vaccine Adverse Event Reporting System.
- C. Explain to the parents that this is a rare but acceptable risk.
- D. Report the incident through the vaccine manufacturer's hotline.
Correct Answer: B
Rationale: Febrile seizures post-vaccination should be reported to VAERS for monitoring vaccine safety.
A nurse administers ranitidine (Zantac) instead of cetirizine (Zyrtec) to an 8-year-old with asthma. The client has suffered no adverse effects. The nurse tells the charge nurse of the incident but fears disciplinary action. The charge nurse should tell the nurse:
- A. If you do not report the error, I will have to.
- B. Reporting the error helps to identify system problems to improve client safety.
- C. Notify the client's physician to see if she wants this reported.
- D. This is not a serious mistake so reporting it will not affect your position.
Correct Answer: B
Rationale: Reporting the error helps identify system problems to improve client safety, promoting a culture of transparency and quality improvement.
When assessing the development of a 15-month-old child with cerebral palsy, which of the following milestones should the nurse expect a toddler of this age to have achieved?
- A. Walking up steps.
- B. Using a spoon.
- C. Copying a circle.
- D. Putting a block in cup.
Correct Answer: D
Rationale: A 15-month-old typically can put a block in a cup, a milestone achievable even with motor challenges from cerebral palsy, unlike the other options which require more advanced skills.
A nurse working in the nursery identifies a goal for a mother of a newborn to demonstrate positive attachment behaviors upon discharge. Which intervention would be least effective in accomplishing this goal?
- A. Provide opportunities for the mother to hold and examine the newborn.
- B. Engage the mother in the newborn's care.
- C. Create an environment that fosters privacy for the mother and newborn.
- D. Identify strategies to prevent difficulties in parenting.
Correct Answer: D
Rationale: Preventing parenting difficulties is less directly related to fostering immediate attachment.