Nokea
The nurse assesses a 6-month-old for vaccination readiness. Which finding would most likely indicate the need to delay administering the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine?
- A. A family history of sudden infant death syndrome (SIDS).
- B. A fever of 38.5°C following the 4-month vaccinations.
- C. An acute bilateral ear infection.
- D. Living with a family member who is immunosuppressed.
Correct Answer: C
Rationale: An acute infection is a contraindication for vaccination due to the risk of adverse reactions.
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Which of the following actions indicates that the parents of a 12-month-old with iron deficiency anemia understand how to administer iron supplements?
- A. They administer iron supplements in combination with fruit juice.
- B. They administer iron supplements with meals.
- C. They report dark stools.
- D. They brush the child's teeth after administering the iron supplements.
- E. They decrease dietary intake of foods fortified with iron.
Correct Answer: A,C,D
Rationale: Iron with fruit juice enhances absorption, dark stools are expected, and brushing teeth prevents staining. Iron with meals reduces absorption, and fortified foods should not be decreased.
Which of the following should the nurse use to determine achievement of the expected outcome for an infant with severe diarrhea and a nursing diagnosis of Deficient fluid volume related to passage of profuse amounts of watery diarrhea?
- A. Moist mucous membranes.
- B. Passage of a soft, formed stool.
- C. Absence of diarrhea for a 4-hour period.
- D. Ability to tolerate intravenous fluids well.
Correct Answer: A
Rationale: Moist mucous membranes indicate adequate hydration, the goal of treatment.
The nurse caring for a 7 -year-old child who has undergone a cardiac catheterization 2 hours ago finds the dressing and bed saturated with blood. The nurse should first:
- A. Assess the vital signs.
- B. Reinforce the dressing.
- C. Apply pressure just above the catheter insertion.
- D. Notify the physician.
Correct Answer: C
Rationale: Direct pressure is the first measure that should be used to control bleeding. Taking the vital signs will not control the bleeding. This should be done while another person is being sent to notify the physician. The dressing can be reinforced after the bleeding has been contained.
Which of the following actions initiated by the parents of an 8-month-old indicates they need further teaching about preventing childhood accidents?
- A. Placing a fire screen in front of the fireplace.
- B. Placing a car seat in a front-seat, front-facing position.
- C. Inspecting toys for loose parts.
- D. Placing toxic substances out of reach or in a locked cabinet.
Correct Answer: B
Rationale: A front-seat, front-facing car seat is unsafe for an 8-month-old; rear-facing in the back seat is recommended.
A mother has heard that several children have been diagnosed with mononucleosis. She asks the nurse what ascendancy what precautions should be taken to prevent this from occurring in her child. The nurse should instruct the mother to:
- A. Take no particular precautionary measures.
- B. Sterilize the child's eating utensils before they are reused.
- C. Wash the child's linens separately in hot, soapy water.
- D. Wear masks when providing direct personal care.
Correct Answer: A
Rationale: Mononucleosis spreads through saliva, but routine hygiene is sufficient; no special precautions are needed.